Every winter season (and year-round in many tropical countries), paediatric wards and emergency departments fill with young children struggling to breathe. Two of the commonest causes are bronchiolitis and croup, both usually viral. Most children recover with supportive care, but some become seriously ill. Nurses need to assess breathing accurately, recognise deterioration, and support anxious families.
Telling them apart
| Bronchiolitis | Croup | |
|---|---|---|
| Typical age | Under 2 years, peak 3–6 months | 6 months to 3 years (can be older) |
| Main cause | Respiratory syncytial virus (RSV), others | Parainfluenza virus, others |
| Area affected | Small airways (bronchioles) in the lungs | Upper airway (larynx and trachea) |
| Key sounds | Wheeze and/or crackles; cough | Barking “seal-like” cough, hoarse voice, stridor |
| Main treatment | Supportive: oxygen if needed, feeding support | Corticosteroid (dexamethasone); nebulised adrenaline if severe |
Assessing work of breathing
- Respiratory rate: count for a full minute while the child is calm. Use age-appropriate ranges. See our vital signs guide.
- Recession: subcostal, intercostal, sternal (more severe).
- Nasal flaring, head bobbing, tracheal tug.
- Grunting: a serious sign.
- Apnoea: especially in young infants with bronchiolitis.
- SpO₂, colour, cyanosis.
- Behaviour: agitation (hypoxia) or reduced responsiveness and drowsiness (late, worrying sign).
- Feeding: amount compared with usual; wet nappies.
Many units use a paediatric early warning score (PEWS) to support escalation.
Bronchiolitis care
- Supportive care is the mainstay; symptoms often peak around days 3–5 and cough may last weeks.
- Oxygen if saturations fall below the threshold in local guidance (often around 90–92%). High-flow nasal oxygen or CPAP may be needed in severe cases.
- Nasal suctioning may help if secretions cause distress or feeding problems; avoid routine deep suctioning.
- Feeding support: small, frequent feeds; nasogastric or IV fluids if the child can’t feed enough (often less than about 50–75% of usual).
- Evidence-based guidelines generally do not recommend routine salbutamol, steroids, antibiotics or chest physiotherapy for typical bronchiolitis.
- Higher-risk groups: premature babies, infants under 3 months, those with heart or lung disease or immunodeficiency.
- Prevention: hand hygiene, avoiding smoke exposure, breastfeeding, and RSV prevention products (monoclonal antibodies for infants or maternal vaccination) where available.
Croup care
- Keep the child calm, on a parent’s lap. Crying worsens airway obstruction. Don’t examine the throat with a tongue depressor if there’s stridor (in case of epiglottitis).
- Oral dexamethasone (single dose) is recommended for all severities in many guidelines; it reduces symptoms within hours.
- Nebulised adrenaline for severe croup gives rapid but temporary relief; observe for several hours afterwards as symptoms can return.
- Oxygen if hypoxic.
- Humidified air/steam is not recommended (no proven benefit; scald risk).
Red flags: escalate immediately
- Stridor at rest, especially if becoming quieter while the child tires.
- Severe recession, grunting, apnoea.
- SpO₂ below target despite oxygen.
- Drowsiness, lethargy, cyanosis.
- Drooling, unable to swallow, high fever, toxic-looking child (consider epiglottitis or bacterial tracheitis).
- Signs of dehydration.
Talking with parents
- Explain what’s causing the noise or breathing difficulty, and what to expect.
- Teach them to watch for worsening breathing, poor feeding, fewer wet nappies, and pauses in breathing.
- Explain why antibiotics aren’t usually needed for viral illness.
- Advise on fever and fluids; avoid smoke exposure.
- Give clear advice on when and where to return urgently.
In settings using WHO IMCI, fast breathing and chest indrawing in children with cough also prompt assessment for pneumonia, a leading killer of under-fives. See our IMCI guide.
Based on NICE NG9 (Bronchiolitis in children), NICE CKS Croup, American Academy of Pediatrics bronchiolitis guideline and WHO IMCI. Educational content: follow local protocols.