Paeds · respiratory-sleep-and-airway
Croup
Also known as Laryngotracheobronchitis · Viral croup · Acute laryngotracheitis · Spasmodic croup · Barking cough illness
Fellowship guide to croup (viral laryngotracheobronchitis): the parainfluenza-driven subglottic oedema that gives a barking cough, inspiratory stridor and a hoarse voice in a young child; the Westley score; the discriminators from epiglottitis, bacterial tracheitis and foreign body; steroid for every child, nebulised adrenaline for stridor at rest, calm handling, observation and disposition; and the ANZ, UK and North American guideline differences.
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Target exams
Red flags
- Inspiratory stridor and increased work of breathing at rest — this child has at least moderate croup, needs steroid now and observation, and must not be sent home before reassessment
- A rising respiratory rate that then falls with a tiring, drowsy or pale child — the ominous sign of a failing airway, not of improvement; call the airway team
- A silent chest with poor air entry in a child who was stridulous — impending respiratory arrest; prepare for a difficult airway with senior anaesthetic and ENT support
- A toxic, drooling child sitting forward who will not cough — think epiglottitis or bacterial tracheitis, do not examine the throat, and mobilise the airway team
- Stridor that does not respond, or responds only briefly, to nebulised adrenaline and steroid — reconsider the diagnosis and escalate rather than repeating treatment indefinitely
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Acute respiratory illness
- Upper airway obstruction and stridor
- Current 2026 PREP curriculum — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Acute and critical care
- Paediatric airway and acute respiratory competencies
- Clinical Applications
- Acute paediatrics and the upper airway
- Short Cases
- Acute assessment scenarios
- Communication scenarios
- 4. Professional skills and knowledge: Patient management
- 6. Acute and emergency care
- General Paediatrics: Recognises and manages upper airway obstruction
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Acute respiratory illness; stridor
- Clinical
- History and management planning
- Acute airway assessment
- General Pediatrics Content Outline — Domain 2: Emergency Medicine
- General Pediatrics Content Outline — Domain 17: Respiratory System
- General Pediatrics EPA: Assess and manage the acutely ill child
- Patient Care 1: History and Physical Examination
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Emergency and acute care
- Medical Knowledge 1: Clinical Knowledge
- Systems-Based Practice: escalation and airway teamwork
- Medical Expert
- Communicator
- Collaborator
- Scholar
- Pediatrics: Core EPA — Assess and manage the acutely ill child with respiratory distress
Overview & Definition
Picture the two-year-old whose parents wake at 2 a.m. to a strange seal-like bark and a high-pitched noise every time she breathes in. She had a runny nose and a low fever yesterday, she is frightened but not toxic, and the noise softens when her mother holds her still. That midnight scene — the barking cough, the inspiratory stridor and the hoarse voice in a well-ish young child with a viral prodrome — is croup, and recognising it quickly is what separates a calm steroid-and-observe pathway from a panicked airway. [1] [2]
Croup is an acute viral infection of the larynx, trachea and (to a lesser extent) the bronchi, so its full name, laryngotracheobronchitis, tells you where the trouble is. The inflammation and oedema concentrate in the subglottis, the narrowest part of a young child's airway, which is why a modest amount of swelling produces a disproportionate amount of noise and obstruction. [1] [9]
Why this matters at fellowship level is that croup is one of the commonest causes of acute upper-airway obstruction in early childhood, it is almost always self-limiting, and the modern evidence base has made it a model of high-value care: a single dose of a cheap steroid changes the trajectory, and the real skill is recognising the small minority who are deteriorating and the mimics that masquerade as croup. [3] [10]
References11ShowHide
- [1]Bjornson CL, Johnson DW. Croup. Lancet, 2008.PMID 18295000
- [2]Bjornson CL, Johnson DW. Croup in children. CMAJ, 2013.PMID 23939212
- [3]Gates A, Gates M, Vandermeer B, et al. Glucocorticoids for croup in children. Cochrane Database Syst Rev, 2018.PMID 30133690
- [4]Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane Database Syst Rev, 2011.PMID 21249651
- [5]Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med, 2004.PMID 15385657
- [6]Dobrovoljac M, Geelhoed GC. 27 years of croup: an update highlighting the effectiveness of 0.15 mg/kg of dexamethasone. Emerg Med Australas, 2009.PMID 19682017
- [7]Bjornson C, Russell K, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev, 2013.PMID 24114291
- [8]Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child, 1978.PMID 347921
- [9]Petrocheilou A, Tanou K, Kalampouka E, et al. Viral croup: diagnosis and a treatment algorithm. Pediatr Pulmonol, 2014.PMID 24596395
- [10]Johnson DW. Croup. BMJ Clin Evid, 2014.PMID 25263284
- [11]Fernandes RM, Wingert A, Vandermeer B, et al. Safety of corticosteroids in young children with acute respiratory conditions: a systematic review and meta-analysis. BMJ Open, 2019.PMID 31375615