Paediatric · Respiratory
Westley Croup Score
Clinical severity score for croup (Westley 1978). Stridor + retractions + air entry + cyanosis + consciousness. Plus dexamethasone dosing, when to nebulise adrenaline, admission criteria, and how to distinguish from epiglottitis.
Last reviewed 31 May 2026
Westley croup score + dexamethasone
Severity + treatment in one go
Level of consciousness
Cyanosis
Stridor
Air entry
Retractions
Westley total · Mild (≤ 2)
0 / 17
Dexamethasone 0.15 mg/kg PO single dose. Safety-net discharge: return if increasing stridor at rest, increased work of breathing, drooling, or unable to drink. Most resolve in 48–72 h.
Educational tool only — not medical advice. Westley 1978; Cochrane 2018 (Russell, 43 RCTs of glucocorticoids in croup). Prednisolone 1 mg/kg PO is an acceptable alternative (NICE 2019). Decisions by paediatric / emergency team.
What does this mean?
Croup (laryngotracheobronchitis) is the classic barking cough + stridor + hoarse voice in 6 mo– 6 yr children, usually peaking at 18–24 months and most commonly parainfluenza virus type 1. It looks dramatic and frightens parents but most cases are mild and resolve within 48–72 hours with a single dose of oral dexamethasone. Cochrane 2018 (43 RCTs) confirms: glucocorticoids reduce admission, return visits, intubation, and ICU stay; the effect is fast (~ 2 h to measurable benefit) and lasts > 24 h. The big practical rule: even mild cases get dexamethasone (0.15 mg/kg); moderate/severe get the full 0.6 mg/kg. The single most important danger sign is stridor at rest — that’s when nebulised epinephrine is added and observation extended. Differentials to remember: epiglottitis (rare since Hib vaccine but emergency), bacterial tracheitis, foreign body aspiration. Quiet child + drooling + tripoding = NOT croup, DON’T examine the throat, get ENT/anaesthesia.
What is the Westley Croup Score?
Clinical severity scoring system for croup (Westley CR et al., Am J Dis Child 1978). Five components scored together:
- Stridor — severity at rest / when agitated.
- Retractions — chest indrawing.
- Air entry — breath sounds on auscultation.
- Cyanosis — absent / with agitation / at rest.
- Level of consciousness — normal / disoriented.
Total 0-17.
Score bands & treatment
- 0-2 Mild: home care; oral dexamethasone if accessible.
- 3-7 Moderate: oral dexamethasone 0.15 mg/kg; observe 3-4 hours; usually discharge.
- 8-11 Severe: dexamethasone + nebulised adrenaline; observe 2-4h; may need admission.
- 12-17 Impending respiratory failure: airway emergency — PICU prep, intubation possible, senior support.
Dexamethasone for croup
Game-changer. Single oral dose 0.15 mg/kg (UK NICE), up to 0.6 mg/kg (US). Max 12-16 mg single dose. Effect 30-60 min; full effect 1-3 hours; lasts 24-48 hours. Cochrane Russell 2018: reduces severity, hospitalisation, return visits, intubation rates by ~50-80%. Alternative if no oral: IM injection; nebulised budesonide.
Nebulised adrenaline / epinephrine
For moderate-severe (Westley ≥ 4-6 with significant distress). RACEMIC EPINEPHRINE 2.25% (0.5 mL in 3 mL saline) OR L-EPINEPHRINE 1:1000 (5 mL undiluted, up to 5 mL). Nebulised over 10-15 min.
Effect 10-30 min; peaks 30 min; lasts 1-2 hours. REBOUND can occur 1-2 hours later as medication wears off — always give dexamethasone alongside; observe 2-4 hours post-neb.
What causes croup?
Viral infection of upper airway. Parainfluenza viruses (types 1, 2, 3) cause ~75% of cases. Also RSV, influenza, adenovirus, coronaviruses. Inflames vocal cords + subglottic trachea. Peak age 6 months to 3 years. Most children get 1-2 episodes between 6 months and 5 years.
What does croup sound and look like?
- Barking / seal-like cough — “woof woof” sound.
- Hoarse voice or lost voice.
