In this section
Criteria Led Discharge
- Acute upper airway obstruction- Inhaled foreign body
- viral inflammation of upper airway, larynx, trachea and bronchi- worse at night - peak night two or three
Differential diagnoses see Acute upper airway obstruction)
- Inhaled foreign body- Epiglottitis- Bacterial tracheitis
Children with croup should have minimal examination. Do not examine throat. Do not upset child further.
- barking cough- inspiratory stridor- may have associated widespread wheeze- increased work of breathing- may have fever, but no signs of toxicity
Risk factors for severe croup- pre-existing narrowing of upper airways
- previous admissions with severe croup- uncommon <6 months, rare <3 months of age. Consider alternative diagnosis. Acute upper airway obstruction.
Increasing irritability and/or lethargy
Stridor only when active or upset
Some stridor at rest
Stridor present at rest
Increased Resp rateTracheal TugNasal Flaring
Marked increase or decreaseTracheal TugNasal Flaring
Accessory Muscle Use
None or minimal
Moderate chest wall retraction
Marked chest wall retraction
No oxygen requirement
No oxygen requirement
Hypoxemia is a late sign of significant upper airways obstruction
* The loudness of the stridor is not a good guide to the severity of the obstruction.
Children with cough only do not require treatment.
Steroids have been shown to decrease the length of hospital stay, need for nebulised Adrenaline and other interventions. Drug Doses link
Mild to Moderate Croup
Prednisolone 1mg/kg, AND prescribe a second dose for the next evening. OR a single dose of Oral Dexamethasone 0.15mg/kg. (NB. Oral dexamethasone suspension ONLY available in hospitals, NOT available at commercial pharmacies)
Observe for half an hour post steroid administration. Discharge once stridor-free at rest.
Nebulised adrenaline (1 mL of 1% adrenaline solution* plus 3ml Normal Saline, or 4ml of adrenaline 1:1000.)
(*some hospitals stock bottles of 1% adrenaline solution, often for ophthalmic use. If not available use 1:1000 vials)
Give 0.6mg/kg (max 12mg) IM/IV dexamethasone
If good improvement, observe for 4 hours post adrenaline. Consider discharge once stridor free at rest.
Improvement then deterioration
Give further doses of adrenaline. Consider admission/transfer as appropriate.
Reconsider diagnosis. Acute upper airway obstruction.
- Severe airways obstruction.- No improvement with nebulised adrenaline.- Child has risk factors (see above)
- No improvement following nebulised adrenaline.- >2 doses of nebulised adrenaline are required.- Children requiring care above the level of comfort of the local hospital.
For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.
- Four hours post nebulised adrenaline (if given) and/or half an hour post oral steroid, and stridor free at rest
Parents should be advised and able to seek help if stridor at rest regardless of whether they have received steroids
Parent information sheet:
Children with croup are usually admitted under the General Paediatric Team.
Consider ICU review of any child admitted to RCH requiring frequent nebulised adrenaline, or treatment above to comfort level of the medical staff and/or ward.
- Antibiotics have no role in uncomplicated croup as it has a viral aetiology- Antitussives such as codeine, have no proven effect on the course or severity of croup and may increase sedation, thus interfering with assessment.- Humidified air has not been proven to change the severity of croup- Heliox has not been shown to be better than nebulised adrenaline in severe croup.
Last updated April 2011