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What is Croup?
Croup is one of the most common childhood respiratory illnesses with an annual incidence in the under 6s of between 1.5% and 6%.
The peak incidence is between 1 and 2 years. It typically presents with hoarseness, inspiratory stridor and a harsh barking cough.
It lasts approx 4 to 5 days. It is most often caused by a viral illness and affected children may have accompanying symptoms of runny nose or sore throat.

The guidance is only applicable once a diagnosis of croup has been established and other differential diagnoses have been excluded.

Do not attempt to visualise the throat, as this may precipitate laryngospasm

Differential diagnosis

When seeing a child who is unwell with cough and stridor it is important to consider alternative diagnoses to croup. If the history of stridor is not recent or there is evidence of both inspiratory and expiratory stridor, an anatomical/structural cause may be more likely.

It is important to elicit the history of onset of stridor and exclude foreign body inhalation.

If a child is particularly unwell or toxic looking, epiglottitis or tracheitis may be the cause. The child with epiglottitis will also have an extremely sore throat, and may be unable to swallow, resulting in drooling. It is worth asking if immunisations, particularly Hib, are complete, though this would not rule out the diagnosis.
Consider also allergic causes and direct irritation, such as smoke inhalation, peritonsilar abscess, Diptheria and congenital causes eg laryngomalacia, subglottic stenosis or vocal cord palsy.

Consider referral for admission regardless of severity if:

Less than 6 months old

  • Re-presenting/poor response to initial treatment
  • Family circumstances difficult or long distance from medical assistance
  • History of severe croup
  • Immunocompromised
  • Poor fluid intake.
Is this croup?
  • Is there a harsh barking cough, stridor on inspiration, hoarseness?
  • Is there any question of foreign body inhalation?
  • Is the child very unwell+/-incomplete immunisations-could it be epiglottitis?
Mild Croup
  • Happy alert child, eating/drinking/playing.
  • Barking cough, no stridor at rest but may be present if upset.


  1. Reassurance.
  2. Ensure home circumstances adequate.
  3. Consider single dose of steroid in discussion with parents – see box below on Oral Steroid Doses
Moderate Croup
  • Child remains interactive and alert.
  • Stridor at rest, intercostal recession, mild tracheal tug.


  1. Give oral or nebulised steroid – see below.
  2. Consider admission depending on home circumstances.
  3. Review 1 to 2 hours after steroid if need for admission in balance. The steroid dose can be repeated after 12 to 24 hours if necessary.
Severe Croup
  • Child agitated or lethargic, tachycardia.
  • Marked intercostal recession, tracheal tug and tachypnoea.


  1. Do not disturb child, keep with parent.
  2. High flow oxygen.
  3. Give oral or nebulised steroid – see box below.
  4. Arrange urgent admission if not already in hospital.
  5. Ambulance transfer with Paramedic or retrieval if SaO 2 <92%.
Life Threatening Features
  • Decreased level of consciousness, floppy.
  • Cyanosis or marked pallor.


  1. As for severe croup, plus Adrenaline 1 in 1,000 by nebuliser: 0∙4ml/kg (Max 5ml). Effect may be brief. Can be repeated.
  2. Call for senior help (eg Consultant Paediatrician, anaesthetist).
  3. Give budesonide by nebuliser 2mg.
  4. Give IV ceftriaxone.
  5. Repeat observations every 15 to 30 minutes.
  6. Intensive care will be required. Discuss transfer arrangements with consultant paediatrician on call.


Oral and Nebulised Steroid Doses

Dexamethasone liquid 150 microgram/kg – if weight available or

Dexamethasone tablets, <1 year, 2mg; otherwise 4mg. Can be dissolved in water.

If no dexamethasone available, alternatives are:

  • Oral prednisolone 1 to 2mg/kg (<2years, 10mg; 2 to 5 years, 20mg; >5 years, 40mg).
  • Budesonide 2mg via nebuliser, if oral administration not possible.

Onset of action of steroids: within 30 to 60 minutes.

Editorial Information

Last reviewed: 31 March 2015

Next review: 31 December 2016

Author(s): Consultant Paediatrician

Approved By:

Reviewer Name(s): Dr Deborah Shanks

Document Id: TAM332