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Omicron variant of SARS-CoV-2 associated with increased croup virus in children

Researchers at Boston Children’s Hospital have identified a link between increased prevalence of croup among children and the omicron variant of SARS-CoV-2. (Credit: Olga Siletskaya/Moment via Getty Images)

The underlying SARS-CoV-2 has changed during the course of the COVID-19 pandemic. Early forms of SARS-CoV-2 infection in children largely affected the lower respiratory system, although later variations had varied effects. The SARS-CoV-2 Omicron variant, in contrast, favors the upper respiratory tract.

Although it is well recognized that common coronaviruses may induce croup, or a “barking cough”, nothing is known regarding the relationship between croup and SARS-CoV-2 infection.

In a new longitudinal study, croup incidence and clinical characteristics in kids with SARS-CoV-2 infection were analyzed.

According to the new research, the emergence of the omicron variant in December 2021 coincided with a dramatic rise in the prevalence of croup and a concurrent SARS-CoV-2 infection. The study showed that out of the 75 children assessed for COVID-19 related croup, 81% presented with the omicron variant. Other substantial increases in COVID-19 incidence did not correspond to an increase in croup incidence. SARS-CoV-2 infection may have a more severe phenotype than other viral illnesses, according to observations of hospitalization and redosing rates for croup-directed therapy.

The authors explained their results, stating, “Taken together; our preliminary findings lend compelling evidence to the hypothesis that the omicron variant causes laryngotracheobronchitis [croup].”

It’s important to note that the data used in this research study came from a single hospital. The study’s findings may not be generalizable to a wider population because the sample size is small. However, this study is the largest and first investigation on COVID-19-related croup.

The paper concludes by stating, “Further research is needed to characterize the underlying mechanisms of COVID-19–associated croup, differences in clinical features from other viral etiologies, and appropriate management strategies in the SARS-CoV-2 era.”


The study was published in Pediatrics on May 13th, 2022.

Abstract. As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has evolved, so has its effects on the pediatric population.1  Although early variants typically resulted in lower respiratory infections, the recently identified ο variant may exhibit a predilection for the upper airways.2  The relatively smaller upper respiratory tract in children compared to adults has been thought to predispose them to more severe clinical presentations resembling laryngotracheobronchitis, or croup. Caused by viral-induced subglottic airway inflammation, croup is classically characterized by sudden onset “barking cough,” inspiratory stridor, and respiratory distress. Endemic coronaviruses have been linked to croup; however, only sparse case reports have described croup specifically associated with SARS-CoV-2, and it remains unclear if croup cases constitute a causative relationship or result of coinfection with another virus.36  To address this knowledge gap, we performed a retrospective analysis of the incidence and clinical characteristics of croup associated with SARS-CoV-2 infection at a large freestanding children’s hospital.

Ryan CL Brewster, Chase Parsons, Jess Laird-Gion, Sidney Hilker, Margaret Irwin, Alba Sommerschield, Katherine A Michaelis, Michael Lam, Andrew Parsons, Jonathan M Mansbach; COVID-19–Associated Croup in Children. Pediatrics June 2022; 149 (6): e2022056492. 10.1542/peds.2022-056492

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