Management of Croup in children aged over three months
Calderdale and Huddersfield
NHS Trust
Guidelines for the management of croup in children aged over three
months
Purpose of guideline
These guidelines were developed in order to reduce variance and promote best
practice for the management of croup in the emergency departments of the Trust.
Scope and Locations where this guideline applies
The guidelines apply to all nursing and medical staff involved in the care of children
aged over three months who present with croup at the emergency departments of the
Calderdale and Huddersfield NHS Trust. It reflects what is currently regarded as safe
practice, but does not replace the need for the application of clinical judgement to
each individual presentation.
Contents
Background ............................................................................................................ 2
Local Issues ............................................................................................................ 2
Guideline at a Glance
3
Flow Chart
5
Detail of recommendations and supporting evidence.
6
References, including national guidelines ........................................................... 14
Guideline developed by: ..................................................................................... 14
List of interested groups....................................................................................... 14
Distribution list and areas where guideline should be readily available .............. 14
Arrangements for training .................................................................................... 15
List of changes and dates of changes
16
Draft Version 1.0 May 06
Page 1 of 16
Management of Croup in children aged over three months
Background
Croup is a common cause of upper airway obstruction in young children. It is usually
mild and self-limiting, though occasionally it may cause severe respiratory obstruction
[1]. Before the widespread use of corticosteroids, studies reported that as many as
31% patients with croup required hospitalisation and 1.7% required intubation [2].
Acceptance of the use of corticosteroids for the treatment of croup for the last decade
has dramatically reduced the number of patients requiring admission to hospital and
endotracheal intubation [3].
Croup, also known as laryngotracheobronchitis, is a clinical syndrome of a hoarse
voice, barking cough and inspiratory stridor [3]. It is usually caused by a viral
infection of the upper airway that results in inflammation of the larynx, trachea and
bronchi, thereby compromising airflow through the proximal airway. A number of
viruses may cause croup, although the most common are parainfluenza 1 and 2 and
respiratory syncytial viruses [4]. It mostly affects children between 6 and 36 months,
although it may occur in older children [5].
Most patients have an upper respiratory tract infection for several days before cough
becomes apparent. With progressive compromise of the upper airway, a characteristic
sequence of symptoms and signs occurs. At first there is a mild brassy cough with
intermittent inspiratory stridor. As obstruction increases, stridor becomes biphasic and
is associated with worsening cough, nasal flaring, and suprasternal, infrasternal and
intercostal retractions. As inflammation extends to the bronchi and bronchioles,
respiratory difficulty increases. The child’s temperature may only be slightly elevated;
it rarely reaches 39-40oC. Symptoms are characteristically worse at night and often
occur with decreasing intensity for several days [6].
Local Issues
Traditionally, the emergency departments at Huddersfield Royal Infirmary and
Calderdale Royal hospital have differed in their approaches to management of croup.
Therefore, the purpose of this guideline is to provide a systematic and standardised
approach to care.
Draft Version 1.0 May 06
Page 2 of 16
Management of Croup in children aged over three months
Management of Croup in children aged over three months
Guideline at a Glance
1. Diagnostic criteria should include: further points page 6
 An appropriate history

Croup symptoms

Clinical examination

Exclusion of other causes of upper airway obstruction: Table (1) p.7
2. Assessment of severity: further points page 7

Utilize the Westley Croup Scale (WCS): p.8. C

Complete assessment of respiratory function including, respiratory rate,
oxygen saturation and heart rate should supplement the WCS. D

Assessment of airway obstruction: p. 9
3. Treatment: further points page 10
All parents should receive appropriate verbal advice and be given a copy of the
information leaflet on croup.
3.1 Mild





No specific treatment
Mild croup does not need pharmacological treatment.
There is evidence to suggest the use of mist therapy is ineffective.
Parental advice
Discharge home- see key factors for admission. p.11
3.2 Moderate
Children with moderate croup who demonstrate stridor and chest wall retractions should
receive :

Corticosteroids- Oral dexamethasone 0.15mg/kg if not tolerated nebulised
budesonide 2mg should be considered. A
Whilst oral, intravenous, intramuscular and nebulised corticosteroids are all
efficacious, the use of oral corticosteroid is kindest to the patient, easy to
administer and inexpensive.

Discuss with on-call paediatrician and arrange for transfer to paediatric
assessment unit
Draft Version 1.0 May 06
Page 3 of 16
Management of Croup in children aged over three months
3.2 Severe croup
Children with severe croup should receive systemic corticosteroids and nebulised
adrenaline, unless contraindicated, and be assessed by a senior paediatrician in the
emergency department. The child must be stable before transfer to the paediatric
ward. Rarely children with severe airway obstruction will need transfer to the PICU in
Leeds.

