How Severe is Your Child’s Croup?

Viral croup is a childhood illness that can occur in infants as young as 3 months or as old as 12 to 15 years although it is most common in children from 6 months to four years of age.

It may start with the sudden onset of a barking cough (like a seal). Frequently, there is noisy breathing on inspiration (called an inspiratory stridor). There may be hoarseness and the child may have trouble breathing.

The child may have retractions. Retractions, the inward movement of the skin of the chest wall or the inward movement of the breastbone (sternum) during inspiration, is an abnormal breathing pattern. See the blog post Retractions—A Serious Sign of Trouble Breathing In Infants and Children at


There are four stages of croup: Mild, moderate, severe, and impending respiratory failure. We can use the Westley Croup Score to characterize severity. Mild croup has a score of less than four. Moderate croup is a score of four to six. Severe croup is a score of seven or more. And impending respiratory failure is a child appearing lethargic, drowsy, or out of it.

The Westley Croup Score

Inspiratory stridor:
Not present – 0 points.
When agitated/active – 1 point.
At rest – 2 points.

Intercostal retractions:
None – 0 points
Mild – 1 point.
Moderate – 2 points.
Severe – 3 points.

Air entry:
Normal – 0 points.
Mildly decreased – 1 point.
Severely decreased – 2 points.

None – 0 points.
With agitation/activity – 4 points.
At rest – 5 points.

Level of consciousness:
Normal – 0 points.
Altered – 5 points.
Possible score 0-17: <4 = mild croup, 4-6 = moderate croup, >6 =severe croup.


Oxygen should be given to children who are having trouble breathing. The oxygen saturation should checked with an oximeter (a painless device placed on the child’s finger). Mist therapy has not been found to help. Children who are agitated or upset (signs of significant trouble breathing) or with significant retractions should receive a nebulizer treatment with racemic epinephrine.

All children diagnosed with viral croup (even those with mild croup and only a barky cough should be treated with dexamethasone (a medicine related to cortisone).

If a child is still having a lot of trouble,significant retractions, or an audible stridor (inspiratory noise) four hours after receiving the dexamethasone, he or she should be admitted to the hospital.

It may be a good idea to admit children who live a long way from the hospital or who don’t have reliable transportation. A second visit to the emergency department for this episode of croup may be a good reason to admit the child.

Another post that you might find helpful is Serious Breathing Problems in Children at

If you’d like to learn more about croup see the Guideline for the Diagnosis and Treatment of Croup at:$File/CROUP.PDF

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