Croup in children – CMAJ 2013

Croup – Key Points

  • Caused by a viral URTI & 2nd most common cause of respiratory distress in children
  • Characterized by the abrupt onset of barky cough, inspiratory stridor, hoarseness and respiratory distress
  • Oral corticosteroids reduce the severity & duration of respiratory distress, the need for admission, airway intubations and repeat visits.
  • Severe Respiratory distress, neb epinephrine yields rapid but temporary relief
  • Most children, including many with severe respiratory distress at presentation can be safely discharged home after Tx & a few hours of observation
  • Etiology: Parainfluenza > RSV
  • Epidemiology: 6-36mo (can be as young as 3mo but rare beyond 6yo) in Sept till Dec

2 Before attributing stridor to croup, consider other possible causes (e.g., anaphylaxis, foreign body (airway or esophagus), retropharyngeal abcess, epiglottitis). 

3 In any patient presenting with respiratory symptoms, look specifically for the signs and symptoms that differentiate upper from lower respiratory disease (e.g., stridor vs. wheeze vs. whoop).

Differential dx of stridor

Common: Croup
Less common:
  • Bacterial tracheitis 
    • by staph aureus, H. influenzae, Strep pneumo, Moraxells catarrhalis, S. Pyogenes
    • Pediatric Airway Emergency (rare) – high fever, toxic
    • 1mo to 6yo in fall/winter in previous healthy children
    • Stridor, cough (similar to croup), prefer to lie flat, sometimes forming pseudomembranes
    • Lateral / AP neck x-ray -ragged edge or membrane spanning trachea
    • Clinical dx: differentiate from Croup by poor response to Epi + dexamethasone 
    • Definitive dx: direct endoscopy – done in OR or ICU – may be needed to remove pseudomembrane
    • Tx: Maintain airway, IV, Tx with Clinda + cetriaxone
  • Epiglottitis – Airway emergency
    • Rapid infection and edema of epiglottis caused by HIB (H influenzae type B), Group A/B/C strep.
    • Peak at 2-8 yo and 35-39yo
    • Tripod position, drooling, no barky cough, stridor (late finding), hoarse/muffled voice, fever, sore throat, dysphagia, cervical LN
    • Avoid airway exam; coexisting AOM, PNA, meningitis, cellulitis
    • Tx: OR/ICU for intubation, Direct laryngoscopy in OR – cherry red epiglottis, IV corticosteroids + ceftriaxone, O2, IV
    • Avoid racemic epi
    • Prevention – Vaccination
  • Peritonsillar abscess
    • Polymicrobial with pus behind tonsil
    • s/sx: odynophagia, “hot potato” voice, trismus, otalgia,  sore neck, dysphagia
      • drooling, halitosis, Uvula deviation + soft palate asymmetry
    • clinical dx, can use bedside u/s to differentiate abscess vs cellulitis
    • Tx: Aspiration + Clavulin x 10-14 days + hydration + pain control
  • Retropharyngeal abscess
    • GAS ± aerobes / anaerobes of mouth flora
    • Extension of pharyngeal infection or due to FB
    • s/sx: odynophagia, torticollis, neck swelling/pain/mass, cerv LN
    • lateral neck x-ray: bulging posterior pharynx >7mm at C2 & >14mm at C7
    • CT is the image of choice for deep neck space infection
    • Tx: secure airway, I&D, Pen G x 10 days
  • FB aspiration or ingestiontracheal or esophageal
  • anaphylaxis – Allergic reaction causing upper airway edema
  • Angioedema
  • Laryngeal diphtheria

Level of severity of croup & clinical features

4 In a child presenting with a clear history and physical examination compatible with mild to moderate croup, make the clinical diagnosis without further testing (e.g., do not routinely X-ray).

Front neck x-ray – Steeple sign = subglottic narrowing

  • order only if unsure of dx and r/o coexisting pneumonia (usually pt not responding to Tx)

5 In patients with a diagnosis of croup, use steroids (do not under treat mild-to-moderate cases of croup).


  • Barky cough: occasional
  • No Stridor
  • Indrawing (suprasternal and / or intercostal): none to mild

Tx: 0.6mg/kg dexamethasone

  • Educate parents about anticipated course of illness, signs of respiratory distress, when to seek medical assessment
  • Non pharm: hand hygiene, contact avoidance


  • Barky cough: frequent
  • Stridor: easily audible at rest (key to assessment of severity)
  • Indrawing (suprasternal and / or intercostal): visible at rest
  • No Distress or agitation

Tx: Minimize intervention by placing child on parent’s lap and provide position of comfort

  • 0.6mg/kg of body weight & observe for improvement
  • Pt improves if no chest wall indrawing, stridor at rest – educate parents & d/c home
  • Admission if no improvement by 4hr

1 In patients with croup,
a) Identify the need for respiratory assistance (e.g., assess ABCs, fatigue, somnolence, paradoxical breathing, in drawing)
b) Provide that assistance when indicated.


  • Barky cough: frequent
  • Stridor: Prominent inspiratory and occasionally expiratory
  • Indrawing (suprasternal and / or intercostal): marked or severe
  • Substantial Distress or agitation
  • No Lethagry

Impending respiratory failure

  • Barky cough: often not prominent because of fatigue
  • Stridor: audible at rest, but may be quiet or hard to hear
  • Indrawing (suprasternal and / or intercostal): may not be marked
  • Lethargy or decreased LOV
  • Pallor, Dusky or cyanotic without supplemental oxygen

Tx: Minimize intervention, provide blow-by oxygen (optional unless cyanotic)

  1. Nebulized epinephrineracemic epinephrine 2.25% (0.5ml in 2.5ml saline) or L-epi 1:1000 (5ml)
  2. Dexamethasone 0.6mg/kd & may repeat once – if vomiting or too distressed, budesonide 2mg neb with epi
  3. Intubate prn
  4. Good response to epi – observe for 2 hr
    • persistent mild symptoms or no chest wall indrawing or no stridor at rest
      • provide education and d/c home
  5. If recurrent of severe respiratory distress
    • repeat neb epi & if good response, continue to observe
  6. Consider admission if
    • received steroid >=4hr ago with moderate respiratory distress (no agitation or lethargy) & stridor at rest with chest wall indrawing.
    • Dehydration
    • Relative indications: social factors / distance from hospital
  7. Poor response to neb epi – repeat neb epi
    • contact ICU for further Rx

6 In a patient presenting with croup, address parental concerns (e.g., not minimizing the symptoms and their impact on the parents), acknowledging fluctuating course of the disease, providing a plan anticipating recurrence of the symptoms

  • Worse at night, 2-5 days of prodrome, fluctuating dz course, mild fever, rhinorrhea, sore throat
  • incubation period is 3-6d and lasts 4-7 days
Posted in 20 Croup, 99 Priority Topics, FM 99 priority topics, Resp

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