Chapter 4.6.1 Viral croup

Croup causes obstruction in the upper airway which, when severe, can be life-threatening. Most severe episodes occur in children < 2 years of age.  this section deals with croup caused by various respiratory viruses. For croup associated with measles, see section 6.4.1.


Mild croup is characterized by:

  • fever
  • a hoarse voice
  • a barking or hacking cough
  • stridor that is heard only when the child is agitated.

Severe croup is characterized additionally by:

  • stridor even when the child is at rest
  • rapid breathing and lower chest indrawing
  • cyanosis or oxygen saturation < 90%


Mild croup can be managed at home with supportive care, including encouraging oral fluids, breastfeeding or feeding, as appropriate.

A child with severe croup should be admitted to hospital for treatment as follows:

 Steroid treatment. Give one dose of oral dexamethasone (0.6 mg/kg) or equivalent dose of some other steroid: dexamethasone or prednisolone.  If available, use nebulized budesonide at 2 mg.  Start the steriods as soon as possible.  It is preferable to dissolve the tablet in a spoonful of water for children unable to swallow tablets.  Repeat the dose of steroid for children who vomit.

Antibiotics. These are not effective and should not be given.

Monitor the child closely and ensure that facilities for an emergency intubation and/or tracheostomy are  available immediately if required, as airway obstruction can occur suddenly.

In a child with severe croup who is deteriorating, consider the following:

Intubation and/or tracheostomy: If there are signs of incipient complete airway obstruction, such as severe lower chest wall indrawing and restlessness, intubate the child immediately.

If this is not possible, transfer the child urgently to a hospital where intubation or emergency tracheostomy can be done. Tracheostomy should be done only by experienced staff.

Avoid using oxygen unless there is incipient airway obstruction. Signs such as severe lower chest wall indrawing and restlessness are more likely to indicate the need for intubation or tracheostomy than oxygen. Nasal prongs or a nasal or nasopharyngeal catheter can upset the child and precipitate obstruction of the airway.

However, oxygen should be given if there is incipient complete airway obstruction and intubation or tracheostomy is deemed necessary. Call for help from an anaesthetist and surgeon to intubate or perform a tracheostomy.

Supportive care

  • Keep the child calm, and avoid disturbance as much possible.
  • If the child has fever (> 39 °C or > 102.2 °F) that appears to be causing
    distress, give paracetamol.
  • Encourage breastfeeding and oral fluids. Avoid parenteral fluids, as this involves placing an IV cannula, which can cause distress that might precipitate complete airway obstruction.
  • Encourage the child to eat as soon as food can be taken.
  • Avoid using mist tents, which are not effective, which separate the child from the parents and which make observation of the child’s condition difficult. Do not give sedatives or antitussive medicines.


The child’s condition, especially respiratory status, should be assessed by nurses every 3 h and by doctors twice a day. The child should occupy a bed close to the nursing station, so that any sign of incipient airway obstruction can be detected as soon as it develops.