Croup

Croup is the most common cause of upper airway obstruction in children. It is characterized by acute onset of barky cough +/- stridor. The typical age of presentation is between 6 months and 5 years with a peak around 2 years. In children with severe symptoms, poor or transient response to croup treatment, OR presentation outside the typical age range, consider alternative causes of upper airway obstruction, including foreign body, bacterial tracheitis, epiglottitis, and retropharyngeal abscess.

• Give a single dose of PO dexamethasone to ALL children presenting to the ED with croup. Evidence supports 0.15–0.6 mg/kg, but 0.6 mg/kg (MAX 12 mg) is the most widely used dose in practice.
• Use nebulized epinephrine in SEVERE croup to provide transient improvement in upper airway obstruction.
• If oral steroids are not tolerated or are contraindicated, use budesonide 2 mg nebulized (can be administered together with epinephrine, if required).
• Minimize interaction and place the child in a position of comfort (e.g., caregiver’s lap) in a quiet environment, as agitation can precipitate significant respiratory distress.
• X-rays are not routinely needed to diagnose croup but may be useful when considering other diagnoses.
• Do not use antibiotics as croup symptoms are triggered by a viral infection. Treat fever, if required.

• Croup severity scores have been validated for research purposes but not for routine clinical care.
• The key clinical findings that differentiate croup severity and guide management are:

1. 1. Stridor
   2. Indrawing
   3. Level of consciousness (LOC)
   4. Oxygenation

• Altered LOC, hypoxia/cyanosis and/or marked decreased air entry are hallmarks of impending respiratory failure.
• Risk factors for severe croup include: history of previous severe croup, pre-existing narrowing of upper airway, pre-existing reduced airway tone (e.g., Trisomy 21), younger age. Croup is uncommon under 6 months and rare under 3 months, consider alternative diagnosis.

• Absence of inspiratory stridor and signs of respiratory distress (suprasternal, intercostal and/or chest wall indrawing) at rest.
• Caregiver is able to bring child back to the ED if there is any clinical deterioration.
• Provide reassurance and croup education for caregiver, including return to ED instructions. A child in respiratory distress is very scary for both the patient and the caregiver.
• For more information, refer caregivers to the Croup Video: a barky seal-like cough on the TREKK website.

• Persistence of stridor at rest and signs of respiratory distress >4 hours after treatment with dexamethasone and repeated doses of nebulized epinephrine.
• Barriers to patient returning to ED for care.

• Persistent severe croup despite treatment with dexamethasone and 2 doses of nebulized epinephrine OR impending respiratory failure at any time.
• Contact PICU/Pediatric Referral Centre/Transport Team.

Thank you to the following content experts who led the development of the Croup Bottom Line Recommendations:

David W Johnson, MD, Professor Emeritus of Pediatrics; University of Calgary, Cumming School of Medicine.

Jennifer Turnbull, MD, FRCPC, Assistant Professor, Division of Pediatric Emergency Medicine, McGill University Health Centre;  Co-Director, McGill Global Child Health Program; Montreal Children’s Hospital.

Terry Klassen, MD, MSc, FRCPC, Provincial Department Head & Professor, Pediatrics, University of Saskatchewan.

Thank you to the TREKK Editorial Committee, editor Dr. Sarah Reid (CHEO), who provided editorial support and expertise in  the development of this resource. Thank you as well to Mateja Carevic, TREKK Project Coordinator (University of Manitoba) who coordinated the development process.

1. Aregbesola A, Tam CM, Kothari A, et al. Glucocorticoids for croup in children. Cochrane Database Syst Rev. 2023;1:Cd001955.
2. Alberta Medical Association. Diagnosis and Management of Croup, Summary of the Alberta Clinical Practice Guideline.  Update 2014.
3. Bjornson et al. The Cochrane Library and the Treatment of Croup in Children: An Overview of Reviews. Evidence-based Child Health 2012; 5:1555-65

For a complete list of the evidence that informed the creation of the Croup Bottom Line Recommendations see the Evidence Repository here.

The purpose of this document is to provide healthcare professionals with key facts and recommendations for the diagnosis and treatment of community acquired pneumonia in children in the emergency department. The TREKK Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. THIS DOCUMENT IS SUBJECT TO FULL DISCLAIMER HERE: trekk.ca/terms-of-use