Evidence-Based Guideline for Diagnosis & Management of
Children with Croup
How do I know it’s croup?
A child is likely to have croup if they present with abrupt onset of barking cough, inspiratory stridor and hoarseness.
The following clinical features should alert you to look for conditions other than croup in a child with croup-like
• Age less than 3 months • Drooling, difficulty swallowing, anxiety
• Expiratory wheeze or loss of voice • Prolonged, or recurrent stridor
• Toxic appearance or high-grade fever • Poor response to treatment
Consider other diagnoses in children with recurrent croup.
Radiography should not be used to diagnose croup or differentiate it from epiglottitis.
X-rays may occasionally be warranted in patients with stridor where the diagnosis is uncertain.
How do I assess severity?
Mild Moderate Severe Life Threatening
• Normal mental state • Anxious, tired • Agitated, exhausted • Confused, drowsy
• No stridor or only when • Stridor at rest
• No or subtle accessory • Minor accessory muscle use, • Marked accessory muscle • Maximal accessory muscle
muscle use, tracheal tug or tracheal tug or chest wall use, tracheal tug or chest use, tracheal tug or chest
chest wall retraction retraction wall retraction wall retraction or exhaustion
• Normal heart rate • Increased heart rate • Markedly increased heart
• Able to talk and/or feed • Some limitation of ability to • Increased respiratory rate • Poor respiratory effort
talk and/or feed • Too breathless to talk and/or • Silent chest
• Extreme pallor • Cyanosis
• Low muscle tone
Loudness of stridor is NOT a good indicator of the severity of croup
Nasopharyngeal aspiration should NOT be undertaken in children with suspected croup.
Distressing procedures should be kept to a minimum as agitation may worsen airway obstruction.
How do I manage it?
Any child with croup who also has a pre-existing upper airway abnormality, or a significant relevant comorbidity or
chronic illness should be sent by ambulance to an emergency department.
Steroid use should be considered in mild croup and given in moderate–severe croup. Steroids should preferably be
given orally, or intramuscularly if the child is vomiting.
Use either: 0.60mg/kg dexamethasone or 1mg/kg oral prednisolone
? Unlike asthma, there is insufficient evidence to determine whether multiple doses of corticosteroids are more
effective than single doses
Mild croup Moderate croup Severe or life-threatening croup
Consider steroids Give steroids Call an ambulance
Send home for observation if you Children with moderate croup Give oxygen
are confident the parent/carer should be given corticosteroids
can adequately manage the and observed over a 2-4 hour
child’s illness period. These children can be o Nebulise four 1ml vials
managed in the surgery if (a total of 4mls) of 1:1000
facilities are available, otherwise adrenaline solution
the child should be sent to o Do NOT dilute as this will
hospital decrease the effectiveness
o Drive nebulisation with oxygen
How do I advise parents of children with croup?
Use of mist or humidified air is NOT an effective treatment for croup.
Cold air has NOT been established as an effective treatment for croup.
Children with croup should be allowed to adopt the position they find most comfortable.
If at any time there is concern about a child’s ability to breathe, an ambulance should be
called to take the child to hospital.
Parent information is available at www.healthforkids.net.au
Mild Croup Moderate Croup Severe Croup
Your receptionist slots in three- Your receptionist calls you to see You hear a frantic knock on your
year-old Suzy at 9.30am. four-year-old Mei Ling who she door…. “Please come quickly, this
has placed in the treatment room child looks very sick”.
Suzy has previously been well.
Mum says she had symptoms of a as she looks unwell. An anxious looking mother is
cold for the last 48 hours and As you walk in the door you clutching a three-year-old boy
then last night at 2 am woke with notice that the child looks anxious who appears very pale, agitated
a barking cough and a hoarse and is sitting quietly on her and exhausted. He has marked
voice. From time to time through father’s knee. She has inspiratory chest wall retraction and tracheal
the night when she was running stridor at rest and when you tug and is too breathless to
around she had funny noisy examine her chest you note that respond to your questions. Mum
breathing but it settled by this there is some tracheal tug and says he developed noisy
morning. Mum thinks she might chest wall retraction. Her pulse breathing through the night and
have croup as Suzy's older rate is 130. Dad says she was not has deteriorated rapidly this
brother had it when he was her able to eat or drink that morning. morning.
age. You diagnose moderate croup and On examination he has an
On examination Suzy is happy, administer 17mg of prednisolone increased pulse and respiratory
alert and playing with the toys in (her weight is 17kg). rate and poor air entry. You
your consulting room. She has a diagnose severe croup and
You explain the diagnosis to dad, administer oxygen while asking
"seal" like cough from time to provide him with information on
time, there is no temperature, no your receptionist to call an
the condition and then ring the ambulance.
accessory muscle use, no local emergency department. You
inspiratory stridor and her chest explain to the father that the You nebulise 4 x 1 ml vials of
is clear. Heart rate is normal and child will require observation in 1:1000 adrenaline using the
she is able to talk, albeit with a hospital to ensure she improves. oxygen tank to drive it. Because
hoarse voice. the boy is unable to tolerate any
A provisional diagnosis of mild oral intake, you draw up and
croup is made. You explain the administer dexamethasone IM at
diagnosis to mum and provide her a rate of 0.60mg/kg.
with information on the condition By the time you do all that the
asking her to call or to return if ambulance has arrived and
symptoms worsen. transports the child to hospital.
Myths dispelled: We don’t know: Facts confirmed:
The use of mist or ? whether a second dose of Steroid use has markedly
humidified air is NOT steroid after 24 hours is decreased the number of
effective in the treatment helpful when a child has children needing hospital
of croup continuing symptoms admission with croup
Loudness of Either prednisolone
stridor is NOT a or dexamethasone
good indicator of can be used to
the severity of treat croup
Based on the Southern Health Evidence-Based Guideline for the Management of Croup in Children 2005
available at www.healthforkids.net.au