Upper airway disorders are among the most common reasons children see a health care provider. Most are mild viral infections, but a few (epiglottitis, severe croup, foreign body aspiration) can close the airway within minutes. The nurse's first task is always to decide whether the airway is threatened.
Why children are at higher risk
| Feature of the child's airway | Consequence |
|---|
| Narrow airway diameter | A small amount of swelling causes a large rise in resistance; 1 mm of edema greatly narrows an infant's airway |
| Large tongue, large tonsils and adenoids, floppy epiglottis | Obstruction during sleep and with infection |
| Infants are preferential nose breathers for the first months | Nasal congestion interferes with feeding and breathing |
| Short, straight eustachian tubes | Middle ear infection follows colds |
| High metabolic rate and oxygen use | Hypoxemia and fatigue develop quickly |
Main conditions in this topic
- Nasopharyngitis (common cold) — viral (rhinovirus and others); self-limited
- Pharyngitis and tonsillitis — mostly viral; about a third in school-age children is group A streptococcus (GAS). Untreated GAS can lead to acute rheumatic fever and post-streptococcal glomerulonephritis, and locally to peritonsillar abscess
- Adenotonsillar hypertrophy and obstructive sleep apnea (OSA) — enlarged tonsils and adenoids block the airway during sleep
- Acute otitis media (AOM) — often follows a cold; peaks between 6 and 24 months
- Croup syndromes — inflammation and swelling of the larynx and subglottic area
| Feature | Laryngotracheobronchitis (viral croup) | Acute epiglottitis | Bacterial tracheitis |
|---|
| Cause | Parainfluenza virus most often | Bacteria; historically Haemophilus influenzae type b (Hib), now rare where Hib vaccine is used | Staphylococcus aureus and others, often after viral croup |
| Age | About 6 months to 3 years | Any age; classically 2–7 years | Young children |
| Onset | Gradual, after a cold; worse at night | Sudden, rapid progression | Croup that worsens instead of improving |
| Cough | Barking, "seal-like" cough, hoarseness | Little or no cough | Brassy cough, thick purulent secretions |
| Key signs | Inspiratory stridor, low-grade fever | Drooling, dysphagia, muffled voice, tripod position, high fever, toxic look | High fever, toxic look, poor response to croup treatment |
| Danger | Usually mild; severe cases can obstruct | Complete airway obstruction | Airway obstruction |
Foreign body aspiration peaks between 1 and 3 years (mouthing, running while eating, no molars). Common items: nuts, grapes, hot dogs, popcorn, coins, toy parts, and button batteries.
Signs of respiratory distress (assess every child)
- Tachypnea for age, nasal flaring, grunting, head bobbing
- Retractions (subcostal, intercostal, suprasternal) — suprasternal retractions indicate upper airway obstruction
- Stridor: a high-pitched sound, mainly on inspiration, from narrowing of the upper airway. Stridor at rest means significant obstruction
- Restlessness and anxiety are early signs of hypoxemia; lethargy, decreasing stridor with worsening effort, and cyanosis are late, ominous signs
Pediatric respiratory rates (approximate, awake)
| Age | Breaths/min |
|---|
| Infant (to 1 year) | 30–53 |
| Toddler (1–2 years) | 22–37 |
| Preschool (3–5 years) | 20–28 |
| School age (6–11 years) | 18–25 |
| Adolescent | 12–20 |
Condition-specific findings
- GAS pharyngitis: sudden sore throat, fever, tonsillar exudate, tender anterior cervical nodes, palatal petechiae, sometimes headache, abdominal pain, or a sandpaper rash (scarlet fever). Cough, runny nose, and hoarseness suggest a virus
- OSA: loud habitual snoring, pauses in breathing and gasping during sleep, mouth breathing, daytime behavior problems
- AOM: ear pain (tugging at the ear in infants), fever, irritability; a bulging, red tympanic membrane with reduced mobility
- Croup: barking cough and hoarseness after 1–2 days of cold symptoms; stridor worse with crying and at night
- Epiglottitis — the four Ds: drooling, dysphagia, dysphonia (muffled voice), distress; child sits upright leaning forward with the chin out
- Foreign body: sudden choking, coughing, gagging, or wheezing during eating or play. After the first episode the child may look well, but may have unilateral wheeze, reduced breath sounds on one side, or recurrent pneumonia in the same area
| Test | Use and key points |
|---|
| Pulse oximetry | First objective measure of oxygenation in any child with respiratory distress |
| Rapid antigen detection test (RADT) for GAS | Test when the picture suggests GAS. In children and adolescents a negative RADT is backed up by throat culture |
| Throat culture | Diagnostic standard for GAS; results in 24–48 hours |
| Testing not routinely done | Children younger than 3 years (GAS pharyngitis and rheumatic fever are uncommon) and children with clear viral features |
| Polysomnography (sleep study) | Confirms OSA and its severity before surgery |
| Otoscopy | Diagnosis of AOM |
| Croup severity (Westley score) | Rates stridor, retractions, air entry, cyanosis, and level of consciousness |
| Neck X-ray | Not needed in typical croup ("steeple sign"); lateral view may show a swollen epiglottis ("thumb sign") but never delays airway management |
| Bronchoscopy | Diagnoses and removes an aspirated foreign body. A normal chest X-ray does not rule it out — most food items are not radiopaque |
Epiglottitis rule: do not examine the throat with a tongue blade, do not lay the child down, and do not attempt blood draws or IV insertion that upset the child before the airway is secured. Examination is done in a controlled setting (operating room) with airway experts present.