Oxygen – Immediate treatment for severe viral coup with significant oxygen
desaturation. D

Corticosteroids- Oral dexamethasone 0.15mg/kg if not tolerated nebulised
budesonide 2mg should be considered. A

Adrenaline -nebulised adrenaline 0.4mg/kg (maximum 5mg). A
Remember these are only guidelines, individual presentations or
circumstances may require alternative treatments and management.
Draft Version 1.0 May 06
Page 4 of 16
Management of Croup in children aged over three months
Management Flowchart
CROUP
Exclude other causes of upper airway obstruction
Life Threatening Airway Obstruction?
(Cyanosis or Decreased Consciousness?)
No
Yes
Do not disturb the child unnecessarily
Administer high flow oxygen
Call Senior A&E, Paediatrics and Anaesthetist
Assess Severity
Mild Croup?
Moderate Croup?
Severe Croup?
Barking Cough.
Stridor at rest
Nil or intermittent stridor.
Tracheal tug and chest
retractions
Biphasic stridor at
rest
Apathetic or restless
Marked tracheal tug.
WCS 2-7
WCS 8 or more
Dexamethasone
0.15mg/kg oral
Call Senior
Paediatrician and
senior A&E Dr.
WCS </= 1
No Specific treatment.
Parental explanation and
advice sheet.
Or if oral not tolerated
Competent parents,
transport available.
2mg Nebulised
Budesonide
No extenuating
circumstances
Discuss with on-call
paediatrician and
arrange for transfer to
paediatric assessment
unit for observation
Disturb as little as
possible.
Oxygen
Discharge Home
Nebulised
Adrenaline 5mls 1:
1000
Dexamethasone
0.15mg/kg
Or
Budesonide 2mg
nebulised if oral
steroids not
tolerated.
Consider need for
intubation and PICU
Draft Version 1.0 May 06
Page 5 of 16
Do not move from
Emergency
Department until
child has been
assessed by senior
Dr. and is stable.
Management of Croup in children aged over three months
Detail of recommendations and supporting evidence.
1. Diagnosis
1.1 Distinguishing viral from spasmodic croup
Typically viral croup develops over days with a concurrent typical coryzal
illness and the symptoms of airway obstruction disappear over 3-5 days [3].
Conversely, spasmodic croup is said to be more common in atopic older
children and comes on rapidly overnight in children who were perfectly well
when they went to sleep [7]. Spasmodic croup often runs a shorter clinical
course [8]. However, the history and assessment of airway obstruction will
determine treatment rather than the sometimes erroneous subclassification of its aetiology [9].
1.2 Diagnostic criteria should include:
1.2.1. An appropriate history
(Child typically aged 6-36 months. Usually 2-3 days coryzal
symptoms, often low grade fever, usually happy to eat and drink, often
presents at night)
1.2.2. Croup symptoms
(Hoarse voice, barking cough, inspiratory stridor)
1.2.3. Clinical examination
(Non-toxic child, well-perfused, possible tracheal and intercostal
recessions)
1.2.4. Exclusion of other causes of upper airway obstruction
(Table 1, page 6).
Only when all 4 criteria are satisfied should the clinical condition of
croup be diagnosed [6]. D
1.3 What is not croup?
There are a number of structural and infective conditions that cause upper
airway obstruction. These may be thought of anatomically [Table (1) p.7]. In
addition there are three factors to consider when deciding whether the
presence of stridor and use of accessory muscles of respiration relate to croup
or an alternative diagnosis [10].
1.3.1. Age of the child.
A child less than 3 months of age is more likely to have a structural
airway problem (e.g. laryngomalacia) with or without a concurrent
viral infection. Similarly, tracheomalacia may present with a brassy
cough and variable stridor.
A child between 1 and 3 years with the acute onset of respiratory
difficulty without fever may have inhaled a foreign body. Bronchial
foreign bodies will usually have an associated localised expiratory
wheeze (rather than inspiratory stridor) and may have evidence of air
trapping on an expiratory chest x-ray below the level of the obstruction
(ball-valve effect).
Draft Version 1.0 May 06
Page 6 of 16
Management of Croup in children aged over three months
1.3.2. Character of the stridor.
The combination of inspiratory and expiratory stridor increases the
likelihood of an underlying fixed tracheal obstruction (e.g.
retropharyngeal abscess). These children need urgent assessment.
1.3.3. Toxicity of the child.
Children with croup do not appear toxic (pale, very febrile and poorly
perfused). This is more commonly seen in bacterial tracheitis or
epiglottitis.
Table (1.) Causes of upper airway obstruction
Supraglottic
Acute tonsillar enlargement
Epiglottitis
Retropharygeal Abscess
Foreign Body
Acute Angioedema
