Croup (Laryngotracheobronchitis)

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  • See also

    Acute upper airway obstruction 
    Inhaled foreign body

    Key Points

    1. Minimise distress to the child, as this can worsen upper airway obstruction. Note: Swabbing for COVID-19 or other viruses should not be performed until deemed safe to do so by a senior clinician
    2. Consider early transfer and involvement of senior staff if concerns regarding worsening upper airway obstruction
    3. For severe and life-threatening croup, use nebulised adrenaline
    4. Less severe cases can be managed with corticosteroids alone


    • Croup is inflammation of the upper airway, larynx and trachea, usually triggered by a virus
    • Occurs generally between the ages of 6 months and 6 years
    • Often worse at night
    • Alternative diagnoses include: bacterial tracheitis, inhaled foreign body, anaphylaxis. See Acute upper airway obstruction


    Children with croup should have minimal examination so as not to upset them further. Throat examination is rarely required


    • Barking cough
    • Inspiratory stridor
    • Hoarse voice
    • May have associated widespread wheeze
    • Increased work of breathing
    • May have fever, but no signs of toxicity

    Risk factors for severe croup include:

    • pre-existing narrowing of upper airways
    • previous admissions with severe croup
    • young age: uncommon <6 months old, rare <3 months of age. Consider alternative diagnosis and causes of upper airway obstruction

    Assessment of severity

       Mild    Moderate    Severe
    Behaviour Normal  Intermittent mild agitation Increasing agitation, drowsiness
    Stridor* No stridor, or only when active or upset Intermittent stridor at rest Persistent stridor at rest
    Respiratory Rate Normal Increased respiratory rate  Marked increase or decrease
    Accessory Muscle Use None or minimal  Moderate chest wall retraction  Marked chest wall retraction
    Oxygen saturations** Hypoxia is a late sign which indicates life-threatening croup 

    * Loudness of stridor is not a good indicator of severity of obstruction. Soft stridor in the presence of worsening clinical picture may be a sign of imminent airway obstruction

    ** It is not necessary to measure oxygen saturations in children with mild to moderate croup 



    No investigations are needed in croup (including nasopharyngeal aspirate, X-rays and blood tests) and they may cause distress to the child and worsening of symptoms  


    • Minimal handling to avoid worsening symptoms — limited examination
    • Keep children with carers to reduce distress
    • Children will adopt a position of comfort that minimises airway obstruction, do not change this
    • Treat mild croup with steroids alone. Barking cough with no other symptoms does not always require steroids
    • Moderate croup is usually managed with steroids alone, consider adrenaline if persistent or worsening symptoms
    • Severe croup requires nebulised adrenaline and steroids. See flowchart
    • Supplemental oxygen is not usually required. If needed, treat for severe upper airway obstruction
    • Defer intravenous (IV) access
    • Consider a longer period of observation than 4 hours for a child who:
      • presents overnight
      • lives far from medical care
      • presents with stridor more than once during the same illness
      • has risk factors for severe croup


    * Consider nebulised Budesonide 2mg if oral corticosteroids not tolerated

    Consider consultation with local paediatric team when

    • Severe airway obstruction present
    • Child has risk factors or an atypical presentation
    • Child <3 months of age
    • No improvement with nebulised adrenaline

    Consider transfer when

    • No improvement following nebulised adrenaline
    • Child requiring repeated doses of nebulised adrenaline
    • Child requiring care above the level of comfort of the local hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    Stridor free at rest 


    • minimum of 4 hours post nebulised adrenaline (if this has been required)
    • 30 minutes post dose of oral steroids (and adrenaline not required)

    Parents should be advised to seek medical attention if recurrence of stridor at rest despite having received oral steroids     

    Parent information

    Kids Health Info 

    Additional notes

    • Antibiotics have no role in uncomplicated croup as it has a viral aetiology
    • Anti-tussives such has codeine, have no proven effect on the course or severity of croup, and may cause respiratory depression and increase sedation
    • 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 May 2020 

  • Reference List

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