Croup: Signs, Symptoms, and Treatment in Children
Clinical Presentation
Croup presents with a distinctive barking cough, inspiratory stridor, hoarse voice, and varying degrees of respiratory distress due to upper airway obstruction. 1, 2, 3
Key Signs and Symptoms:
- Barking "seal-like" cough - the hallmark feature 2, 4, 3
- Inspiratory stridor (high-pitched breathing sound on inhalation) 2, 4, 5
- Hoarse voice due to laryngeal inflammation 3, 5
- Low-grade fever with preceding upper respiratory symptoms (coryza, congestion) 3, 6
- Respiratory distress with use of accessory muscles, retractions, nasal flaring 1
- Symptoms typically worse at night and usually resolve within 2 days in mild cases 3
Severity Assessment Indicators:
- Respiratory rate (>70 breaths/min in infants, >50 breaths/min in older children indicates severe disease) 7, 1
- Oxygen saturation (<92-94% indicates need for hospitalization) 7, 1, 8
- Stridor at rest versus only with agitation 1, 4
- Ability to speak/cry normally 1
- Signs of exhaustion, cyanosis, or silent chest indicate life-threatening disease 1, 4
Treatment Algorithm
All Cases of Croup (Mild to Severe):
Administer oral corticosteroids immediately to all children with croup, regardless of severity. 1, 3
- Dexamethasone 0.15-0.60 mg/kg orally as a single dose (maximum 10 mg) is the preferred first-line treatment 1, 3
- Prednisolone 1-2 mg/kg (maximum 40 mg) is an alternative if dexamethasone is unavailable 1, 2
- This single dose reduces symptom severity, emergency department visits, and hospital admissions 3, 5
Moderate to Severe Croup (Stridor at Rest or Respiratory Distress):
Add nebulized epinephrine to corticosteroids for children with stridor at rest or significant respiratory distress. 1, 3, 5
- Nebulized epinephrine 0.5 mL/kg of 1:1000 solution (or 4 mL of 1:1000 undiluted for severe cases) 1, 2
- Effect is short-lived (1-2 hours), requiring close monitoring 1
- Observe for at least 2 hours after the last epinephrine dose before considering discharge 1
- Never discharge within 2 hours of epinephrine administration due to risk of rebound symptoms 1
Supportive Care:
- Administer oxygen via nasal cannulae, head box, or face mask to maintain oxygen saturation ≥92-94% 7, 1
- Position younger children (<2 years) with neutral head position and roll under shoulders to optimize airway patency 1
- Minimize handling to reduce metabolic and oxygen requirements 7
- Antipyretics can be used for comfort 7
- Avoid chest physiotherapy - it provides no benefit 7
What NOT to Do:
- Do NOT use humidified or cold air therapy - current evidence shows no benefit 1, 3
- Do NOT use nebulized epinephrine in outpatient settings where immediate return is not feasible 1
- Do NOT perform blind finger sweeps if foreign body aspiration is suspected 1, 8
- Do NOT routinely obtain radiographs - diagnosis is clinical 1, 8
Hospitalization Criteria
Admit to hospital when three or more doses of racemic epinephrine are required. 1
Additional Admission Indicators:
- Oxygen saturation <92% despite oxygen therapy 7, 1
- Respiratory rate >70 breaths/min in infants or >50 breaths/min in older children 7, 1
- Stridor at rest with severe respiratory distress 4
- Signs of exhaustion, cyanosis, or poor respiratory effort 1, 4
- Inability to feed or signs of dehydration 7
- Age <18 months (higher risk) 1
- Family unable to provide appropriate observation 7, 1
Recent guidelines show that limiting admission until 3 doses of epinephrine are needed reduces hospitalization rates by 37% without increasing adverse outcomes 1
Critical Red Flags Requiring Alternative Diagnosis Consideration
Consider bacterial tracheitis if the child appears toxic with high fever (>39°C), progressive respiratory distress despite standard treatment, and purulent secretions. 8
Other Important Differentials:
- Foreign body aspiration: sudden onset without fever or antecedent respiratory symptoms 1, 8
- Epiglottitis: toxic appearance, drooling, tripod positioning 8, 3
- Bacterial tracheitis: failure to respond to standard croup treatment, high fever, toxic appearance 8, 3
- Retropharyngeal or peritonsillar abscess 8, 3
Special Considerations
Recurrent Croup (≥2 Episodes Per Year):
- Consider asthma as a differential diagnosis, especially with nocturnal cough worsening, exercise triggers, or family history of atopy 1, 6
- Consider anatomic abnormalities - flexible bronchoscopy may be indicated for persistent or atypical presentations 1, 6
- Consider gastroesophageal reflux if vomiting or feeding difficulties are present 1
Discharge Instructions:
- Review with general practitioner if deteriorating or not improving after 48 hours 7, 1
- Educate families on managing fever, preventing dehydration, and recognizing deterioration 7
- Ensure reliable family able to monitor and return if worsening 1