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peds.croup.v1PRODUCTION
peds.croup.v1

Pediatric Croup (Laryngotracheobronchitis)

pediatricsacutepediatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm acute croup (subglottic — barky cough + inspiratory stridor + hoarseness, URI prodrome, 6 mo-6 yr) vs epiglottitis (supraglottic, drooling, tripod, muffled voice, toxic) / bacterial tracheitis / foreign body / anaphylaxis / retropharyngeal abscess as the dominant diagnosis (AAP/CPS pediatric croup CPG)

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Croup framing confirmed; epiglottitis / tracheitis mimics noted

Patient inputs (18)

Typical croup 6 mo-6 yr (peak 6-36 mo); age <6 mo or >6 yr is atypical and flags possible subglottic stenosis / airway anomaly (contemporary croup reviews)

Gradual onset after a 12-48 h URI prodrome favors croup; abrupt afebrile choking favors foreign body; rapid toxic onset favors epiglottitis/tracheitis (AAP/CPS pediatric croup CPG)

Tachycardia from distress / fever / nebulized epinephrine; baseline + post-epinephrine monitoring (AAP/CPS pediatric croup CPG)

Low-grade fever typical of viral croup; high fever + toxic supports the bacterial-tracheitis pivot (AAP/CPS pediatric croup CPG)

Steroid / β-lactam allergy clarification for the bacterial-tracheitis branch; baseline meds (AAP/CPS pediatric croup CPG)

Barky/"seal-bark" cough is the cardinal croup feature; its presence + absence of drooling/tripod/muffled voice shifts strongly away from epiglottitis (AAP/CPS pediatric croup CPG)

Stridor at rest (vs only with agitation/crying) is the pivotal moderate+ severity discriminator — drives steroid-only vs steroid+epinephrine+observe (AAP/CPS pediatric croup CPG)

Retractions / accessory use / decreasing air entry — Westley components + severity trajectory (AAP/CPS pediatric croup CPG)

Agitation → lethargy / fatigue = pre-arrest pivot (escalates severe → impending respiratory failure) (AAP/CPS pediatric croup CPG)

Biphasic stridor + toxic appearance + high fever + thick purulent secretions + poor steroid/epinephrine response = bacterial-tracheitis pivot (NOT viral croup) (AAP/CPS pediatric croup CPG)

Hypoxia (SpO2 drop) is a LATE sign in croup — do not wait for desaturation to escalate (AAP/CPS pediatric croup CPG)

Westley croup score (consciousness + cyanosis + stridor + air entry + retractions): mild ≤2 / moderate 3-7 / severe ≥8 — drives the regimen tier; computed inline (no canonical calc id) (AAP/CPS pediatric croup CPG)

Dexamethasone (mg/kg), nebulized epinephrine (L-epi mL/kg), and bacterial-tracheitis antibiotics are all weight-based (AAP/CPS pediatric croup CPG)

Tracheal aspirate / bronchoscopic culture obtained ONLY in the bacterial-tracheitis pathway to direct antibiotic narrowing (AAP/CPS pediatric croup CPG)

Recurrent (≥3) / spasmodic episodes or prior intubation flags atypical course → subglottic-stenosis / airway-anomaly evaluation (contemporary croup reviews)

Pre-existing subglottic stenosis / prior prolonged intubation predisposes to severe/recurrent croup and changes airway planning (contemporary croup reviews)

Hib / routine immunization status modifies the bacterial-tracheitis / epiglottitis differential prior (AAP/CPS pediatric croup CPG)

AP neck radiograph "steeple sign" ONLY if diagnosis uncertain + child stable — rendered inline; poor sens/spec; a normal film does NOT exclude croup; never delay treatment of a distressed child (AAP/CPS pediatric croup CPG)

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Severity triggers (6)

