Croup

What is Croup?

Croup is a viral respiratory infection that causes inflammation and swelling of the larynx (vocal cords) and trachea (windpipe). It occurs primarily in infants and young children between 6 months and 3 years of age, and is rarely seen in children older than 6 years old. It is most commonly seen in the fall and early winter months when cold viruses are going around.

Parainfluenza virus and Influenza virus (the Flu) are the most common respiratory viruses to cause croup, but any viral respiratory infection can cause it. These viruses also cause other respiratory illnesses, like a head cold, pneumonia, or bronchiolitis. How any particular virus affects any one patient depends on the age of the patient and the shape of the patient's respiratory system, among other factors. Infants and young children have small airways to begin with, which is why they are prone to croup.

Symptoms

Croup is usually mild and lasts less than one week, although it is possible for symptoms to become severe and life-threatening. Symptoms may start gradually or abruptly, usually beginning with nasal congestion and drainage, which progresses within 12 to 48 hours to hoarseness and a characteristic barking cough. The cough is often described as sounding like a seal or dog barking. Symptoms are usually much worse at night, and the second and third nights of the illness are usually the worst.

If croup progresses, the upper airway becomes swollen and narrow. High-pitched, noisy breathing when breathing in (called stridor) can develop. The child may breathe faster and may possibly appear restless or anxious as breathing becomes more difficult.

Fever is often present and ranges from mild (100.4°F or 38°C) to very high (104°F or 40.5°C). Dehydration can occur because of decreased fluid intake.

Contagiousness

Croup is caused by viruses which can be spread easily through coughing, sneezing, and coming into contact with respiratory secretions. Children with croup should be considered contagious for three days after the illness begins and until the fever is gone.

Diagnosis

The diagnosis of croup can usually be made on the basis of the child's symptoms, including a barking cough and stridor. Laboratory testing and X-rays and are rarely needed.

Treatment

The treatment of croup depends upon the severity of symptoms. Children with mild symptoms generally are treated with conservative measures at home. A child with moderate to severe symptoms, or who is at risk for rapid worsening, should be treated in an emergency department.

Mild to moderate croup

Warm steam is often very helpful. Try steaming up your bathroom and sit with your child. Cold dry air also works very well. If it is cold outside, bundle your child up and take him for a walk.

If your child has a fever, give her Tylenol or Motrin to make her more comfortable.

Warm clear fluids may help with coughing spells.

Smoking in the home should be avoided; smoke can worsen a child's cough.

Keep your child's head elevated. This can be accomplished with pillows for older children or with a phone book under a crib mattress for infants. Consider sleeping in the same room with your child during an episode of croup so you will be immediately available if your child begins to have difficulty breathing.

Moderate to severe croup

If you think your child has severe croup, call our office immediately or proceed to the nearest emergency room. If you think your child's croup is moderate but not responding to steam and cold air, call our office or take your child to the emergency room.

For moderate to severe croup, oral steroids such as Orapred or Decadron are usually prescribed. These medications help decrease inflammation and, therefore, the cough and stridor as the body fights off the virus.

If breathing is labored, breathing treatments (racemic epinephrine) can provide relief. The breathing treatment lasts about four hours, so the child needs to be observed carefully for continuation or worsening of symptoms as the medication wears off.

Other therapies

Other therapies, such as antibiotics, cough medicines, or decongestants are not routinely recommended for children with croup.

Prevention

Unfortunately, there is no way to prevent croup. Handwashing and use of alcohol based hand rubs help decrease transmission.

Seek help immediately for:

• Difficulty breathing that is unresponsive to steam or cold air, or difficulty breathing even while at rest and calm
• Pale or blue-tinged (cyanotic) skin
• Severe coughing spells
• Drooling or difficulty swallowing
• Inability to speak, cry, or drink due to difficulty taking a breath
• Sucking in of the skin around the ribs and top of the sternum (retractions) with breathing

***Parents should not attempt to drive their child to the hospital if the child is severely agitated, cyanotic, struggling to breathe, or excessively drowsy (lethargic); emergency medical services should be called by dialing 911.