Croup (Viral Laryngotracheobronchitis)

Croup is caused by parainfluenza virus causing subglottic oedema, producing the characteristic barking cough and inspiratory stridor. Most common in children aged 6 months–3 years. Severity is graded by the Westley score. All children requiring…

Westley Croup Score

The pathway

1 · Westley score

0–2: mild
3–5: moderate
≥6: severe

Assess: stridor (0–2), recession (0–3), air entry (0–2), cyanosis (0–4), consciousness (0–5).

2 · Do not distress the child

Keep with parent, minimal examination. Do NOT examine throat if severe — risk of complete obstruction. Do NOT lay flat.

3 · Oral dexamethasone

0.15mg/kg PO (max 8mg) for all children requiring hospital assessment. Single dose. Effect within 30 min, lasts 12–24h.

4 · Nebulised adrenaline (moderate-severe)

Adrenaline 1:1000, 0.5ml/kg (max 5ml) via nebuliser. Onset <30 min. Observe for 2–4h post-nebuliser (rebound effect).

5 · Anaesthetics if severe

Westley ≥6, SpO₂ falling, exhaustion — call anaesthetics for controlled intubation. Do NOT attempt uncontrolled intubation on a ward.

6 · Exclude epiglottitis

Unimmunised child, drooling, high fever, toxic — suspect epiglottitis (H. influenzae). Do not examine throat. Anaesthetics + ENT urgently.

Drugs

Drug	Dose	Route	Notes
Dexamethasone	0.15mg/kg	PO	Max 8mg. Single dose. Oral is as effective as nebulised budesonide.
Adrenaline 1:1000	0.5ml/kg (max 5ml)	Nebulised	For moderate-severe. Observe 2–4h post for rebound. Repeat PRN.
Budesonide	2mg	Nebulised	Alternative if unable to swallow. Less evidence than oral dexamethasone.

When to escalate

Westley ≥6 or SpO₂ dropping — call anaesthetics, prepare for intubation,Drooling, toxic, unimmunised — suspect epiglottitis: anaesthetics + ENT immediately,No response to nebulised adrenaline — PICU referral,Recurrent croup — consider subglottic stenosis, refer ENT

Reference: NICE Evidence: Croup / Westley Croup Score / BNFc

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