Compare Severity / admission thresholds for Croup across NICE, RCPCH, and APLS. Built for Children. Setting: Emergency & Paediatrics. Urgency: Urgent.
Clear thresholds help clinicians answer "when do I act?" for croup, aligning expectations between NICE, RCPCH, and APLS. Use this side-by-side view to decide when to refer, escalate, monitor, or initiate treatment.
| Guideline body | Position | Population & urgency |
|---|---|---|
| NICE | Position on Severity / admission thresholds for Croup | Children | Urgency: Urgent | Setting: Emergency & Paediatrics |
| RCPCH | Position on Severity / admission thresholds for Croup | Children | Urgency: Urgent | Setting: Emergency & Paediatrics |
| APLS | Position on Severity / admission thresholds for Croup | Children | Urgency: Urgent | Setting: Emergency & Paediatrics |
Croup affects approximately 3% of children annually in the UK, primarily those aged 6 months to 3 years. The clinical challenge lies in differentiating viral croup from more serious conditions like epiglottitis while balancing the need for timely intervention against unnecessary hospital admissions. Missing severity thresholds can lead to delayed steroid administration, progressive airway obstruction, and respiratory distress requiring emergency management.
NICE provides evidence-based thresholds focusing on cost-effectiveness and primary care management. RCPCH emphasizes practical paediatric assessment tools tailored to hospital settings. APLS delivers emergency-focused guidance with rapid escalation criteria for critical airway compromise. Understanding these philosophical differences helps clinicians apply the most appropriate threshold based on their clinical context.
| Guideline | Primary Focus | Typical Setting | Publication/Update |
|---|---|---|---|
| NICE | Evidence-based standards across NHS | Primary care through to hospital | 2023 (NG 120) |
| RCPCH | Paediatric specialist care | Secondary care and paediatric units | 2024 |
| APLS | Emergency and critical care | Emergency departments and ICU | 2024 (7th edition) |
Use NICE as the default standard for community and general hospital practice. Consult RCPCH guidelines when managing patients in paediatric specialty units. APLS provides critical emergency thresholds for deteriorating patients requiring urgent airway management. Cross-reference between guidelines when patients transition between care settings or when uncertainty exists about the appropriate escalation pathway.
| Severity Category | NICE Threshold | RCPCH Threshold | APLS Threshold | Clinical Notes |
|---|---|---|---|---|
| Mild | Barking cough, no stridor at rest | Intermittent stridor, mild recession | Stridor only when agitated | Usually managed at home |
| Moderate | Stridor at rest, mild recession | Audible stridor at rest, moderate recession | Stridor at rest, tachycardia | Requires oral dexamethasone |
| Severe | Marked recession, agitation/lethargy | Significant work of breathing, tachycardia | Stridor at rest with distress, tachycardia | Admission indicated |
| Life-threatening | Cyanosis, decreased air entry | Exhaustion, cyanosis, silent chest | Impending respiratory failure | Emergency intervention required |
| Trigger | NICE Action | RCPCH Action | APLS Action |
|---|---|---|---|
| Stridor at rest | Consider oral dexamethasone, review in 2 hours | Administer steroids, admit for observation | Immediate steroid administration, prepare for nebulised adrenaline |
| Moderate-severe recession | Urgent hospital assessment | Paediatric team review, consider admission | Emergency department referral, continuous monitoring |
| Tachycardia >160 bpm | Emergency assessment | Immediate paediatric review | Critical trigger - prepare for airway intervention |
| Oxygen saturation <92% | Emergency admission | Urgent senior review, oxygen therapy | Immediate emergency intervention |
| Agitation or lethargy | Hospital admission indicated | Sign of severity - admit immediately | Pre-terminal sign - emergency airway management |
| Failed initial treatment | Secondary care referral | Senior paediatrician review | Emergency escalation protocol |
Presentation: 18-month-old with barking cough, intermittent stridor at rest, mild intercostal recession, respiratory rate 35, heart rate 140. Appears comfortable when undisturbed.
Analysis: NICE would recommend oral dexamethasone with community follow-up. RCPCH would suggest hospital assessment and observation. APLS would recommend emergency department evaluation. The community-based approach may be appropriate if reliable follow-up exists, but hospital assessment provides greater safety margin.
Presentation: 2-year-old with severe stridor, marked recession, tachycardia (170 bpm), and increasing agitation. Oxygen saturation 94% on room air.
Analysis: All guidelines agree on immediate hospital admission. NICE emphasizes steroid administration and monitoring. RCPCH adds structured scoring and paediatric team involvement. APLS focuses on preparing for nebulised adrenaline and potential airway intervention. The APLS approach is most appropriate given the rapid deterioration risk.
Presentation: 9-month-old with stridor, fever 38.5°C, drooling, and toxic appearance. Differentiating croup from epiglottitis.
Analysis: All guidelines prioritize ruling out epiglottitis. NICE recommends urgent hospital assessment. RCPCH emphasizes paediatric specialist review. APLS focuses on emergency airway management preparation. The APLS approach is critical here due to the higher risk of airway obstruction in infants with atypical presentations.
The Westley Croup Score provides objective severity assessment, though its use varies between guidelines:
Practical application: A score of 3-5 suggests moderate croup requiring steroids and observation. Scores ≥8 indicate severe croup needing urgent intervention. Remember that clinical judgement supersedes numerical scores, particularly in rapidly changing situations.
Refer to the full guidelines for exact wording and local adaptations. This summary is for rapid orientation and multidisciplinary alignment.