- Stridor — high-pitched harsh sound on breathing IN.
- Runny nose / mild fever first 1-2 days.
- Almost always worse 1-3 AM — classic timing.
- Improves over 3-7 days.
When does croup need hospital admission?
- Westley score ≥ 6 or moderate-severe.
- Persistent stridor at rest after dexamethasone.
- Needed nebulised adrenaline.
- Baby under 6 months.
- Previous severe croup.
- Underlying condition (subglottic stenosis, asthma).
- Social factors (parent unable to monitor, far from hospital).
- Presentation in early evening (predicts overnight worsening).
Croup vs Epiglottitis — critical differential
| Croup | Epiglottitis | |
|---|---|---|
| Cause | Viral | Bacterial (Hib classic) |
| Onset | Days, after URI | Hours, sudden |
| Appearance | Coughing but interactive | SICK, toxic, drooling |
| Position | Any | Tripod (forward sitting) |
| Cough | BARKING | Usually NO barking cough |
| Voice | Hoarse | Muffled “hot potato” |
| Drooling | No | YES (can’t swallow) |
| Fever | Low-mild | HIGH |
Epiglottitis is an airway emergency. Don’t examine throat. Don’t lie flat. Immediate paediatric anaesthetic + ENT for theatre airway management + IV antibiotics. Rare in Hib-vaccinated populations.
Different scenarios — common croup presentations
Scenario 1: 2-year-old, 3 AM barking cough, hoarse, no stridor at rest
Mild croup (Westley 0-2). Calm reassurance, sit upright, consider cool air. Oral dexamethasone if GP / out-of-hours accessible. Usually settles within 24 hours.
Scenario 2: 18-month-old, stridor with agitation, chest indrawing, alert
Moderate croup (Westley 4-7). ED assessment. Oral dexamethasone 0.15 mg/kg. Observe 3-4 hours. Often discharged same day with safety netting.
Scenario 3: 3-year-old with stridor at rest, marked indrawing, restless
Severe croup (Westley 8-11). Dexamethasone + nebulised adrenaline + observation 2-4 hours. Likely admission. Monitor for rebound.
Scenario 4: 4-year-old, drooling, sitting forward, high fever, NO barking cough
NOT typical croup — suspect epiglottitis. Don’t examine throat. Don’t agitate. Senior anaesthetic + ENT immediately. Theatre airway management. IV antibiotics (ceftriaxone).
Scenario 5: Recurrent severe croup, 5 episodes in 12 months
ENT referral for subglottic stenosis / haemangioma / structural assessment. Consider GORD; trial of PPI sometimes helpful. Spasmodic croup variant possible.
Care guidance — safety netting parents
- Return immediately if: stridor at rest; chest indrawing; baby not drinking; very sleepy; blue lips.
- Worse at night is classic — sit child upright; cool air; calm reassurance.
- Don’t give cough syrup — no benefit; may sedate.
- Dexamethasone lasts 24-48 hours; if still symptomatic after this, return.
- Most croup resolves in 3-7 days.
- Recurrent croup (multiple episodes) — book GP follow-up.
Sources
- Westley CR, et al. Nebulized racemic epinephrine by IPPB for the treatment of croup. Am J Dis Child 1978.
- Russell KF, et al. Glucocorticoids for croup in children. Cochrane 2018.
- NICE CKS. Croup.
- AAP Clinical Report. Croup management.
- RCH Melbourne. Clinical Practice Guidelines: Croup.
Frequently asked questions
What is the Westley croup score?
Clinical severity scoring system for croup (laryngotracheobronchitis) — viral inflammation of the upper airway in children, peak age 6 months to 3 years. Developed by Westley CR et al. (Am J Dis Child 1978). Five components: STRIDOR severity, RETRACTIONS (chest indrawing), AIR ENTRY, CYANOSIS, LEVEL OF CONSCIOUSNESS. Total score 0-17. Used by paediatric ED and ICU teams to standardise assessment and guide treatment. Higher score = more severe croup needing escalation.
What do Westley scores mean for treatment?
