Croup

In residency, we used to say that we could make a croup diagnosis as soon as a child walks into a waiting room. 

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The reason for this, is, of course, the characteristic cough - kids with croup sound like they swallowed a seal. But that’s only one important thing to know as a parent. Here are some others.

What is it?

“Croup” is actually the name given to the cough caused by a narrowing upper airway. In many cases, this is caused by infection - but there are many other possible causes as well.

Regardless of the cause, the mechanism that creates the cough remains the same. The tell-tale barky cough and stridor are a result of air passing through the narrowed upper airway (larynx, trachea).

Croup is more common in fall and winter and we see it most in the youngest children - under 5y - because they have the smallest airways.

Why is it a problem?

Narrowing of the airway can cause problems with air passage. In younger children, who have smaller airways to begin with, croup can progress to worsening respiratory distress and become quite serious.

Symptoms

These can include:

• Hoarse voice

• Classic seal-like barky cough (I posted examples on my instagram today)

• Stridor (which is a high-pitched sound that is typically heard when breathing in)'

• Sometimes - but not always - you can see:

  • Fever

  • Runny nose, congestion

  • Post-nasal drip

  • Vomiting or diarrhea

The Pediatrician Mom Tip: Because laying down increases postnasal drip and irritation/swelling of the airway, croup often gets worse at night or when sleeping.

Causes

Any reason for airway narrowing can trigger the symptoms of croup. These can include:

• Viruses (most commonly parainfluenza, which is different from influenza — although the flu can certainly cause these symptoms)

• Allergies

• Reflux

• Anatomy: some kids naturally have smaller airways and become croupy-sounding every time they have a cold. If this is your child, talk to your pediatrician about an ENT evaluation.

Transmission & Incubation:

These can vary based on the specific cause of the croup symptoms.

• If it is viral, then it usually spreads through respiratory secretions and sometimes via contact or on surfaces. This is why hand-washing and distance can be so important.

Incubation period in most people is 2-7 days, but again this can vary.

Who is at highest risk?

As with so many other viral illnesses, those at higher risk tend to be the youngest (especially under 2y), the oldest (especially over 65y), and those with underlying health issues (such as immune-compromise, asthma or other lung disease, heart issues, developmental delay and muscle tone issues, etc)

Treatment:

f your child’s croup is caused by other issues, such as laryngomalacia or other airway abnormalities, or reflux, their treatment likely will depend on the cause.

For most children, however, croup symptoms are caused by an infection and the focus is often supportive care. But there are some specific things to watch out for:

Things to try

Assess breathing: 

• See my other posts on this, but briefly; check breathing rate over 1 minute, assess work of breathing, comfort, color, and listen for extra sounds. Increased work of breathing may be evident by nasal flaring, retractions, or head bobbing. There are examples of all of these on my instagram page.

• Listen for stridor specifically

  • Stridor is a high pitched sound typically heard when breathing in.

  • If you hear stridor, note:

    • Is it only when upset or crying or even when they are relaxed/sleeping (“at rest”)?

    • Stridor at rest is an emergency. Stridor with agitation still needs an immediate phone call to your pediatrician, but in the meantime you can try some of the steps below.

The Pediatrician Mom Tip: If your child has stridor with agitation, or even if you simply suspect croup, try your best to keep them calm and relaxed while you assess and talk to your pediatrician (yes, yes, easier said than done).

Steam inhalation:

• This post outlines several tips and products to help.

• We really like the steam shower method, and this can be done several times a day for comfort.

Cold air:

• Stepping out into the cool air or breathing in front of the freezer can both be very helpful as well!

Fever:

• Remember, your focus here is comfort. Sometimes fever can make kids uncomfortable, less likely to drink, and breathe faster - so use fever-reducing medications as needed. But the fever is not dangerous and if your child is calm and comfortable then they do not need medication.

• Dosing for fever reducers is here.

Hydration:

• Pedialyte, popsicles, smoothies, cold jello

• Watch for signs of dehydration; see this post for more.

Other treatment options

If you end up at the doctor, they will assess your child and determine what, if anything, is needed. Interventions can include:

• Steroids: can be given orally or IV and work to decrease the inflammation in the upper airway (thereby making it less narrow). They can work quite quickly.

• Breathing treatments: can be racemic epinephrine, which is not the same medication as is used for asthma. If your child needs this, they will typically be on a monitor and need observation afterwards.

• IV fluids and other supportive care

When to call the pediatrician

This is not a comprehensive list. In general, always err on the side of calling your pediatrician if you have any concerns about your child. There is a lot to be said for a parent’s gut instinct, and I promise: your pediatrician would rather you called!

If your child is not improving within a few days, or if they seem to be getting worse, call your pediatrician. Other concerning symptoms include:

• Stridor (especially if at rest but any at all warrants a call)

• Dehydration — see my prior posts for signs to look for. I also have a new free cheat sheet under guides with step by step instructions on what to do.

• Any signs of difficulty breathing (see here).

• Lethargy/difficulty arousing

• Drooling or difficulty swallowing

• Any underlying medical conditions or risk factors, including young infants under 6-12 months

• A history of recurrent croup

• Anything else tickling your spidey sense!!

FAQs

Why do some kids get recurrent croup?

Some kids are prone to this because of an intrinsically narrow airway. If your child gets croup more than twice per year, talk to your pediatrician about whether or not they recommend an ENT evaluation.

What is spasmodic croup?

Sometimes allergies or reflux can cause sudden-onset croup that seems to come out of nowhere (usually at night). The symptoms are the same - hoarseness, stridor, and a barky croup - and it may need treatment of the underlying cause.

Does my child need to stay home from school?

Yes. Keep them home until they are feeling better (able to stay hydrated, acting more like themselves) and fever free for >24h.

Take a little extra time for snuggles - we know that can help little ones stay calm and feel better!

Croup is tough - and can change really quickly - so watch closely and stay in close touch with your pediatrician - remember, we would prefer that you called!