Practice 10-Minute Consultation

Stridor in children

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c2193 (Published 04 May 2010) Cite this as: BMJ 2010;340:c2193
  1. Laura J L Halpin, paediatric ST21,
  2. Claire L Anderson, paediatric ST32,
  3. Nicole Corriette, general practitioner3
  1. 1Medway Maritime Hospital, Gillingham ME7 5NY
  2. 2Royal Brompton Hospital, London SW3 6NP
  3. 358 Kirby Road, Dunstable LU6 3JH
  1. Correspondence to: L J L Halpin laurajhalpin{at}doctors.org.uk
  • Accepted 7 April 2010

A 6 month old presents to the general practitioner’s surgery with his mother. She is concerned because he has a runny nose and makes a “funny” loud noise when breathing in, which you diagnose as stridor.

What issues you should cover

Stridor is caused by partial upper airway obstruction and is typically heard in inspiration, although it can also be heard on expiration if the obstruction is below the larynx. It sounds different from wheeze, which is a high-pitched whistling expiratory sound, and from stertor, a snoring sound.

How long has the stridor been present?

  • Acute onset stridor is typically associated with infection or an inhaled foreign body.

  • Chronic stridor (weeks to months) is most commonly due to laryngomalacia, “floppy larynx.” It may also be secondary to congenital anomalies (such as haemangioma), birth trauma (such as vocal cord paralysis), or gastro-oesophageal reflux.

Associated features

  • Cough—a “barking” cough, often worse at night, in young children (infants and toddlers) suggests viral croup, the most likely diagnosis in the scenario and the commonest acute cause.

  • Fever—low grade pyrexia is typically seen in croup. A high fever (>38.5°C) indicates bacterial tracheitis or epiglottitis.

  • Shortness of breath—breathing difficulties or “blue episodes” suggests severe illness requiring referral.

  • Unexpected drooling—may indicate a foreign body or epiglottitis.

  • Feeding difficulties and reduced wet nappies—dehydrated children may need referral.

  • Exacerbating factors—can provide useful information, especially if stridor is absent when you see the child. In laryngomalacia, for instance, stridor is usually intermittent and worsens with effort (for example, during feeding, crying, or intercurrent illness).

History

  • Neonatal history—preterm infants are at increased risk because of their smaller airways. Previous intubation is associated with subglottic stenosis and vocal cord paralysis, both causes of stridor.

  • Allergies—consider anaphylaxis.

  • Immunisation history—check Hib vaccination status, although epiglottitis can occur in immunised children.

  • History of choking—suspect foreign body.

  • Recent travel—consider diphtheria.

What you should do

Physical examination

Is the child well (talking, smiling) or unwell (cyanosed, lethargic)? Is stridor present at rest or only when agitated? Determine respiratory rate, pulse (table), temperature, capillary refill time, and oxygen saturations. Look for signs of respiratory distress such as recessions and tracheal tug. Auscultate the chest to check for equal air entry and to detect or exclude other pathology (for example, consolidation).

Normal heart and respiratory rates at rest by age

View this table:

If the child is distressed or unusually drooling, or if you suspect foreign body inhalation, do not upset or inspect the child’s mouth; this can precipitate complete airway obstruction.

Management

  • Urgently refer any child who is unwell, has respiratory distress, or may have inhaled a foreign body, by ambulance. Clinically dehydrated children may need referral.

  • Croup is usually self limiting, lasting a few days. Mild croup can be managed at home with careful observation and good hydration. Inhalation of steam from a hot bath, shower, or humidifier in a supervised closed room may help, although there is no scientific evidence of efficacy. Advise parents to seek urgent medical attention if symptoms worsen.

  • Pharmacological treatments include dexamethasone (150 µg/kg, oral/injection), prednisolone (1-2 mg/kg, oral), or budesonide nebuliser (2 mg as single dose or in two divided doses separated by 30 minutes) for moderate or severe croup. Adrenaline nebulisers are usually reserved for severe croup. Rarely, intubation is necessary.

  • Refer children with chronic stridor to paediatric or ear, nose, and throat clinics, urgently for those with associated failure to thrive. Most cases will be due to laryngomalacia, which typically resolves by age 18-24 months, but it is important to exclude other causes.

Useful reading

Tasker RC, McClure RJ, Acerini CL. Oxford Handbook of Paediatrics. Oxford University Press, 2008

Kliegman R, Behrman R, Jenson H, Stanton B. Nelson Textbook of Paediatrics. 18th ed. Saunders, 2007.

Notes

Cite this as: BMJ 2010;340:c2193

Footnotes

  • This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs

  • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) they have no support from any company for the submitted work; (2) they have had no relationships with any company that might have an interest in the submitted work in the previous 3 years; (3) their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and (4) they have no non-financial interests that may be relevant to the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.