MILD (0-2): often manage at home with calm reassurance + cool air + oral dexamethasone if accessible. MODERATE (3-7): oral dexamethasone 0.15 mg/kg single dose (game-changer; reduces severity, hospitalisation, return visits, intubation rates by ~50-80%); observe 3-4 hours; usually discharged home. SEVERE (8-11): dexamethasone + nebulised adrenaline (epinephrine 1:1000, 0.5 mL/kg up to 5 mL); observe for 2-4 hours after adrenaline; may need admission. IMPENDING RESPIRATORY FAILURE (12-17): airway emergency — intubation prep, PICU transfer; nebulised adrenaline + dexamethasone + IV corticosteroid; senior paediatric / anaesthetic support immediately.
What causes croup?
Viral infection of upper airway. PARAINFLUENZA viruses (types 1, 2, 3) cause ~75% of cases. Also: respiratory syncytial virus (RSV), influenza, adenovirus, coronaviruses, occasionally measles. The virus inflames vocal cords and subglottic trachea (the narrow part just below voice box). Because under-3s have very narrow airways anyway, this swelling produces the classic stridor, barking cough, and hoarse voice. Peaks autumn / early winter. Most children get 1-2 episodes between 6 months and 5 years.
What does croup actually sound and look like?
BARKING / SEAL-LIKE COUGH — distinctive 'woof woof' sound, especially worse at night. HOARSE VOICE OR LOST VOICE. STRIDOR — high-pitched harsh sound on breathing IN (inspiratory). RUNNY NOSE / MILD FEVER first 1-2 days then cough develops. Most cases have mild stridor only when crying/upset. SEVERE: stridor at rest, chest indrawing, restless, tired. ALMOST ALWAYS worse 1-3 AM (classic croup timing). Improves over 3-7 days.
What is the dexamethasone dose for croup?
Single oral dose: 0.15 mg/kg (UK NICE), up to 0.6 mg/kg (US guidelines vary, often 0.6 mg/kg). MAX 12-16 mg single dose. Effect within 30-60 min; full effect 1-3 hours; lasts 24-48 hours. AAP / NICE / RCH all support. Reduces severity, hospitalisation, return visits, intubation needed by ~50-80% (Cochrane Russell 2018). REPEAT DOSE not usually needed. IF can't tolerate oral: IM injection alternative; budesonide nebulised if dex unavailable.
What is nebulised adrenaline / epinephrine?
RACEMIC EPINEPHRINE 2.25% (0.5 mL in 3 mL saline) OR L-EPINEPHRINE 1:1000 (5 mL undiluted = ~0.5 mg/kg up to 5 mL). Nebulised over 10-15 min. Effect within 10-30 min; peaks at 30 min; lasts 1-2 hours (REBOUND can occur). RESERVED for moderate-severe croup (Westley ≥ 4-6 with significant respiratory distress). Mechanism: alpha-adrenergic vasoconstriction reducing mucosal oedema. OBSERVE 2-4 hours after dose for rebound. AAP / NICE: discharge possible 2-4 hours post-adrenaline if asymptomatic.
What's the rebound effect after adrenaline?
Symptoms can return 1-2 hours after adrenaline as the medication wears off. CLASSIC: child looks much better at 30 min post-neb, then deteriorates again at 90-120 min. WHY: adrenaline addresses swelling but doesn't treat underlying inflammation; dexamethasone takes time to kick in. STRATEGY: ALWAYS give dexamethasone alongside adrenaline; observe 2-4 hours after adrenaline dose. Repeated doses sometimes needed in severe cases. Don't discharge too early.
When does croup need hospital admission?
ADMIT if: WESTLEY SCORE ≥ 6 or moderate-severe; persistent stridor at rest after dexamethasone; needed nebulised adrenaline; baby under 6 months (more rapid deterioration possible); previous severe croup; underlying condition (subglottic stenosis, asthma); social factors (parent unable to monitor; far from hospital); presentation at unusual time (deterioration in early evening predicts overnight worsening). DISCHARGE possible if: stable for 2-4 hours after treatment; tolerating fluids; no stridor at rest; reliable parents who can return if worse.
How is croup different from epiglottitis?
