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Evidence Repository

Croup

Developed by:ARCHE & TREKK

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Last Updated
Mar 2026

Topic
Croup

EVIDENCE REPOSITORIES

This evidence repository is a collection of best available resources and evidence collated by a knowledge synthesis team at Alberta Research for Health Evidence (ARCHE) and the clinical content team.

The knowledge synthesis team utilizes a pyramid-shaped framework, built upon the “4S” hierarchy of evidence model, to provide detailed evidence appropriate to meet stakeholders’ needs. They search a combination of databases (Cochrane Library, PubMed, TRIP Database) and web-based search engines (Google, Google Scholar) to locate evidence for the knowledge pyramids. Publication types sought in the initial topic searches are organized into five levels that determine the order in which resources are presented:

  1. Bottom Line Recommendations
  2.  Clinical Practice Guidelines and Pathways
  3. Overviews and Summaries of Systematic Reviews
  4. Systematic Reviews
  5. Key Studies

Where applicable resources for families and parents are also listed.

The knowledge synthesis team collaborates with the clinical content team to select the most relevant guidelines, reviews, and key studies, which can be found below. This evidence repository is not intended to be an exhaustive list of resources for a topic, but rather a curated list of current, evidence-based resources, based on expert consensus of relevance and usability for a general emergency department setting. Every effort is made to identify resources that are open access (i.e. publicly available, free of charge, not requiring a subscription).

More information about the creation of our evidence repositories can be found here.

Content Team

Thank you to the following clinical content experts and Knowledge Synthesis team who led the development of this evidence repository.

David Johnson, MD Professor Emeritus of Pediatrics; University of Calgary, Cumming School of Medicine

Jennifer Turnbull, MD FRCPC Assistant Professor, Division of Pediatric Emergency Medicine, McGill University Co-Director, McGill Global Child Health Program, Montreal Children’s Hospital

Samantha Guitard, MSc Evidence Synthesis Scientist, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta

Sarah Elliott, PhD Assistant Director, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta

TREKK developed resources for healthcare providers and parents & families can be found here.

References in bold correspond to those used in the Bottom Line Recommendations.

Clinical Practice Guidelines And Pathways

  1. Ann & Robert H. Lurie Children’s Hospital of Chicago. Croup Algorithm. 2025.
  2. Children’s Hospital Colorado. Croup Clinical Pathways. 2025.
  3. Royal Children’s Hospital Melbourne. Clinical Practice Guidelines: Croup (Laryngotracheobronchitis). Updated 2024.
  4. Ashford & St Peter’s Hospitals NHS Foundation Trust. Management of Croup. NHS Foundation Trust. 2024.
  5. UCSF Benioff Children’s Hospitals. Consensus Guidelines for Management of Croup. 2023.
  6. Children’s Hospital of Philadelphia (CHOP). Croup Clinical Pathway – Emergency Department and Inpatient. Updated 2023.
  7. Children’s Minnesota. Croup Guideline (Age 3 months–8 years). 2023.
  8. Nationwide Children’s Hospital. Croup Clinical Pathway. Updated 2023.
  9. Children’s Health Queensland. Croup – Emergency management in children. Updated 2023.
  10. Bjornson C, Johnson D. BMJ Best Practice: Croup. BMJ Best Practice. Updated 2023.
  11. Ortiz-Alvarez O. Acute management of croup in the emergency department. Paediatr Child Health. 2017;22(3):166-73.
  12. Alberta Medical Association. Diagnosis and Management of Croup, Summary of the Alberta Clinical Practice Guideline. 2015.

Overviews And Summaries of Systematic Reviews

  1. Kadam SJ, Daley SF, Carr B. Croup. StatPearls. Updated 2025.
  2. Hou Y, Shi Q, Zhang X, et al. Clinical advances in racemic epinephrine for pediatric croup: a mini‑review of evidence and practice. Front Pediatr. 2025;13:1616521.
  3. Shlomovich M, Hyatt S, Cassel-Choudhury G. Croup and Epiglottitis. Pediatr Rev. 2025; 46(7):366-372.
  4. Hibberd O, Chylinska AA, Finn K, et al. Use of corticosteroids for croup in children. Arch Dis Child Educ Pract Ed. 2024;109(6):306-311.
  5. Bjornson CL, Johnson DW. Croup in children. CMAJ. 2013;185(15):1317-23.
  6. Bjornson C, Russell, K, Vandermeer, B, et al. Cochrane Summary: Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2013;CD006619.
  7. Bjornson C, Russell, K, Foisy, M, et al. Cochrane Overview: The Cochrane Library and the treatment of croup in children: an overview of reviews. Evid Based Child Health. 2010;(5):1555-1565.

