Croup

What is it?

Croup is soreness and swelling of the tissue in a baby’s or toddler’s voice box, windpipe, and breathing tubes. The same viruses that cause colds and laryngitis in older children and adults can cause croup in babies and toddlers. Most cases of croup happen during the late fall to early spring "viral season," but a few babies get croup at other times of the year. Croup is most common in children between about 6 months and 4 years, though it can occur outside of these age ranges. Croup almost always starts off with cold symptoms like a runny nose, sneezing, and coughing. After a day or two the cough becomes more persistent and changes its sound. The typical sound of a croup cough is called a "barky" or "seal-like" cough. In more severe cases you can hear raspy breathing even when the baby is not coughing. It sounds like this.  Babies with croup have sore, painful throats, so they tend not to feed as well as usual. They often cry after trying to swallow or use their voices. Most cases of croup follow a very predictable pattern: after the cough begins, it stays for about 36-72 hours and then goes away fairly quickly. Croup is almost always worse at night, and is usually at its most severe on the second night of the cough. Most children with croup are entirely better by the fifth day after the cough begins.

The most important concern in croup is to be sure that the child is able to move air through his or her windpipe and into the lungs. Because babies and young children have smaller sized windpipes, a little bit of swelling can close off a fairly large amount of space. Imagine trying to breathe through a straw, and you can get a feeling for how hard a baby with croup must work to move air. The air moving through the smaller space makes the raspy sound we call "stridor," and the swelling of the vocal cords adds the typical "barky" sound to the cough. If the space inside the windpipe becomes too small, it can be very hard for the baby to breathe. In the worst cases, babies become so exhausted from working hard to breathe that they may stop breathing. This is very rare.

Pain control and feeding are the other concerns in croup. Painful breathing and swallowing both make babies fussy and cranky. They may feed less, or even show no appetite at all. Parents often feel terrible because the baby seems hungry, starts to feed, and then cries when s/he swallows. Some babies can get dehydrated if this continues for too long.

Most babies with croup develop a fever between about 100.4°F (38°C) and 104°F (39.5°C). The fever is caused by the same virus that causes the croup, and is not dangerous.

Most croup goes away on its own after a few days. These days most doctors give a single dose of a steroid medication such as dexamethasone (Decadron® and others). Steroids reduce swelling and pain, and at this dose they are very safe. Doctors usually give one dose right at the office or hospital. The medication lasts about 3 days, and croup is usually better by the time it wears off, so there is rarely any need to re-dose it. In more severe cases, emergency room doctors often use a mist of a medicine called epinephrine (adrenaline). This medicine rapidly shrinks the swollen tissues and makes it easier for the baby to breathe. Your doctors will have watched you in the hospital for a few hours if they gave your baby an epinephrine treatment. It is safe to go home after a few hours, but you will still want to watch the baby carefully and give other measures for comfort.

You can do a few things that help your child to breathe more easily and to reduce the pain and the cough. Cool, moist air always helps soothe babies with croup. If possible, please run a humidifier in the baby’s room to keep a steady supply of moist air. Please do not put any medication in the humidifier – some medications can be irritating to the baby.

Croup usually gets better by day and worse by night, and it can change fairly quickly. If your child with croup gets worse, we recommend going outside onto a porch, balcony, or deck for 15-20 minutes (of course, make sure you and the baby dress warmly). Since croup usually happens in the cooler months, chances are the outside air is just the right temperature. If your child’s breathing seems OK, but you find yourself wondering if you need to return to the doctor or hospital, you might try first taking the baby for a drive around the block a few times with the windows open (again, warmly covered). Very often, in less time than it would have taken to get to the doctor, the baby feels much better and you’ve saved a trip. If the baby isn’t better after 15-20 minutes, you can head for the hospital already loaded into the car. If it is not safe or practical to go outside, you can try running the shower to make steam or mist, and sitting in the bathroom with the baby. If these measures make the baby more comfortable, it is safe to stay home.

Talk, sing, or read to the baby to help soothe and calm him or her – this makes the breathing much easier. You can use acetaminophen (Tylenol®) or ibuprofen (Advil® or Motrin®) to control fever and pain in children over 3 months. Check with your doctor about using it in younger babies. Fever is not dangerous, but it can make the baby uncomfortable. If your baby seems comfortable there is no reason to give any medication just for fever. Please do not use any cough or cold medications. These can make matters worse, and they do not help in croup.

Because croup can change fairly quickly, some parents prefer to move the baby into their own rooms at night. This is fine, or you may want to use a baby monitor.

Most cases of croup are mild, but the disease can change quickly. Warning signs of a more severe case of croup include:

• Pulling in of the skin over the collarbones, between the ribs, or above the breastbone when the baby breathes in
• Flaring nostrils
• Raspy breathing sounds that you can hear when the baby is just breathing quietly and not crying (we call this "stridor at rest")
• Paleness or a bluish color around the lips, eyes, and fingernails
• Extreme irritability or extreme sleepiness (lethargy)
• Signs of dehydration including dry mouth, sunken eyes or fontanel (soft spot), cool hands and feet, or decreased urination
• Drooling or inability to swallow
• In children old enough to sit, a posture of leaning forward, head tilted up, with the mouth open to breathe (the "sniffing position")

Most children get croup only once or twice. A few children, however, seem to develop croup almost every time they get a cold. Parents of these children learn to gauge when their child is getting bad enough to need a trip to the doctor. Often, starting the comfort measures like cool air and humidity at the first signs of a cold can help to head off a more severe attack of croup.

Most children with the symptoms of croup just have a viral infection and will get better as we’ve outlined above. In some cases, though, a raspy, barky cough and difficulty breathing can be caused by something else. Here are a few possibilities:

• An object (like a coin or a small part of a toy) stuck in the child’s throat, windpipe, or esophagus. Children with foreign objects like these are usually having a great deal of trouble breathing or speaking. They usually do not have a fever, and the symptoms start very suddenly. This is an emergency and requires an ambulance visit to an emergency room.
• Sudden swelling of the flap that protects the windpipe from food and liquids – this condition is called "epiglottitis" (epp-ee-glott-eye-tiss). Children have a very high fever, are flushed, and have glassy eyes. They often are sitting up, leaning forward with their head tilted up in the "sniffing position." This is an emergency and requires an ambulance visit to an emergency room. Fortunately, epiglottitis is very rare in children who have had their vaccination against the germ called "Hib."
• Very rarely, children develop a condition called "bacterial tracheitis." In this severe illness, there is a bacterial infection in the trachea that causes swelling and can completely block the airway. Children with bacterial tracheitis have high fevers, are ill-appearing, and are usually struggling to breathe. They may look a little better after an epinephrine treatment, but get worse very rapidly. If your doctor suspects bacterial tracheitis, s/he will keep your child in the hospital for observation.

Having a sick child at home can be tiring and frustrating. As badly as you feel for your child, you yourself may feel out of control, inadequate, or even angry – these are normal feelings. Babies and children who are sick are often fussy and irritable, and parents often feel stressed to the breaking point, especially when there are other children or adults to take care of. One of the best things you can do for your child is to be sure you take care of yourself. If possible, try to have other adults take care of your child for an hour or two each day so you can get some rest or just some quiet time. If you get so stressed that you are worried about your baby’s safety, call your local Parents’ Anonymous Hotline or visit the Parents Anonymous website to find a group near you.