6 need judgement
  • informationallife_threateningimpending_respiratory_failure_croup
    Impending respiratory failure — lethargy / decreasing air entry / dusky-cyanotic / marked fatigue / falling SpO2 (a clinical state independent of the numeric Westley tier) (AAP/CPS pediatric croup CPG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningbacterial_tracheitis_pivot
    Bacterial-tracheitis overlay — toxic appearance + high fever + biphasic stridor + thick purulent tracheal secretions + POOR response to corticosteroid + nebulized epinephrine (S. aureus incl. MRSA, S. pyogenes, Moraxella, H. influenzae) — this is NOT viral croup (AAP/CPS pediatric croup CPG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_croup_westley_ge_8
    Severe croup — Westley ≥8 (marked stridor at rest + marked retractions + agitation + decreased air entry) (AAP/CPS pediatric croup CPG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemoderate_croup_westley_3_to_7
    Moderate croup — Westley 3-7 (stridor at rest + retractions, no/minimal agitation, no impending-failure signs) (AAP/CPS pediatric croup CPG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_or_atypical_subglottic_stenosis_flag
    Recurrent (≥3 episodes) / atypical croup — age <6 mo or >6 yr, baseline biphasic stridor, prior prolonged intubation, or repeated failure to respond — flags possible congenital/acquired subglottic stenosis or airway anomaly (contemporary croup reviews)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildmild_croup_westley_le_2
    Mild croup — Westley ≤2 (barky cough, no stridor at rest, normal air entry, no/minimal retractions) (AAP/CPS pediatric croup CPG; Bjornson NEJM mild-croup RCT)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives severity classification
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Recommended regimen

Corticosteroids — single dose for ALL severities including mild (dexamethasone PO/IM/IV first-line; prednisolone alternative; nebulized budesonide if vomiting) (Cochrane glucocorticoids-for-croup; Bjornson NEJM mild-croup RCT; AAP/CPS pediatric croup CPG)
axis: peds_croup_corticosteroids
Selected axis "Corticosteroids — single dose for ALL severities including mild (dexamethasone PO/IM/IV first-line; prednisolone alternative; nebulized budesonide if vomiting) (Cochrane glucocorticoids-for-croup; Bjornson NEJM mild-croup RCT; AAP/CPS pediatric croup CPG)" by default fallback (first axis)
  • dexamethasone
    first line
    corticosteroid_systemic
    0.15-0.6 mg/kg PO/IM/IV SINGLE dose (commonly 0.6 mg/kg; max 16 mg) — 0.15 mg/kg non-inferior in dose-finding trials; PO preferred (= IM efficacy, less invasive) • PO/IM/IV • single dose (all severities including mild) (max: 16 mg single dose)
    triggers: any_clinical_croup_any_severity_including_mild
    Cochrane glucocorticoids-for-croup — ↓ Westley score at 6-12 h, ↓ return visits, ↓ admissions/LOS, ↓ subsequent epinephrine use; Bjornson NEJM established benefit specifically in MILD croup
    rxcui 3264
  • prednisolone
    contraindication substitute
    corticosteroid_systemic
    1-2 mg/kg PO once (consider a 2nd-day dose given shorter half-life vs dexamethasone) • PO • once ± 2nd-day dose
    triggers: dexamethasone_unavailable, parental_preference_or_palatability
    Acceptable alternative where dexamethasone is unavailable; shorter half-life may warrant a 2nd-day dose (Cochrane glucocorticoids-for-croup); RxCUI omitted pending RxNav validation per task contract
  • budesonide (nebulized)
    second line
    corticosteroid_inhaled
    2 mg nebulized once • inhaled • single dose
    triggers: vomiting_child_cannot_retain_oral_steroid, oral_retention_uncertain_or_iv_undesirable
    Equivalent to oral dexamethasone in trials but costlier — reserved for the vomiting child / uncertain oral retention (Cochrane glucocorticoids-for-croup); RxCUI omitted pending RxNav validation per task contract

ed playbook — drug actions (5)

