Paediatrics
Westley Croup Score
Severity of croup in children.
Education and reference only. Not a substitute for clinical judgement, local policy or product labelling. Always verify before clinical use. Values are calculated in your browser and never stored.
Background
The Westley croup score grades the severity of croup (laryngotracheobronchitis) in children using five clinical features: level of consciousness, cyanosis, stridor, air entry and chest-wall retractions. Each feature is weighted, and the points are summed to a maximum of 17. It was originally devised as a research tool to assess response to treatment, and is now used to standardise severity assessment and help guide management and disposition. The most heavily weighted items — altered consciousness and cyanosis — reflect the most dangerous signs.
Interpreting the result
A total of 2 or less indicates mild croup, usually manageable with supportive care. A score of 3 to 5 indicates moderate croup, where corticosteroid treatment and a period of observation are appropriate. A score of 6 or more indicates severe croup or impending respiratory failure, requiring urgent treatment and close monitoring. The presence of stridor at rest, marked retractions, altered consciousness or cyanosis are particularly concerning and should prompt escalation regardless of the precise total.
Worked example
A child with croup has stridor audible at rest (2 points), moderate retractions (2 points), and mildly decreased air entry (1 point), but normal consciousness and no cyanosis. The total is 5, placing the child in the moderate category — warranting corticosteroid treatment and observation, with readiness to escalate if they worsen.
Pearls / pitfalls
- Avoid distressing the child during assessment — agitation worsens stridor and respiratory effort and can precipitate decompensation.
- Cyanosis and altered consciousness are late, dangerous signs carrying the highest weight — their presence mandates urgent action.
- The score guides but does not replace clinical judgement; a child who looks unwell should be treated as such regardless of the number.
- Most croup is mild and viral; consider alternative diagnoses (e.g. foreign body, bacterial tracheitis, epiglottitis) if the picture is atypical.
Evidence & validation
Derived by Westley and colleagues in 1978 to quantify croup severity in a treatment trial, the score has since been used widely in research and clinical practice as a standardised measure, and underpins severity definitions in paediatric croup guidance.
Frequently asked questions
What Westley score indicates severe croup?
A score of 6 or more indicates severe croup or impending respiratory failure, requiring urgent treatment and close monitoring. Scores of 3–5 are moderate and 2 or less are mild.
Which signs in the score are most worrying?
Altered level of consciousness and cyanosis carry the most points and are the most dangerous, late signs. Their presence, along with stridor at rest and marked retractions, should prompt immediate escalation.
Should I examine the throat of a child with suspected croup?
Avoid distressing examinations, including of the throat, as agitation can worsen airway obstruction. Keep the child calm and assess from a distance where possible, escalating if there are danger signs.
Is corticosteroid treatment used in croup?
Yes, corticosteroids are a mainstay of croup management across mild to severe disease, given to reduce airway inflammation. The Westley score helps gauge severity and the need for additional measures and observation, though specific treatments are decided clinically.
References
- Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child. 1978;132(5):484–487.
- NICE Clinical Knowledge Summaries: Croup. National Institute for Health and Care Excellence.
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