GAS pharyngitis — antibiotics prevent rheumatic fever
- Penicillin V or amoxicillin orally for a full 10 days (amoxicillin can be given once daily, about 50 mg/kg, maximum 1,000 mg)
- Benzathine penicillin G IM single dose when adherence is uncertain: 27 kg (60 lb) or less: 600,000 units; over 27 kg: 1.2 million units (AHA/IDSA, US). WHO 2024 uses under 30 kg / 30 kg or more
- Penicillin allergy: cephalexin (non-severe allergy), clindamycin, or azithromycin (5 days)
- Child may return to school after at least 12 hours of antibiotic therapy and when fever-free
Tonsillectomy and adenoidectomy — for recurrent severe throat infections or OSA from adenotonsillar hypertrophy.
AOM — pain control first. High-dose amoxicillin (80–90 mg/kg/day divided twice daily, maximum 4 g/day); watchful waiting for selected older children with mild illness. Recurrent AOM: tympanostomy tubes.
Croup
- Dexamethasone single oral dose (0.15–0.6 mg/kg, maximum 16 mg) for all severities, including mild croup — reduces return visits and admissions
- Nebulized epinephrine (racemic or L-epinephrine) for moderate to severe croup with stridor at rest — acts within 10–30 minutes; the effect wears off in about 2 hours, so the child is observed for 2–4 hours after the dose
- Oxygen for hypoxemia; intubation with a smaller-than-usual tube for impending respiratory failure
- Humidified or cool mist air has not been shown to help and is no longer a treatment
Epiglottitis — secure the airway (intubation in the operating room or tracheostomy), then IV antibiotics (e.g., ceftriaxone).
Foreign body aspiration — rigid bronchoscopy removal. Button batteries in the esophagus are an emergency removal.
Drug safety (doses are weight-based and verified against a pediatric reference before giving)
| Drug | Key safety points |
|---|
| Penicillins (amoxicillin, penicillin V, benzathine penicillin G) | Ask about allergy; watch for rash, anaphylaxis; diarrhea. Benzathine penicillin is deep IM only, never IV; observe after injection. Amoxicillin in a child with infectious mononucleosis often causes a rash |
| Cephalexin | Cross-reactivity is low but avoid after a severe (anaphylactic) penicillin reaction |
| Macrolides (azithromycin) | GI upset; QT prolongation; higher GAS resistance |
| Dexamethasone | Single dose is well tolerated; transient hyperglycemia, mood change; caution with active varicella exposure |
| Nebulized epinephrine | Tachycardia, pallor, tremor; symptoms can return as the effect ends — monitor for 2–4 hours |
| Acetaminophen | 10–15 mg/kg every 4–6 hours (max 1 g/dose, 75 mg/kg/day, 4 g/day), no more than 5 doses in 24 hours; hepatotoxicity; check combination products |
| Ibuprofen | 5–10 mg/kg every 6–8 hours (max 400 mg/dose, 40 mg/kg/day); not under 6 months; avoid with dehydration and bleeding |
| Aspirin | Avoid in children and adolescents with viral illness — risk of Reye syndrome |
| Codeine and tramadol | Contraindicated in children under 12 years and after tonsillectomy or adenoidectomy in children under 18 — ultra-rapid metabolizers develop fatal respiratory depression |
| Over-the-counter cough and cold medicines | Not for children under 2 years (FDA); labeled not for use under 4 years (infant toxicity) |
Listed in priority order.
