What it is
The Westley croup score is a validated clinical severity score for laryngotracheobronchitis (croup). It standardises the bedside assessment of airway obstruction, helps decide who needs nebulised adrenaline and admission, and gives an objective before/after measure of treatment response.
The components
Five clinical items, no investigations needed:
| Item | Scoring |
|---|---|
| Level of consciousness | Normal (incl. sleep) = 0; disoriented = 5 |
| Cyanosis | None = 0; with agitation = 4; at rest = 5 |
| Stridor | None = 0; with agitation = 1; at rest = 2 |
| Air entry | Normal = 0; decreased = 1; markedly decreased = 2 |
| Retractions | None = 0; mild = 1; moderate = 2; severe = 3 |
Total range 0–17. Note the score is weighted toward the two ominous signs — altered consciousness and cyanosis at rest each contribute 5 points.
Severity bands
- ≤ 2 — mild: barky cough, stridor only when upset, no resting stridor or recession.
- 3–5 — moderate: stridor and recession at rest, child still interactive.
- 6–11 — severe: stridor at rest with marked recession, agitation or lethargy.
- ≥ 12 — impending respiratory failure: decreasing air entry, cyanosis, fatigue.
When to use it
Use it at triage and after each intervention in any child with stridor and a barky cough. Re-score after dexamethasone or nebulised adrenaline, before deciding on disposition or escalation.
Worked example
A child with stridor at rest (2), moderate retractions (2), decreased air entry (1), no cyanosis (0), normal consciousness (0) scores 5 — moderate croup. Give corticosteroid, observe, and re-score.
Treatment mapping
- All severities, including mild, get a corticosteroid. Dexamethasone 0.15–0.6 mg/kg PO/IM/IV (commonly 0.6 mg/kg, single dose) reduces re-attendance, length of stay, and the Westley score at 6 and 12 hours.
- Nebulised adrenaline (racemic, or 1:1000 L-adrenaline) is added for moderate–severe croup (resting stridor/recession, roughly score ≥ 3–6 and worsening). It buys rapid, transient relief.
- Observe for rebound. Adrenaline’s effect wanes by ~2 hours; a child who received it must be watched at least 2–3 hours for return of obstruction before any discharge.
Pitfalls and caveats
- Rebound after adrenaline is the classic trap — never discharge straight after a neb.
- Agitation worsens obstruction; keep the child calm and on the parent’s lap. Don’t force examination.
- Consider alternatives to croup — bacterial tracheitis, epiglottitis, foreign body, retropharyngeal abscess — if the course is atypical, toxic, or drooling/dysphagia dominate.
- The score guides but does not replace continuous clinical judgement; a tiring child can deteriorate faster than the number suggests.
Run it: Westley Croup Score
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.