Stridor in Children

Differential Diagnosis

Common Diagnoses

  • 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)

Occasional Diagnoses

  • Laryngomalacia
  • Laryngeal Trauma
  • Bacterial Tracheitis
  • Pseudomembranous Croup (Staphylococcal)
  • Upper Airway Burn

Rare Diagnoses

  • 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)
  • Diphtheria
  • Retropharyngeal Abscess

Ready Reckoner

Key distinguishing features of the most common diagnoses

Viral CroupEpiglottitisLaryngitisObstructionLaryngeal Paralysis
Very Sudden OnsetNoYesNoYesNo
Continuous StridorPossibleYesNoYesYes
Toxic and FeverishPossibleYesNoNoNo
Drooling SalivaNoYesNoNoNo
Very Sore ThroatNoYesNoPossibleNo

Possible Investigations

  • 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).

Top Tips

  • 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.

Red Flags

  • 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.

Published: 2nd August 2022 Updated: 10th April 2024

Report errors, or incorrect content by clicking here.

What is Nursing in Practice Reference?

Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

Learn More

Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.