Systematic Reviews

  1. Garzon Mora N, Jaramillo AP, Briones Andriuoli R, et al. An Overview of the Effectiveness of Corticoids in Croup: A Systematic Literature Review. Cureus. 2023;15(10):e46317.
  2. Aregbesola A, Tam CM, Kothari A, et al. Glucocorticoids for croup in children. Cochrane Database Syst Rev. 2023;1(1):CD001955.
  3. Moraa I, Sturman N, McGuire TM, et al. Heliox for croup in children. Cochrane Database Syst Rev. 2021;8(8)):CD006822.
  4. Gates A, Gates M, Vandermeer B, et al. Glucocorticoids for croup in children. Cochrane Database Syst Rev. 2018;8(8):CD001955.
  5. Bjornson C, Russell K, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2013;(10):CD006619.
  6. Moore M, Little P. Humidified air inhalation for treating croup. Cochrane Database Syst Rev. 2006;19(3):CD002870.

Key Studies

  1. Novi B, Kahne K, Psihos C, et al. Delivery of L‑Epinephrine by Metered‑Dose Inhaler Compared to Racemic Epinephrine by Nebulizer for the Treatment of Croup. J Emerg Med. 2025;79:198-205.
  2. D’Arienzo D, Nasser M, Gill PJ, et al. Dexamethasone regime and clinical outcomes in children hospitalized with croup: A cohort study. J Hosp Med. 2025;20(5):454-462.
  3. Akcan Yildiz L, Akca H, Kurt F, et al. Improving croup management at a pediatric emergency department. Postgrad Med. 2024;136(4):438-445.
  4. Siebert JN, Salomon C, Taddeo I, et al. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023;152(3):e2023061365.
  5. Asif A, Tayyab A, Qazi S, et al. Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: a randomized-controlled trial. Ann Med Surg (Lond). 2023;85(5):1379-1384.
  6. Walsh PS, Lipshaw MJ. Diurnal Variation in Frequency and Severity of Croup in the Emergency Department. Hosp Pediatr. 2022:e2022006682.
  7. Pierantoni L, Stera G, Andreozzi L, et al. Multicentre study revealed significant gaps between evidence-based recommendations for using corticosteroids for croup and clinical practice. Acta Paediatr. 2022;111(10):2010-2016.
  8. Park S, You J, Lee J, et al. Two Case Reports of Life-Threatening Croup Caused by the SARS-CoV-2 Omicron BA.2 Variant in Pediatric Patients. J Korean Med Sci. 2022;37(24):e192.
  9. Meckler GD, Alqurashi W, Eltorki M, et al. Epinephrine metered-dose inhaler for pediatric croup. Acad Emerg Med. 2022;30(2):144-146.
  10. Hester G, Nickel AJ, Watson D, et al. Use of a Clinical Guideline and Order set to Reduce Hospital Admissions for Croup. Pediatrics. 2022;150(3):e2021053507.
  11. Brewster RC, Parsons C, Laird-Gion J, et al. COVID-19-Associated Croup in Children. Pediatrics. 2022;149(6):e2022056492.
  12. Pound CM, Knight BD, Webster R, et al. Predictors of Hospitalization for Children with Croup, a Population-Based Cohort Study. Hosp Pediatr. 2020;10(12):1068-1077.
  13. Bagwell T, Hollingsworth A, Thompson T, et al. Management of Croup in the Emergency Department: The Role of Multidose Nebulized Epinephrine. Pediatr Emerg Care. 2020;36(7):e387- e392.
  14. Eghbali A, Sabbagh A, Bagheri B, et al. Efficacy of nebulized L-epinephrine for treatment of croup: a randomized, double-blind study. Fundam Clin Pharmacol. 2016;30(1):70-75.
  15. Kawaguchi A, Joffe A. Evidence for Clinicians: Nebulized epinephrine for croup in children. Paediatr Child Health. 2015;20(1):19-20.
  16. Garbutt JM, Conlon B, Sterkel R, et al. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Clin Pediatr. 2013;52(11):1014-21.
  17. Dobrovoljac M, Geelhoed GC. How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial. Emerg Med Australas. 2012;24(1):79-85.
  18. Rosychuk RJ, Klassen TP, Voaklander DC, et al. Seasonality patterns in croup presentations to emergency departments in Alberta, Canada: a time series analysis. Pediatr Emerg Care. 2011;27(4):256-60.
  19. Rosychuk RJ, Klassen TP, Metes D, et al. Croup presentations to emergency departments in Alberta, Canada: a large population-based study. Pediatr Pulmonol. 2010;45(1):83-91.
  20. Eboriadou M, Chryssanthopoulou D, Stamoulis P, et al. The effectiveness of local corticosteroids therapy in the management of mild to moderate viral croup. Minerva Pediatr. 2010;62(1):23-8.
  21. Chub-Uppakarn S, Sangsupawanich P. A randomized comparison of dexamethasone 0.15 mg/kg versus 0.6 mg/kg for the treatment of moderate to severe croup. Int J Pediatr Otorhinolaryngol. 2007;71(3):473-7.
  22. Scolnik D, Coates AL, Stephens D, et al. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial. JAMA. 2006;295(11):1274-80.
  23. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med. 2004;351(13):1306-13.
  24. Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral dosing. Pediatrics. 2000;106(6):1344-8.
  25. Klassen TP, Craig WR, Moher D, et al. Nebulized budesonide and oral dexamethasone for treatment of croup: a randomized controlled trial. JAMA. 1998;279(20):1629-32.
  26. Johnson DW, Jacobson S, Edney PC, et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med. 1998;339(8):498-503.
  27. Geelhoed GC, Macdonald WB. Oral and inhaled steroids in croup: a randomized, placebo-controlled trial. Pediatr Pulmonol. 1995;20(6):355-61.
  28. Tibballs J, Shann FA, Landau LI. Placebo-controlled trial of prednisolone in children intubated for croup. Lancet. 1992;340(8822):745-8.

