Pediatric Recurrent Croup: An International Delphi Consensus Statement

Recurrent croup lacks a consistent diagnostic definition, resulting in substantial variation in investigation and management. We aimed to develop international consensus-based recommendations for the evaluation and management of pediatric recurrent croup.

PubMed/MEDLINE, Scopus, Cochrane Library, and EMBASE searched from 1st January 2000 to 15th August 2026, with results reported in accordance with PRISMA guidelines.

An international modified Delphi consensus process was conducted. Panelists rated statements using a 9-point Likert scale across two rounds. Strong consensus was defined as a mean ≥ 8.00 with no outliers; consensus as mean ≥ 7.00 with no more than one outlier.

Review of 28 studies confirmed substantial heterogeneity in the definition and investigation of recurrent croup, with most studies at moderate to high risk of bias. Strong consensus was achieved on prioritizing direct laryngoscopy and bronchoscopy in atypical presentations, including subglottic sizing and exclusion of a laryngeal cleft, and limiting allergy testing to children with clinical suspicion of atopic disease. Consensus supported shared otolaryngology-respiratory management, avoidance of routine imaging, and reserving advanced reflux investigation for refractory cases. No consensus was reached on empirical inhaled corticosteroids or antireflux therapy.

This study provides the first international multidisciplinary consensus guidance for the evaluation and management of recurrent croup, supported by a proposed risk-stratified management algorithm. Agreement on core diagnostic and endoscopic priorities may help standardize clinical practice, while the absence of consensus on optimal medical management identifies clear priorities for future research in a field where high-quality prospective data remain lacking.

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