Croup vs Epiglottitis: Tell Them Apart Fast

Pediatrics · Respiratory (RSV, Asthma, Croup)·Updated 2026-10-28

What it is

Croup (acute laryngotracheobronchitis) is viral inflammation below the vocal cords, usually from parainfluenza virus, seen most often in children 6 months to 3 years old. Epiglottitis is a bacterial infection of the epiglottis and surrounding supraglottic tissue that swells within hours and can close the airway completely. Because a child's airway is narrow, a small amount of edema sharply increases airway resistance. Croup is managed with corticosteroids and calm observation; epiglottitis is an airway emergency managed by an airway team.

What the NCLEX focuses on

Croup: cold symptoms for 1 to 2 days, then a barking, seal-like cough, hoarseness and inspiratory stridor that worsen at night; low-grade fever.
Epiglottitis: abrupt high fever, drooling, dysphagia, a muffled voice, no spontaneous cough, an anxious, toxic appearance and a tripod or sniffing position.
In suspected epiglottitis, never inspect the throat with a tongue blade or obtain a throat culture; keep intubation and tracheostomy equipment ready.
Dexamethasone 0.6 mg/kg as a single dose (oral, IM or IV) is given for croup of every severity.
Nebulized racemic epinephrine is reserved for stridor at rest; observe the child for 2 to 4 hours afterward because the effect wears off and stridor can return.
Stridor at rest, retractions, restlessness, cyanosis, and stridor that fades as the child becomes lethargic signal impending respiratory failure.
The Hib vaccine series prevents most epiglottitis; Hib epiglottitis requires droplet precautions until 24 hours of effective antibiotics.

Priority nursing actions

For suspected epiglottitis, keep the child upright on the parent's lap and calm; do not lay the child down or start upsetting procedures.
Call for the airway team, have emergency intubation and tracheostomy equipment at the bedside, and give humidified oxygen as tolerated (blow-by).
After the airway is secured, obtain cultures and give the prescribed IV antibiotics.
For croup, assess work of breathing, stridor at rest, SpO2 and level of consciousness while the child stays with the parent.
Give the prescribed dexamethasone, add racemic epinephrine for stridor at rest, and observe before discharge.

Numbers to know

Feature	Croup	Epiglottitis
Cause	Viral, most often parainfluenza	Bacterial; Haemophilus influenzae type b (Hib) in unimmunized children
Usual age	6 months to 3 years	Classically 2 to 5 years
Onset	Gradual, after cold symptoms	Abrupt, over hours
Fever	Low grade	High, with a toxic appearance
Cough and voice	Barking cough, hoarse voice	No cough; muffled voice and drooling
Posture	No typical posture	Sits upright, leaning forward, mouth open
Key treatment	Dexamethasone 0.6 mg/kg; racemic epinephrine for stridor at rest	Secure the airway, then IV antibiotics

Common exam traps

Choosing to obtain a throat culture with a tongue blade in a drooling child: wrong because it can trigger laryngospasm and complete obstruction.
Choosing to place the child supine for an IV or examination: wrong because lying down lets the swollen epiglottis fall back over the airway.
Choosing immediate discharge once stridor resolves 30 minutes after racemic epinephrine: wrong because stridor returns as the drug wears off.
Choosing antibiotics for croup: wrong because croup is viral.
Choosing to read quieter stridor in a drowsy child as improvement: wrong because it means air movement and respiratory effort are failing.

What to teach

During a croup attack at night, stay calm, hold the child upright and comfort the child, because crying worsens stridor.
Return or call 911 for stridor at rest, retractions, drooling, inability to swallow, bluish lips or unusual sleepiness.
Offer fluids and give acetaminophen or ibuprofen for fever; never give aspirin to children (Reye syndrome).
Complete the Hib vaccine series in infancy, with the booster at 12 to 15 months.

Try 2 NCLEX-style questions on this topic

From the NCLEXPace question bank. Pick your answers, then check them inside NCLEXPace.

Question 1 · QID 06209172

A 2-year-old is brought to the emergency department at 2 AM after 2 days of a runny nose followed by a barking, seal-like cough and hoarseness. Stridor is heard only when the child cries. The child is calm on the parent's lap with a respiratory rate of 30 breaths per minute. Which treatment should the nurse anticipate?

Select the best answer.

A. Nebulized racemic epinephrine followed by several hours of observation for recurrent stridor
B. A single oral dose of dexamethasone 0.6 mg/kg
C. IV ceftriaxone after obtaining blood cultures and an upper-airway specimen for bacterial testing
D. A 5-day course of oral amoxicillin with close home monitoring for persistent fever or worsening stridor

Question 2 · QID D5DF8407

A 4-year-old arrives at the emergency department with a temperature of 39.4 C (102.9 F), drooling, a muffled voice, and no cough. The child leans forward on the parent's lap, refuses to lie down, and appears anxious. Which action should the nurse take first?

Select the best answer.

A. Obtain a throat culture using a tongue depressor and swab before antibiotics so the organism can be identified before treatment begins
B. Place the child supine on the stretcher and insert a peripheral IV promptly so antibiotics and fluids can be started without delay
C. Obtain a rectal temperature, administer the prescribed antipyretic, and reassess the child's anxiety and fever before further intervention
D. Keep the child upright on the parent's lap and call for airway help

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More tips on Pediatrics

Type 1 Diabetes in Children: Lows, Sick Days and DKATreat hypoglycemia in children safely, keep basal insulin on sick days, spot cerebral edema in DKA, and match self-care to the child's age.Immunizations: Schedule Principles and ContraindicationsKnow which vaccines are live, the true contraindications versus the false ones, the timing rules, and safe administration and teaching.Growth and Development MilestonesLearn the motor, language and social milestones the NCLEX tests, the red flags that need referral, and the type of play expected at each age.

Sources

Hockenberry MJ, Duffy EA, Gibbs KD. Wong's Nursing Care of Infants and Children. 12th ed. Elsevier; 2024.
Briere EC, Rubin L, Moro PL, Cohn A, Clark T, Messonnier N. Prevention and Control of Haemophilus influenzae Type b Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR-01):1-14.
Bjornson CL, Johnson DW. Croup in Children. CMAJ. 2013;185(15):1317-1323.

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