Stridor in Children
Acute stridor is a very frightening experience for both child and parents. The respiratory effort can lead to hyperventilation, making things worse. ‘Difficult’ or ‘noisy’ breathing in a child quite commonly leads to a request for an out-of-hours visit in winter. The usual cause is viral croup, producing mild, harmless stridor – but serious cases do occur. A calm exterior and a methodical approach are the keys to effective management.
- Viral Croup (Laryngotracheobronchitis)
- Acute Epiglottitis
- Acute Laryngitis
- Acute Airways Obstruction: Foreign Body (Small Toy, Peanut)
- Laryngeal Paralysis (Congenital: Accounts for 25% of Infants with Stridor)
- Laryngeal Trauma
- Bacterial Tracheitis
- Pseudomembranous Croup (Staphylococcal)
- Upper Airway Burn
- Laryngeal Stenosis
- Laryngeal Tumours (Papilloma, Haemangioma) and Mediastinal Tumours
- Laryngeal Oedema (Angioneurotic: Oedema also Present in Other Tissues)
- Anomalous Blood Vessels (e.g. Double Aortic Arch)
- Retropharyngeal Abscess
Key distinguishing features of the most common diagnoses
|Viral Croup||Epiglottitis||Laryngitis||Obstruction||Laryngeal Paralysis|
|Very Sudden Onset||No||Yes||No||Yes||No|
|Toxic and Feverish||Possible||Yes||No||No||No|
|Very Sore Throat||No||Yes||No||Possible||No|
- There are no investigations likely to be performed in primary care. The following might be performed in hospital: FBC (WCC raised in infection), lateral X-ray of pharynx (enlarged epiglottis in epiglottitis), CXR (may show foreign body, distal collapse or external compression of larynx or trachea) and laryngoscopy (for direct visualisation of the larynx).
- In practice, the first step is to exclude those conditions requiring immediate admission (epiglottitis or inhaled foreign body), leaving a probable diagnosis of viral croup. Management then depends on the child’s general condition – in particular, the level of respiratory distress.
- Children with viral croup may have marked stridor and some recession when crying. It is reasonable to observe such children at home provided these signs disappear when the child is settled.
- When managing a child at home, make absolutely sure that the parents understand the signs of deterioration. If in doubt, arrange review.
- The toxic child with low-pitched stridor (often not marked), severe sore throat or difficulty in swallowing, and respiratory distress has epiglottitis until proved otherwise. Admit immediately and do not examine the throat (this can provoke respiratory obstruction).
- Restlessness, rising pulse and respiratory rate, increasing intercostal recession, fatigue and drowsiness are ominous signs – admit urgently regardless of precise diagnosis.
- Consider an inhaled foreign body if the onset is very sudden and there are no other symptoms or signs of respiratory infection.