Covid-19 Specific Studies

  1. Pourjoula F, Khalessi N, Ghanbari N. Children with croup during the Omicron surge exhibited increased severity and resource use compared with non‑COVID croup. BMC Pediatr. 2025;25(1):194.
  2. Lam MCY, Lam DSY. The Omicron variant of COVID‑19 and its association with croup in children: a single‑centre study in Hong Kong. Hong Kong Med J. 2024;30(1):44‑55.
  3. Tyler A, Bakel LA, Tucker J, et al. Health Services Use for SARS-CoV-2–Infected Children With Croup or Bronchiolitis. Hosp Pediatr. 2024;14(10):e432-e438.
  4. Scribner C, Patel KI, Tunik M. Pediatric Croup Due to Omicron Infection Is More Severe Than Non- COVID Croup. Pediatr Emerg Care. 2023;39(9):651-653.
  5. Mendez DR, Rumph G, Richardson J, et al. Outcomes of croup in children: COVID‑19 versus non‑COVID‑19 cases. JACEP Open. 2023;4(5):e13053.
  6. Lee EP, Mu CT, Yen CW, et al. Predictors of disease severity and outcomes in pediatric patients with croup and COVID-19 in the pediatric emergency department. Am J Emerg Med. 2023;72:20-26.
  7. Huang Y, Su S, Xu Z, et al. Clinical Features and Outcomes of Omicron‑Associated Croup in Children. Ear Nose Throat J. 2023:1455613231211311.
  8. Lai TC, Walker PJB, Schrader S, et al. COVID‑19–associated croup severity in Australian children. Arch Dis Child. 2023;108(8):e14.
  9. Hayes J, Levine M, Frazier SB, et al. Croup associated with COVID-19: A case series. JEM Rep. 2023;2(1):100011.