  1. 1. keep child calm with caregiver + humidified/cool air; supplemental O2 only if hypoxic
    position of comfort • supportive • continuous
    trigger: All croup — agitation worsens dynamic obstruction
    Calm child; O2 for hypoxia (AAP/CPS pediatric croup CPG)
  2. 2. dexamethasone — ALL severities including mild
    rxcui 3264
    0.15-0.6 mg/kg PO/IM/IV single (commonly 0.6 mg/kg, max 16 mg) • PO/IM/IV • single dose
    trigger: Any clinical croup
    Cochrane + Bjornson NEJM — benefit across severities incl. mild
  3. 3. nebulized epinephrine (L-epi 1:1000 OR racemic 2.25%) — moderate-severe
    rxcui 3992
    L-epi 0.5 mL/kg 1:1000 (max 5 mL) OR racemic 0.5 mL 2.25% • inhaled • single; may repeat for severe/impending
    trigger: Westley ≥3 / stridor at rest
    Rapid α-mediated improvement; pair with steroid (nebulized-epinephrine RCT evidence)
  4. 4. mandatory 3-4 h observation for rebound after epinephrine
    continuous observation + serial Westley • supportive • after each epinephrine dose
    trigger: Any epinephrine given
    Rebound by ~2 h; back-to-mild at 3-4 h with reliable follow-up → safe discharge (AAP/CPS pediatric croup CPG)
  5. 5. bacterial tracheitis → empiric vancomycin + ceftriaxone + ENT/bronchoscopy
    rxcui 11124
    vancomycin 60-80 mg/kg/day IV q6-8h (AUC 400-600) + ceftriaxone 50-100 mg/kg/day IV • IV • q6-8h / daily
    trigger: Toxic + biphasic stridor + purulent secretions + poor steroid/epinephrine response
    Bacterial tracheitis is antibiotics + airway, NOT steroid/epinephrine (AAP/CPS pediatric croup CPG; Rybak IDSA 2020 PMID 32191793)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Barky/"seal-bark" cough ± hoarse voice — classic croup recognition, typically nocturnal worsening after a URI prodrome (AAP/CPS pediatric croup CPG); Inspiratory stridor in a 6 mo-6 yr child (at rest = moderate+ severity) (AAP/CPS pediatric croup CPG); 12-48 h URI prodrome then barky cough + stridor worse at night (AAP/CPS pediatric croup CPG).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pediatric Croup (Laryngotracheobronchitis)** (peds.croup.v1).
Phenotype framing: Croup vs epiglottitis (drooling + tripod + muffled "hot-potato" voice + toxic + NO barky cough) vs bacterial tracheitis (toxic + biphasic stridor + thick purulent secretions + poor steroid/epinephrine response) vs foreign body (abrupt + afebrile + choking) vs anaphylaxis (urticaria + exposure + angioedema) vs retropharyngeal abscess (neck stiffness + dysphagia) — pivot findings encoded (AAP/CPS pediatric croup CPG)
Scope: Confirm acute croup (subglottic — barky cough + inspiratory stridor + hoarseness, URI prodrome, 6 mo-6 yr) vs epiglottitis (supraglottic, drooling, tripod, muffled voice, toxic) / bacterial tracheitis / foreign body / anaphylaxis / retropharyngeal abscess as the dominant diagnosis (AAP/CPS pediatric croup CPG)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Corticosteroids — single dose for ALL severities including mild (dexamethasone PO/IM/IV first-line; prednisolone alternative; nebulized budesonide if vomiting) (Cochrane glucocorticoids-for-croup; Bjornson NEJM mild-croup RCT; AAP/CPS pediatric croup CPG)**.
1. dexamethasone 0.15-0.6 mg/kg PO/IM/IV SINGLE dose (commonly 0.6 mg/kg; max 16 mg) — 0.15 mg/kg non-inferior in dose-finding trials; PO preferred (= IM efficacy, less invasive) PO/IM/IV single dose (all severities including mild) (corticosteroid_systemic, first line) — Cochrane glucocorticoids-for-croup — ↓ Westley score at 6-12 h, ↓ return visits, ↓ admissions/LOS, ↓ subsequent epinephrine use; Bjornson NEJM established benefit specifically in MILD croup
2. prednisolone 1-2 mg/kg PO once (consider a 2nd-day dose given shorter half-life vs dexamethasone) PO once ± 2nd-day dose (corticosteroid_systemic, contraindication substitute) — Acceptable alternative where dexamethasone is unavailable; shorter half-life may warrant a 2nd-day dose (Cochrane glucocorticoids-for-croup); RxCUI omitted pending RxNav validation per task contract
3. budesonide (nebulized) 2 mg nebulized once inhaled single dose (corticosteroid_inhaled, second line) — Equivalent to oral dexamethasone in trials but costlier — reserved for the vomiting child / uncertain oral retention (Cochrane glucocorticoids-for-croup); RxCUI omitted pending RxNav validation per task contract