EPIGLOTTITIS: bacterial (Haemophilus influenzae type b — much rarer since Hib vaccine; also Strep, Staph). VERY ACUTE onset over hours. SICKER appearance. DROOLING, can't swallow. TRIPOD POSITION (sitting forward, mouth open, chin out). HIGH FEVER. MUFFLED 'hot potato' voice. NOT BARKING cough. Don't lie flat. AIRWAY EMERGENCY — different management (no examination of throat which can precipitate obstruction; immediate paediatric anaesthetic + ENT for controlled airway management in theatre; IV antibiotics). Rare in vaccinated populations. Always consider if 'severe croup' not fitting typical picture.
Is croup contagious?
Yes — viral cause means it spreads like a cold. Incubation 2-6 days. Most contagious during cold-symptom phase (first 1-3 days). RISK: siblings often develop similar illness. Spread by respiratory droplets and surface contact. PREVENTION: hand hygiene, cover coughs, don't share cups, stay home from nursery / school while symptomatic. Doesn't trigger full school closure but child shouldn't attend while symptomatic. Most children get 1-2 episodes; immunity develops to specific strains.
What can I do at home for mild croup?
CALM: anxiety worsens stridor — speak softly, hold upright, distract gently. UPRIGHT POSITIONING: sitting on parent's lap. STEAM is debated — older advice 'sit in steamy bathroom' has weak evidence; some studies show no benefit (Cochrane Moraa 2018); not harmful if helps you feel useful. COOL AIR (cool night air, slightly opened window): anecdotal benefit; some evidence. FEVER MANAGEMENT: paracetamol or ibuprofen if uncomfortable. FLUIDS: encourage hydration. AVOID irritants (smoke, strong fragrances). DON'T GIVE: cough syrup (no benefit, may sedate). Most mild cases settle in 3-5 days.
When should I call 999 / go to A&E urgently?
EMERGENCY signs: STRIDOR AT REST (not just when crying); severe chest INDRAWING (visible 'sucking in' between ribs, under ribs, above collarbone); RESTLESSNESS / AGITATION (often pre-cyanosis); EXHAUSTED appearance (fatigue from breathing); pale, grey, or BLUE lips / face; ALTERED CONSCIOUSNESS; persistent stridor 30+ min despite home measures; severe rapid deterioration. Some hospitals also accept self-presentation. CALL 999 if struggling to breathe / blue lips / unresponsive. Don't drive if severely unwell — call ambulance.
Will my child have lasting damage from croup?
Almost never. CROUP IS BENIGN in 99%+ of cases. Complications rare: secondary bacterial infection (bacterial tracheitis — much more serious, may need intubation); intubation for severe airway compromise (rare ~1-3% of admitted cases); rare deaths essentially eliminated with modern dexamethasone era. PSYCHOLOGICAL: some children develop 'fear of breathlessness' or anxiety; reassurance helps. Recurrent croup (4+ episodes/year) warrants ENT review for subglottic stenosis or anatomical concerns.
Can my child have croup more than once?
Yes — many children have 2-3+ episodes between 6 months and 5 years. Same management each time. RECURRENT CROUP (4+ episodes/year, or severe episodes recurring): ENT referral to rule out subglottic stenosis, subglottic haemangioma, laryngomalacia, asthma-overlap. Some recurrent croup associated with GORD; trial of PPI sometimes helpful. SPASMODIC CROUP variant: sudden nighttime onset without preceding cold; can recur over consecutive nights; same treatment approach.
What is the typical croup recovery time?
MILD-MODERATE: improves within 24-48 hours of dexamethasone; full recovery 3-7 days. RESIDUAL barking cough may persist 1-2 weeks. RETURN to nursery / school: 48 hours after acute symptoms (cough, hoarse voice) settle; child looking well. ATYPICAL severity or persistent symptoms warrant paediatric review (bacterial tracheitis differential, secondary infection). MOST children fully recover with no lasting effects.
How does this relate to other calculators on BumpBites?
Companion: /calculators/croup-home-hospital for parent-facing decision-making; /calculators/pews-paediatric for general paediatric severity; /calculators/baby-cough for cough type identification; /calculators/baby-fever for fever differential; /calculators/pediatric-dose for dexamethasone / paracetamol dosing.