Paediatric Clinical Guideline
Croup is an acute clinical syndrome characterised by barking cough, inspiratory
stridor and hoarseness with or without fever. It most commonly occurs in children
aged from 6 months to 6 years. Symptoms are typically worse at night. Most croup
will be dealt with in primary care but up to 30% of cases will require hospitalisation,
of these less than 2% need intubation.
The main differential diagnosis of upper airway obstruction include:
This is now rare due to Hib vaccination but does still occur (check immunisation
history). Consider the diagnosis in a child who is drooling, agitated and who does not
have a cough. If you are unsure call for senior help.
2. Bacterial tracheitis.
Consider in a child with a croup like illness (barking cough and stridor) who has a
high fever and has not responded to treatment for croup. Tracheitis is usually caused
by Staphylococcus aureus (give flucloxacillin).
3. Inhaled foreign body.
Ask for history specifically especially if there is sudden onset of stridor in a well
Associated swelling of the face and tongue, often with urticaria and wheeze. For
management see anaphylaxis protocol.
The child should be assessed where they are most settled (e.g. on parents lap)
AVOID UNECESSARILY UPSETTING THE CHILD. DO NOT EXAMINE
THE THROAT. IV access should not be attempted. X rays are not required.
Assess the clinical severity of the airway obstruction (not the loudness of the stridor).
CALL SENIOR HELP IF CONCERNED
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Mild Moderate Severe
Stridor “Barking” cough, Stridor at rest Stridor may be
intermittent stridor, biphasic or quiet
worse when upset
Recession No recession Mild subcostal Severe recession,
recession, possible marked use of
tracheal tug accessory muscles
Conscious level Normal conscious Agitated (this may Drowsiness (may
level be a sign of indicate impending
hypoxia) respiratory failure)
Heart rate and Normal heart rate Tachycardia, Pronounced
respiratory rate and respiratory rate tachypnoea tachycardia and
when settled tachypnoea
Oxygen SaO2>95% in air SaO2 93-95% in air Bradycardia and
saturations desaturation occur
late and lead to
respiratory arrest if
Croup may present with other coincidental diagnosis e.g. asthma, pneumonia, otitis
TREATMENT OF CROUP
Provide a calm reassuring atmosphere, keeping the child with parents if possible.
1) Mild to moderate croup.
a) Give one dose of 0.3mg/kg dexamethasone orally. Steroid treatment reduces the
severity and duration of symptoms. Dexamethasone is cheaper, easier to give and
as effective as nebulised budesonide.
b) Nebulised budesonide 2 mg as a single dose should be given in a vomiting child
followed by oral dexamethasone once the child can tolerate it.
c) Assess the child hourly. Reassess at 4 hours, if improving consider discharge
(see criteria for discharge).
2) Moderate to severe croup
a) Give humidified oxygen to keep the oxygen saturations >93%.
b) Give oral dexamethasone 0.6mg/kg (or nebulised budesonide 2mg if child is
vomiting or too unwell to take oral medication)
c) Reassess in 1 hour if improving admit to ward and continue hourly assessment.
d) If poor response to steroid child should have senior review. Review diagnosis.
Consider nebulised L-epinephrine – see management of severe croup.
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3) Severe life threatening croup
a) Think “ABC”
b) Give 100% oxygen with continuous cardiac and oxygen saturation monitoring.
a) Call anaesthetic and senior paediatric help urgently.
b) Give nebulised L-epinephrine 1 in 1000 solution.
Age< 1yr: 2.5mls L-epinephrine, diluted with 2.5mls normal saline.
Age> 1yr: 5mls L-epinephrine undiluted.
Effective at 10-30 minutes, but can get “rebound” with worsening obstruction as
effect wears off after 60 – 90 minutes. Can be given continuously if necessary.
c) Give nebulised budesonide 2mg if this will not delay airway management.
d) Transfer to high dependency/ ITU. Nebulised epinephrine should be given on
general paediatric wards only as a holding measure in a child being transferred to
Ideally by a senior paediatric anaesthetist with gas induction, in a controlled
If child is in extremis, intubation by the most experienced person present. The
cords will be swollen, an ETT several sizes smaller than predicted may be
necessary. Do not cut the tube.
f) Give dexamethasone 0.6 mg/kg IV. Do not attempt to gain IV access until
airway is secure.
g) Give antibiotics only if bacterial tracheitis suspected.
CRITERIA FOR DISCHARGE WITH CROUP
1) Parents confident they can manage child’s symptoms and are able to bring the
child back if necessary.
2) Mild or intermittent stridor only with minimal recession. Sat O2 in air> 93%.
3) Dexamethasone given (in all cases even if child only has barking cough).
4) Certain of diagnosis i.e. foreign body, epiglottits etc excluded.
5) Children with pre-existing narrowing of the upper airways (e.g. subglottic
stenosis) and children with Down’s syndrome are prone to more severe croup.
Admission should be considered even with mild symptoms.
6) Never discharge within 3 hours of giving epinephrine.
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Oral dexamethasone in the treatment of croup, 0.15 vs 0.3 vs 0.6mg/kg
Paediatric pulmonolgy. 1995 Dec; 20(6): 362-8 Geelhoed GC, Macdonald WB
Nebulised steroid in the treatment of croup: a systematic review of randomised
Griffin S, Ellis S, Fitzgerald-Barron A, Rose J, Egger M. Br J Gen Prac Feb 2000,
The effectiveness of glucocorticoids in treating croup: meta analysis.
Ausejo M, Saenz A, Pham B, Kellner JD, Johnson DW, Moher D, Klassen TP.
BMJ 1999 Sep 4; 319(7210): 595-600 (Cochrane library)
Nebulised budesonide vs oral dexamethasone for the treatment of croup.
Klassen T, Craig W, Moher D, et al
JAMA 279: 1629-1632, 1998
A comparison of nebulised budesonide, im dexamethasone and placebo in moderately
Johnson et al
New Engl J Med 1998 Aug 20; 339(8):498-503.
Case report – Paediatric myocardial infarction after epinephrine
Pediatrics 104(1) e9 July 1999
The disposition of children with croup treated with racemic epinephrine and
dexamethasone in the emergency dept
J Emerg Med. 1998 Jul-Aug; 16(4):535-9
A randomised trial of a single dose of oral dexamethasone for mild croup. Bjorsen CL
et al. N Engl J Med 2004;351:1306-13
Breathing difficulties: An evidence based guideline for the management of children
presenting with acute breathing difficulty (Children Nationwide – January 2002)
Guideline: Acute Laryngo-tracheo-bronchitis (LTB) (Croup)
Authors: S Jothimurugan, D Luyt
Source: University Hospitals of Leicester NHS Trust
Guideline: Management of Croup
Author: Dr Anu Shankar
Source: King’s College Hospital
Date: March 2001
Guideline: Croup (Laryngotracheobronchitis)
Source: Royal Children’s Hospital Melbourne, Australia
Date: Nov 2001
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MEDICAL GUIDELINES POLICY
ISSUE: 3 VERSION: Final
Author: Carol Bertenshaw
Job Title: Paediatric Specialist Registrar
First issued: July 1997 Date Revised: October 2004
Review Date: October 2007
Document Derivation: Included in guideline Consultation Process:
References: Included in guideline Paediatric Respiratory
Ratified by: Paediatric Guidelines Committee
Chaired by: Dr Louise Wells
Consultant with Responsibility: Dr Stephanie Smith
Distribution: All wards QMC & CHN
MANUAL AMENDMENTS RECORD
(please complete when making any handwritten changes/amendments to protocol and
not processed through protocol committee)
Date Author Description
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