Laryngeal/ subglottic
Viral croup
Spasmodic croup
Laryngomalacia
Bacterial Tracheitis
Foreign Body
Diptheria
Thermal/Chemical Injury
Intubation Trauma
Laryngospasm
Tracheal
Trauma (haematoma)
Foreign Body
Bacterial tracheitis
Congenital Abnormality
Tumour
The differential diagnosis of upper airway obstruction should always be considered
before presuming that the child has croup.
There is no diagnostic or management aid from radiological investigations in children
with uncomplicated croup.
2. Assessment of Severity
Although infrequent, severe airway obstruction is the major clinical concern in croup.
Determining the degree of airway obstruction is therefore the most important aspect
of assessment. It relies almost always on clinical signs. There are validated tools to
aid the assessment of the severity of croup [11,12,13].
2.1 Westley Croup Score (WCS)
The use of the Westley Croup Score Scale (Table 2) for objectively classifying
the severity of croup, into mild, moderate or severe is recommended for use in
the emergency departments [11]. C
The evaluation and documentation of a complete assessment of respiratory
function including respiration rate, oxygen saturations and heart rate should
supplement the use of the WCS in assessing the severity of croup. D
Airway obstruction in croup can worsen rapidly; therefore repeated careful
clinical assessment is essential.
Draft Version 1.0 May 06
Page 7 of 16
Management of Croup in children aged over three months
Table (2.) Westley Croup Score Scale [11]
Score
Symptom
Severity
Stridor
Retractions
Air Entry
Cyanosis in Room Air
Level of Consciousness
None
When agitated
At Rest
None
Mild
Moderate
Severe
None
Decreased
Markedly Decreased
None
When agitated
At rest
Normal
Disorientated
Total
0
1
2
0
1
2
3
0
1
2
0
4
5
0
5
Total Score
Croup Score 0-1
Mild Croup
Croup Score 2-7
Moderate Croup
Croup Score >/=8
Severe Croup
2.2 Oximetry
Oximetry is a useful routine tool in the emergency department. However, it
can never substitute good clinical assessment. It has been demonstrated that
oxygen saturation may be near normal in severe croup and yet significantly
lowered in some children with mild to moderate croup. This is presumed to
relate to lower airway disease causing ventilation/perfusion mismatching.
2.3 Important points to consider when assessing severity:
2.3.1. General appearance.
A child who is agitated, appears to be tiring from the effort of
breathing or has a decreasing level of consciousness has severe croup
and needs to be closely monitored.
2.3.2. Degree of respiratory distress.
The presence of stridor at rest, tracheal tug, and chest wall retractions,
changing respiratory rate and pulse rate or palpable pulsus paradoxus
indicate treatment is necessary.
Draft Version 1.0 May 06
Page 8 of 16
Management of Croup in children aged over three months
2.3.3. Cyanosis or extreme pallor
The presence of cyanosis or extreme pallor indicates the need for
immediate treatment.
2.3.4. Oxygen desaturation
Oxygen desaturation as indicated by pulse oximetry is a LATE sign
and an unreliable measure of croup severity.
2.4 Assessment of airway obstruction
2.4.1. Mild Airway Obstruction (WCS 0-1)
This child will usually appear happy and be prepared to drink, eat, play
and take an interest in the surroundings. There may be mild chest wall
retractions and mild tachycardia, but stridor at rest should not be
present. No pharmacological treatment is needed. The parents should
be reassured, given an explanation of what to expect over the coming
days and be provided with an information sheet (Note: other factors
may warrant hospital admission, see page 11).
2.4.2. Moderate Airway Obstruction (WCS 2-7)
This is indicated by persisting stridor at rest, chest wall retractions, use
of accessory muscles of respiration and increasing heart rate. The child
can be placated and is interactive with people and surroundings. The
child will need systemic corticosteroids and be admitted for
observation for a minimum of four hours. If the child continues to have
stridor at rest, then further treatment will be considered with prolonged
observation.
2.4.3. Progression from Moderate to Severe Obstruction
The child may begin to appear worried, preoccupied or tired. The child
may sleep for short periods. This child will require close, continuing
observation, treatment with systemic corticosteroids and nebulised
adrenaline with regular (minimum 30-6- minutes) clinical review.
Progression of signs will indicate the need for medical assessment and
consideration of further treatment with systemic corticosteroids and
adrenaline.
2.4.4. Severe Airway Obstruction (WCS >/=8)
