Croup

Croup is a common viral respiratory infection in young children. While it is very similar to the common cold, it has some symptoms that can be more serious than a typical cold. It is also sometimes scary to both children and their parents. Croup is characterized by a distinctive cough (“barking cough”) and hoarseness or laryngitis. It usually affects children 4 years old and younger; older children and adults will have a cold with some hoarseness or laryngitis. It typically occurs in the late fall and winter months. Since croup is a viral illness, antibiotics cannot be used to treat it.

Symptoms

• Runny nose
• Fever, which may be as high as 104-105 F. (Remember fever will not harm your child.)
• Dry, harsh cough that sounds like a seal barking. It is very distinctive cough.
• Hoarse voice
• Sometimes a sore throat
• Stridor, a harsh low-pitched sound when the child is breathing in. Usually occurs just when child is crying, upset, or coughing. If it occurs when child is resting or sleeping, this is much more serious.

Cause

Croup is a viral infection in which the infection causes both upper respiratory symptoms like a runny nose and also causes swelling in the throat and vocal cords. The technical term for croup is laryngotracheitis, which means inflammation of the larynx (voice box) and trachea (“windpipe”). Swelling of the vocal cords causes the hoarseness, and swelling of the trachea causes the distinctive cough. Stridor occurs when the airway becomes even narrower. The most common cause of croup is one of the parainfluenza viruses, but it can also be caused by RSV, influenza and other respiratory viruses.

Some children are more prone to croup than others, with frequent croup symptoms whenever the child has a cold. This may be due to the nature of the child’s airway. Whatever the reason, children almost always outgrow it by the age of 5 or 6 years.

Clinical course

Croup starts off as a normal cold, with clear runny nose, nasal congestion and mild cough. There is often a fever, and sometimes the child complains of a sore throat. Two to four days after the runny nose starts, a cough develops, like with many colds. However, in this case the cough is dry and harsh sounding. It has a distinctive sound described like a seal barking. The cough is almost always worse at night. The child usually has a hoarse voice as well. At night, the child often has stridor with agitation or crying. Children often have episodes of cough and stridor followed by relief of symptoms. Episodes usually occur 1-2 nights in a row and then croup symptoms start to get better.

The danger of croup is that the airway can become so narrow that breathing becomes labored or impossible. Warning signs are stridor at rest, drooling, or labored breathing. Moderate to severe croup can be treated in the emergency room with nebulized epinephrine, which decreases the swelling of the airway. The child should then be observed for 2 hours; if stridor at rest or other symptoms do not recur, then the child can usually go home. More seriously ill children require observation and treatment in the hospital. The routine use of steroids has decreased the frequency of severe croup and hospital admission.

Runny nose and congestion can last 7-10 days, along with some cough. The barking cough and stridor episodes typically are at their worst only 1-2 nights before getting better.

Treatment

Treatment for croup episodes

• Traditional treatment has been to breathe water vapor, though recent research suggests that this may not be of any benefit. Take the child into the bathroom and run hot water to steam up the room and let the child breathe the steam. Try to keep your child calm.
• You can also try taking the child out into cool night air or letting the child breathe air in front of your freezer. If you have a humidifier (not a hot vaporizer), you can let your child breathe the mist from it.
• If your child worsens or does not improve after 15-20 minutes, then she may need to be evaluated at an emergency room. If your child turns passes out, has extreme difficulty breathing and/or is turning blue, call 911.

General treatment

• Steroids have become standard treatment for croup, even mild cases. Steroids have been shown to prevent mild croup from becoming severe. Sometimes one dose is given, either orally or as an injection, and sometimes it is given for several days.
• Acetaminophen or ibuprofen can be given for fever or discomfort.
• Cough and cold medicines do not usually help children under the age of 5 and can have side effects. They usually do not help with croup.
• Children over 4 can suck on hard candy or cough drops if they help. Younger children can try 1/2 to 1 teaspoon of corn syrup for the cough.
• Warm, clear fluids can help with congestion and sometimes cough.
• A humidifier may help.
• Most young children who are ill have decreased appetite. It is generally OK if your child does not eat much, as long as she has adequate fluid intake. Adequate fluid intake in a young child means being able to make some urine at least every 6-8 hours, though it may not be as much urine as usual.
• Children with croup require close observation. Since symptoms are worse at night, many parents feel more comfortable sleeping in the same room with their child when the symptoms are at their worst.
• Antibiotics do not treat croup viruses.

Complications

Complications are similar to other respiratory viruses and include otitis media (ear infections), sinusitis, and pneumonia. Severe croup, as noted, may lead to breathing difficulties or respiratory arrest.

Prevention

Like other viral diseases, the primary means of prevention is handwashing and good hygiene. Croup viruses are spread through respiratory secretions.

Return to daycare or school

Croup is contagious, but like other viral illnesses the spread of the infection is almost impossible to prevent. Your child should stay home while she has a fever and while she has significant cough. Your child can return to daycare or school when she feels better and is drinking well on her own.

References

1. Russell, K.F., Liang, Y., O’Gorman, K., Johnson, D.W., and Klassen, T.P. (2011). Glucocorticoids for croup. Cochrane Database Syst Rev CD001955. doi:1002/14651858.CD001955.pub3 PMID: 21249651
2. Moore, M., and Little, P. (2006). Humidified air inhalation for treating croup. Cochrane Database Syst Rev CD002870. doi: 1002/14651858.CD002870.pub2 PMID: 16855994
3. Bjornson, C., Russell, K., Vandermeer, B., Klassen, T.P., and Johnson, D.W. (2013). Nebulized epinephrine for croup in children. Cochrane Database Syst Rev 10, CD006619. doi:10.1002/14651858.CD006619.pub3 PMID: 24114291
4. Cherry, J.D. (2008). Croup. N Engl J Med 358, 384–391. doi:1056/NEJMcp072022 PMID: 18216359
5. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med 2004; 351:1306. doi:1056/NEJMoa033534 PMID: 15385657