- Airway and breathing
- Assess work of breathing, stridor, SpO₂, color, and level of consciousness; measure SpO₂ and give oxygen if needed before sending the child for tests
- Keep the child calm: let the child stay on the parent's lap in a position of comfort (usually upright). Crying increases oxygen demand and worsens airway obstruction
- Do not force the child to lie down or hyperextend the neck; a sniffing or upright position keeps the airway open
- Suspected epiglottitis: no throat examination, no tongue blade, no throat culture; keep the child upright with the parent; give oxygen in a nonthreatening way (blow-by); have intubation and tracheostomy equipment at the bedside; notify the airway team immediately
- Choking child who cannot cough, cry, or speak: infants under 1 year — 5 back blows and 5 chest thrusts; children over 1 year — cycles of 5 back blows and 5 abdominal thrusts. Never do a blind finger sweep; remove an object only if it is seen. Start CPR if the child becomes unresponsive
- Monitor response to treatment
- After nebulized epinephrine, observe for returning stridor and retractions for 2–4 hours
- Reassess using a croup score; report stridor at rest, increasing retractions, restlessness, or decreasing responsiveness
- Hydration and comfort
- Cool fluids and soft foods; monitor urine output; antipyretics and analgesics as ordered
- For infants with colds: saline drops and gentle bulb suction before feeding and sleep
- Infection control
- Hand hygiene; droplet precautions for GAS pharyngitis until 24 hours of antibiotic therapy
- Post-tonsillectomy care
- Position on the side or abdomen until fully awake so secretions drain
- Watch for bleeding: frequent swallowing, clearing the throat, bright red vomitus, restlessness, rising pulse, pallor. Use a flashlight to inspect the throat
- Avoid suction, straws, coughing, and forceful nose blowing; offer cool, clear, non-red fluids (red fluids hide bleeding), then soft foods
- Pain control on a schedule (acetaminophen and ibuprofen); ice collar if tolerated
- Complete the full 10-day antibiotic course for strep throat even when the child feels better — this prevents rheumatic fever
- Croup at home: stay calm and hold the child; an upright position helps. Call emergency services for stridor at rest, severe retractions, blue or gray color, drooling, inability to swallow, or unusual sleepiness
- Tonsillectomy: bleeding risk is highest in the first 24 hours and again about 5–10 days after surgery when the scabs fall off; any bright red bleeding needs urgent evaluation. Encourage fluids; avoid rough and spicy foods
- OSA: observe sleep and record snoring, breathing pauses, gasping, and how long pauses last
- AOM prevention: vaccines, breastfeeding, no secondhand smoke, no propped bottles
- Foreign body prevention: children under 4 should not eat whole nuts, whole grapes, hard candy, popcorn, or round slices of hot dog; cut food into small pieces; children sit down and stay calm while eating (no running, laughing, or playing); keep small objects, coins, and button batteries out of reach; choose age-appropriate toys
- Learn infant and child CPR; keep Hib and other vaccines up to date
| Complication | What to watch for |
|---|
| Complete airway obstruction (epiglottitis, severe croup, foreign body) | Silent chest, inability to speak or cry, cyanosis, falling SpO₂, drop in level of consciousness |
| Impending respiratory failure | Stridor becoming quieter while effort increases, fatigue, bradycardia |
| Peritonsillar abscess | Severe one-sided throat pain, "hot potato" voice, trismus, uvula pushed to one side |
| Rheumatic fever / glomerulonephritis | Joint pain, carditis (2–4 weeks later), chorea (up to months later); edema, dark urine, hypertension (1–3 weeks later) |
| Post-tonsillectomy hemorrhage | Frequent swallowing, bright red blood, tachycardia |
| Button battery ingestion | Tissue burns within 2 hours — emergency |
- Priority in any child with respiratory distress: check SpO₂ and oxygenate before tests or transport
- Croup: barking cough, inspiratory stridor, hoarseness; dexamethasone for all severities, nebulized epinephrine for stridor at rest, observe 2–4 hours afterward; keep the child calm on the parent's lap
- Mist and humidified air are no longer recommended for croup
- Epiglottitis: drooling, dysphagia, muffled voice, tripod position — no tongue blade or throat exam, keep upright, airway team at bedside; Hib vaccine prevents it
- Strep throat: penicillin or amoxicillin for 10 days to prevent rheumatic fever; a negative rapid test in a child is confirmed by culture
- Post-tonsillectomy: frequent swallowing = bleeding; no straws, no red fluids; late bleeding at 5–10 days
- Codeine and tramadol are contraindicated after tonsillectomy in children under 18
- Avoid aspirin in children with viral illness (Reye syndrome)
- Foreign body: a normal X-ray does not exclude aspiration — bronchoscopy is needed when history suggests it
- Choking infant: 5 back blows + 5 chest thrusts; child: 5 back blows + 5 abdominal thrusts; no blind finger sweeps
Country Notes
United States
- Hib, pneumococcal, and influenza vaccines are part of the CDC/ACIP childhood schedule; Hib epiglottitis is now rare.
Philippines
- Hib and pneumococcal vaccines are provided through the DOH Expanded Program on Immunization; mandatory basic immunization for children under 5 is set by the Mandatory Infants and Children Health Immunization Act (RA 10152).
- Rheumatic heart disease remains an important burden, so full treatment of streptococcal pharyngitis is a key prevention step.