As airway obstruction increases, the appearance will be that of
increasing tiredness and exhaustion. Marked tachycardia is usually
present. Restlessness, agitation, irrational behaviour, decreased
consciousness, hypotonia, cyanosis and marked pallor are late signs
indicating that dangerous airway obstruction is now present. The child
should not be unnecessarily disturbed other than the immediate
application of mask oxygen with nebulised adrenaline as preparations
are made to intubate the child by someone skilled in paediatric
intubation (ideally with an inhaled induction). Systemic steroids, if not
previously given, will be administered once the airway is secured.
Draft Version 1.0 May 06
Page 9 of 16
Management of Croup in children aged over three months
3. Treatment
The most important change in the management of croup has been the earlier and
liberal use of corticosteroids the emergency department [5]. In writing the guidelines
other common therapies for croup have been considered.
3.1. Mist Therapy
The use of steam inhalation for treating croup has been advocated since the
19th century [7]. More recently a randomised controlled trial (RCT) examined
the effect of mist in the treatment of mild to moderate croup [14]. B They
concluded there were no benefits of mist therapy in terms of reduction in
croup score, or the duration of symptoms. However, they reported no adverse
effects, and parents who report relief from nursing their children in steamy
bathrooms should not be actively persuaded to avoid this practice. B
3.2. Oxygen
Oxygen is the immediate treatment of choice for children with severe viral
croup who have significant oxygen desaturation. D
3.3. Corticosteroids
The Cochrane Library has recently published the results of a systematic review
of RCTs concerning the effectiveness of glucocorticoids for croup [15]. The
conclusion of this review was that dexamethasone and budesonide are equally
effective in relieving the symptoms of moderate and severe croup as early as
six hours after treatment. A
Dexamethasone 0.15mg/kg has been shown to be as effective as 0.3mg/kg and
0.6mg/kg via the oral route [16, 12]. A
Oral dexamethasone has been shown to be as effective intramuscular
dexamethasone [17,18]. A
In application of the evidence with consideration to patient preference and
cost, it is recommended that oral administration of dexamethasone
0.15mg/kg should be given to children with moderate and severe croup. If
oral medication is not tolerated nebulised budesonide 2mg should be
considered. A
3.4. Adrenaline
Racemic adrenaline has been demonstrated to give short term relief of
symptoms (2-3hours) of moderate and severe croup [19]. A
L-adrenaline (more readily available) has been demonstrated to be equally
effective as racemic adrenaline (Not usually available outside the USA) in the
treatment of croup [20]. A
Thus it is recommended that nebulised adrenaline 0.4mg/kg (maximun
5mg) be administered to children with severe croup. A
Note it is contraindicated in children with ventricular outflow obstruction (e.g.
tetralogy of fallot).
Draft Version 1.0 May 06
Page 10 of 16
Management of Croup in children aged over three months
Close monitoring and observation should be made to identify any side
effects of this treatment (e.g. cardiac arrhythmias).
3.5 Other factors for hospital admission
In particular, the following factors are more likely to increase the need for
admission to hospital despite having clinically mild croup:
1.
2.
3.
4.
5.
6.
7.
Age less than 6 months
Known structural airway anomaly (e.g. subglottic stenosis)
Inadequate fluid intake
Parental anxiety
Proximity of home to hospital/transport issues
Representation to the emergency department within 24hours
Uncertain diagnosis
If in doubt always seek senior A&E or Paediatric opinion.
Draft Version 1.0 May 06
Page 11 of 16
Management of Croup in children aged over three months
Strength of recommendations (Based upon SIGN the Scottish
Intercollegiate Guidelines Network classification)
A
Based on meta-analyses and randomised controlled trials and directly
applicable to the population.
B
Based on high quality case controlled or cohort studies or systematic
reviews and directly applicable to the population or evidence extrapolated
from meta-analysis or randomised control trials.
C Based on lower quality case controlled or cohort studies directly applicable
to the population or evidence extrapolated from high quality case controlled or
cohort studies.
D
Based on non-analytical evidence such as case reports or expert opinion
or evidence extrapolated from lower quality case-controlled or cohort studies.

