Croup-like symptoms

Problem representation

A child of 18 months with a 12 to 24-hour history of respiratory difficulty.

Hypothesis generation 

Croup is the commonest cause of inspiratory stridor and tends to manifest itself with cough and difficult/noisy breathing. This can be a frightening experience for parents and the child. It is important to differentiate croup from other problems that cause upper airway obstruction, as most are medical emergencies.

Likely diagnosis 

• Croup 

Critical diagnosis  

• Anaphylaxis
• Bacterial tracheitis
• Epiglottitis
• Foreign-body aspiration (tracheal, oesophageal)
• Peritonsillar abscess
• Retropharyngeal abscess.

Continued information gathering 

A good understanding of how these different conditions present is needed (see Table 1 below) to help discriminate one problem from another.

We already know that her son has had a cough for up to 24 hours. This is diagnostically useful as cough associated with foreign body aspiration, anaphylaxis and epiglottitis presents with very sudden onset. These conditions are therefore unlikely to be the cause of his cough in this case. 

You ask the mother to describe what the cough sounds like and whether she has noticed any other problems before or during the bouts of coughing. She says he has had a mild fever and runny nose for a few days and the cough has a bark-like quality. This supports croup as the diagnosis as there is often a history of prodromal symptoms and the cough is often described as having a barking/seal-like quality. 

The presence of fever means a diagnosis of a foreign body or anaphylaxis is now very unlikely and the cough suggests abscess is not the cause. A negative history of drooling eliminates epiglottitis. 

Table 1: Condition summary of croup and conditions presenting with croup-like symptoms
	Croup	Tracheitis	Epiglottitis	Foreign body aspiration	Anaphylaxis	Abscess
Age	6 months to 3 years	Any age	2 to 6 years	< 4 years	Any	Any
Onset	Gradual	Gradual	Sudden	Sudden	Sudden	Gradual
Fever	Low grade fever	High grade fever	High grade fever	None	No	Yes
Nature of cough	Barking	Barking	Muffled, guttural cough (if present)	Barking	N/A	N/A
Swallowing	Normal	Difficult	Very difficult	Variable; depends on site of impaction and degree of blockage	Variable; depends on severity	Normal
Preferred posture	Recumbent	Sitting	Sitting upright	N/A	N/A	N/A
Drooling	No	No	Yes	No	No	Yes