Setting playbook (ed) — Recognize croup, keep the child calm, stratify by Westley score, give dexamethasone to ALL, add nebulized epinephrine + 3-4 h observation for moderate-severe, recognize the impending-failure / bacterial-tracheitis pivots, and decide discharge vs admit (AAP/CPS pediatric croup CPG; Cochrane; Bjornson NEJM)
4. keep child calm with caregiver + humidified/cool air; supplemental O2 only if hypoxic position of comfort supportive continuous — All croup — agitation worsens dynamic obstruction (Calm child; O2 for hypoxia (AAP/CPS pediatric croup CPG))
5. dexamethasone — ALL severities including mild 0.15-0.6 mg/kg PO/IM/IV single (commonly 0.6 mg/kg, max 16 mg) PO/IM/IV single dose — Any clinical croup (Cochrane + Bjornson NEJM — benefit across severities incl. mild)
6. nebulized epinephrine (L-epi 1:1000 OR racemic 2.25%) — moderate-severe L-epi 0.5 mL/kg 1:1000 (max 5 mL) OR racemic 0.5 mL 2.25% inhaled single; may repeat for severe/impending — Westley ≥3 / stridor at rest (Rapid α-mediated improvement; pair with steroid (nebulized-epinephrine RCT evidence))
7. mandatory 3-4 h observation for rebound after epinephrine continuous observation + serial Westley supportive after each epinephrine dose — Any epinephrine given (Rebound by ~2 h; back-to-mild at 3-4 h with reliable follow-up → safe discharge (AAP/CPS pediatric croup CPG))
8. bacterial tracheitis → empiric vancomycin + ceftriaxone + ENT/bronchoscopy vancomycin 60-80 mg/kg/day IV q6-8h (AUC 400-600) + ceftriaxone 50-100 mg/kg/day IV IV q6-8h / daily — Toxic + biphasic stridor + purulent secretions + poor steroid/epinephrine response (Bacterial tracheitis is antibiotics + airway, NOT steroid/epinephrine (AAP/CPS pediatric croup CPG; Rybak IDSA 2020 PMID 32191793))

Non-pharmacologic actions:
- Do NOT agitate the child with unnecessary exams/procedures — dynamic subglottic obstruction worsens with crying (AAP/CPS pediatric croup CPG)
- AP neck radiograph (steeple sign) ONLY if diagnosis uncertain + child stable, rendered inline; normal film does NOT exclude croup (AAP/CPS pediatric croup CPG)
- Pivot to peds.epiglottitis.v1 if drooling + tripod + muffled voice + toxic + NO barky cough (AAP/CPS pediatric croup CPG)
- Prepare airway (smaller-than-predicted ETT, ENT/anesthesia) for impending respiratory failure (AAP/CPS pediatric croup CPG)

AVOID / contraindication checks:
- Steroid_for_all_severities_including_mild_benefit_exceeds_single_dose_risk (Cochrane glucocorticoids for croup; Bjornson NEJM)
- Po_route_equivalent_to_im_prefer_least_invasive_tolerated (Cochrane glucocorticoids for croup)
- Budesonide_reserved_for_vomiting_child_not_routine_first_line (AAP/CPS pediatric croup CPG)
- Steroid_is_not_a_substitute_for_epinephrine_or_airway_in_moderate_severe (AAP/CPS pediatric croup CPG)
- Bacterial_tracheitis_steroid_not_primary_treat_with_antibiotics_and_airway (AAP/CPS pediatric croup CPG)

Monitoring

Regimen monitoring:
- serial westley score response by 6 to 12h (Cochrane glucocorticoids-for-croup)
- reduced need for repeat epinephrine after steroid (Cochrane glucocorticoids-for-croup)
- tolerance of oral dose switch to budesonide if vomiting (AAP/CPS pediatric croup CPG)
- return visit surveillance after discharge (Bjornson NEJM mild-croup RCT)

Setting (ed) monitoring:
- Serial Westley score + stridor-at-rest reassessment after each intervention (AAP/CPS pediatric croup CPG)
- Continuous SpO2 + HR during/after nebulized epinephrine (AAP/CPS pediatric croup CPG)
- 3-4 h observation after each epinephrine dose for rebound (nebulized-epinephrine RCT evidence)

Follow-up plan: Caregiver education (calm child, cool/humidified air comfort measure, course 3-7 d with nocturnal peak), return precautions (stridor at rest, marked retractions, drooling, lethargy, poor intake, cyanosis); recurrent/atypical or subglottic-stenosis flag → ENT / airway (flexible-or-rigid laryngoscopy/bronchoscopy) evaluation; complete antibiotics if bacterial tracheitis; primary-care follow-up (AAP/CPS pediatric croup CPG)
- Close-out criterion: Education + return precautions + ENT/airway plan (if flagged) documented

