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Croup is a common respiratory illness affecting 3% of children six months to three years of age. It accounts for 7% of hospitalizations annually for fever and/or acute respiratory illness in children younger than five years. Croup is a manifestation of upper airway obstruction resulting from swelling of the larynx, trachea, and bronchi, leading to inspiratory stridor and a barking cough. Many patients experience low-grade fevers, but fever is not necessary for diagnosis. Less commonly, stridor can be associated with acute epiglottitis, bacterial tracheitis, and foreign body airway obstruction. Laboratory studies are seldom needed for diagnosis of croup. Viral cultures and rapid antigen testing have minimal impact on management and are not routinely recommended. Radiography and laryngoscopy should be reserved for patients in whom alternative diagnoses are suspected. Randomized controlled trials have demonstrated that a single dose of oral, intramuscular, or intravenous dexamethasone improves symptoms and reduces return visits and length of hospitalization in children with croup of any severity. In patients with moderate to severe croup, the addition of nebulized epinephrine improves symptoms and reduces length of hospitalization.

Viral croup is the most common form of airway obstruction in children six months to six years of age. The frightening nature of croup often prompts parents and caregivers to seek physician consultation. For children with mild croup, symptomatic care and mist therapy may be all that is necessary. Epinephrine has been used for decades to treat more severe cases of croup, but recent meta-analyses have found that glucocorticoid use is associated with shorter hospital stays, improvement in croup scores, and less use of epinephrine. Studies have shown that treatment with 0.6 mg per kg of oral dexamethasone is as effective as intramuscular dexamethasone or 2 mg of nebulized budesonide. Oral dexamethasone in dosages as low as 0.15 mg per kg also may be effective. While more studies are needed to establish guidelines, oral dexamethasone can be used to treat mild to moderate croup with close follow-up and instructions for further care, if needed.

Croup is a common childhood disease that has no specific diagnostic test. It must be differentiated from life-threatening diseases, such as epiglottitis, that demand specific interventions. A high degree of toxicity, the presence of dysphagia and the absence of cough help distinguish epiglottitis from croup. The usefulness and safety of visualization of the epiglottis in patients with croup are controversial. Clinical recognition of respiratory distress and failure is vital. Hypoxia is common. Pulse oximetry is helpful in the assessment of hypoxia, but readings do not correlate with clinical status or respiratory failure. Although studies have not proved that mist therapy is beneficial, the efficacy of racemic epinephrine is well documented. High dose corticosteroids have proved effective in the treatment of croup. Outpatient use of racemic epinephrine and steroids remains controversial.

Spasmodic croup has a sudden onset, almost always at night, and usually responds well to humidification. Laryngotracheobronchitis is the most common form of the croup syndrome; children with this disease generally do well, although some require hospitalization and intubation. Bacterial tracheitis may mimic severe laryngotracheobronchitis; diagnosis is usually established during visualization of the airway. Epiglottitis is rare but is often life-threatening.