Recommended best practice based on the clinical experience of the
guideline development group
Draft Version 1.0 May 06
Page 12 of 16
Management of Croup in children aged over three months
References
[1] Fitzgerald DA, Kilham HA. Croup: assessment and evidence-based management.
The Medical Journal of Australia. 2003; 179: (7), 372-377
[2] Marx A, Torok TJ, Holman RC, Clarke MJ. Pediatric hospitalisations for croup
(laryngotracheitis): biennial increases associated with human parainfluenza virus 1
epidemics. Journal of Infectious Diseases. 1997; 176: 1423-1427.
[3] Klassen TP. Croup. A current perspective, Pediatric Clinics of North America.
46. 1999; 1167-1178.
[4] Hendrickson KJ, Khun SM, Savatski LL. Epidemiology and cost of infection
with human parainfluenza virus types 1 and 2 in young children, Clinical Infectious
Diseases. 1994; 18: 770-779.
[5] Knutson D, Aring A. Viral Croup. American Family Physician. 2004; 69: (3), 535542.
[6] Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook of Pediatrics. 16th
Edition. Philadelphia: WB Saunders Company; 2000.
[7] Skolnik N.S. Treatment of croup: a critical review, American Journal of Diseases
in Children. 1989; 143: 1045-1049.
[8] Fitzgerald DA, Mellis CM. Management of acute upper airways obstruction in
children. Modern Medicine in Australia. 1995; 38: 80-88.
[9] Ausejo M, Saenz A, Pham B, Kellner JD. Johnson DW, Moher D, Klassen TP.
The effectiveness of glucocorticoids in treating croup: meta-analysis. British Medical
Journal. 1999; 319: 595-600.
[10] New South Wales Department of Health. Acute Management of Infants and Children
with Croup, Clinical Practice Guidelines. 2003. Available from:
http://www.health.nsw.gov.au
[11] Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for
the treatment of croup. American Journal of Disease in Children. 1978;132: 484-487.
[12] Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup:
randomised, placebo-controlled trial. Pediatric Pulmonology. 1995; 20: 355-361.
a
[13] Bjornson C, Klassen TP, Williamson J, Brant R, Plint A, Bulloch B. The use of
dexamethasone in mild croup: A multi-centre randomised controlled trial. Pediatric
Academic Societies. 2003 May: 3-6.
[14] Neto, Kentab, Klassen et at 2002- no reference
[15] Russell & Wiebe, Saenz, 2004 – no reference
Draft Version 1.0 May 06
Page 13 of 16
Management of Croup in children aged over three months
[16] Geelhoed GC, Turner J, Macdonald WB. Efficacy of a small single dose of oral
dexamethasone for outpatient croup: a double blind placebo controlled clinical trial,
British Medical Journal, 1996; 313: 140-142.
[17] Donaldson D, Poleski D, Knipple E, Filips K, Reetz L, Pasual RG, Jackson RE.
Intramuscular versus Oral Dexamethasone for the Treatment of Moderate-to-severe
Croup: A Randomized, Double-blind Trial. Academic Emergency Medicine. 2003,
10: (1), 16-21.
[18] Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with
dexamethasone: intramuscular versus oral dosing. Pediatrics, 2000; 106: 1344-1348.
[19] Kristjansson S, Berg-Kelly K, Winso E. Inhalation of racemic adrenaline in the
treatment of mild and moderately severe croup. Clinical symptom score and oxygen
saturation measurement for evaluation of treatment effects. Acta Paediatrica. 1994;
83: 1156-1160.
[20] Waisman Y, Klein BL, Boenning DA, Young GM, Chamberlain JM, O’Donnel
R, Ochsenschlager DW. Prospective randomised double-blind study comparing Lepinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis
(croup), Pediatrics. 1992; 89: (2), 302-306.
Guideline developed by:
Insert authors and responsible body
Authors:
Janet Youd: Nurse Consultant
Group name
Paediatric Consultants
A&E Consultants
List of interested groups
Information Requires
only
Sign-off


DATS
Medicines management committee
Clinical Guidelines Steering Group
Date signed off


Distribution list and areas where guideline should be readily available
Listing first the intranet or internet site then other sites.
 Intranet
 A&E
Draft Version 1.0 May 06
Page 14 of 16
Management of Croup in children aged over three months
Arrangements for training
Training coordinator:
Janet Youd
Groups requiring training:
A& E Doctors and nurses Paediatric doctors and
nurses
Frequency of training:
Initial implementation of guidelines then updates as guidelines reviewed
Draft Version 1.0 May 06
Page 15 of 16
Management of Croup in children aged over three months
List of changes and dates of changes
Date change Change (with paragraph reference)
implemented
Draft Version 1.0 May 06
Page 16 of 16
Who
is Full signresponsible for off required
change
(no or fully
signed off)