Monitoring phase: ED: continuous observation 3-4 h after EACH nebulized-epinephrine dose for rebound, serial Westley score, SpO2, work of breathing. Inpatient/PICU: continuous SpO2, work of breathing, response to therapy, secured-tube monitoring if intubated, bacterial-tracheitis secretion/airway monitoring (AAP/CPS pediatric croup CPG)

Disposition

Current setting: ed — Recognize croup, keep the child calm, stratify by Westley score, give dexamethasone to ALL, add nebulized epinephrine + 3-4 h observation for moderate-severe, recognize the impending-failure / bacterial-tracheitis pivots, and decide discharge vs admit (AAP/CPS pediatric croup CPG; Cochrane; Bjornson NEJM)

Disposition criteria:
- Discharge: mild OR back to mild at 3-4 h post-epinephrine, no stridor at rest, normal SpO2, tolerating PO, reliable caregiver + return precautions (AAP/CPS pediatric croup CPG)
- Admit: persistent stridor at rest, hypoxia, ≥2 epinephrine doses, poor PO, unreliable follow-up (AAP/CPS pediatric croup CPG)

Escalation triggers (move to higher acuity):
- Impending respiratory failure (lethargy / ↓ air entry / dusky / fatigue) → prepare airway + PICU (AAP/CPS pediatric croup CPG)
- ≥2 epinephrine doses or persistent stridor at rest → admit (AAP/CPS pediatric croup CPG)
- Bacterial-tracheitis pivot → antibiotics + ENT/bronchoscopy + PICU (AAP/CPS pediatric croup CPG)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Impending respiratory failure — lethargy / decreasing air entry / dusky-cyanotic / marked fatigue / falling SpO2 (a clinical state independent of the numeric Westley tier) (AAP/CPS pediatric croup CPG)
- [LIFE_THREATENING] Bacterial-tracheitis overlay — toxic appearance + high fever + biphasic stridor + thick purulent tracheal secretions + POOR response to corticosteroid + nebulized epinephrine (S. aureus incl. MRSA, S. pyogenes, Moraxella, H. influenzae) — this is NOT viral croup (AAP/CPS pediatric croup CPG)
- [SEVERE] Severe croup — Westley ≥8 (marked stridor at rest + marked retractions + agitation + decreased air entry) (AAP/CPS pediatric croup CPG)

Citations

- Contemporary AAP / CPS / Alberta-Toronto pediatric croup CPG (Westley severity; dexamethasone for ALL severities; nebulized epinephrine + mandatory 3-4 h observation for moderate-severe; supportive care; bacterial-tracheitis pivot; return precautions) + Cochrane glucocorticoids-for-croup (Gates/Russell) + Bjornson NEJM mild-croup dexamethasone RCT + nebulized-epinephrine racemic-vs-L-epinephrine equivalence RCT; vancomycin AUC per Rybak IDSA 2020 for the bacterial-tracheitis branch [PMID:32191793](https://pubmed.ncbi.nlm.nih.gov/32191793/)
- Cited evidence (PMID 15213107) [PMID:15213107](https://pubmed.ncbi.nlm.nih.gov/15213107/)
- Cited evidence (PMID 21975746) [PMID:21975746](https://pubmed.ncbi.nlm.nih.gov/21975746/)
- Cited evidence (PMID 29243064) [PMID:29243064](https://pubmed.ncbi.nlm.nih.gov/29243064/)
- Cited evidence (PMID 1538775) [PMID:1538775](https://pubmed.ncbi.nlm.nih.gov/1538775/)

Last reconciled with current guidelines: 2026-05-15.
References
  • Contemporary AAP / CPS / Alberta-Toronto pediatric croup CPG (Westley severity; dexamethasone for ALL severities; nebulized epinephrine + mandatory 3-4 h observation for moderate-severe; supportive care; bacterial-tracheitis pivot; return precautions) + Cochrane glucocorticoids-for-croup (Gates/Russell) + Bjornson NEJM mild-croup dexamethasone RCT + nebulized-epinephrine racemic-vs-L-epinephrine equivalence RCT; vancomycin AUC per Rybak IDSA 2020 for the bacterial-tracheitis branch — PMID:32191793
  • Cited evidence (PMID 15213107) — PMID:15213107
  • Cited evidence (PMID 21975746) — PMID:21975746
  • Cited evidence (PMID 29243064) — PMID:29243064
  • Cited evidence (PMID 1538775) — PMID:1538775