You are sound asleep. Suddenly, a barking dog wakes you up. But you don’t have a dog. The “barky” cough of croup is notorious for coming on abruptly, often without warning in the middle of the night. It can be frightening for both parents and children. Fortunately, in most cases, the bark is typically worse than the bite!
What is Croup?
Croup is a viral illness that triggers swelling of the larynx and trachea. Those are just fancy words for the voice box and windpipe. A distinctive barking cough and/or high-pitched, “crowing” noise (which we call stridor) happens when air is forced against a constricted airway during a breath in or a cough. The smaller the child, the more prominent the sound.
It primarily affects infants and children, between the ages of 6 months and 3 years of age. It peaks around 24 months of age. As children grow, so do their airways. Therefore, children above the age of 6 are rarely diagnosed with croup.
What are the Symptoms of Croup?
Symptoms progress as the virus travels from the nose to the throat and eventually reaches the upper respiratory tract. The first symptoms that you may notice in your child are that of a common cold such as a runny nose, a hoarse voice, and fever. After 1-2 days of cold symptoms, the telltale barky cough sets in. You may ask yourself – when did my sweet toddler turn into a barking seal?
The stories are all very similar – the child that was once well-appearing goes to bed and wakes suddenly in the middle of the night with a harsh cough and difficulty breathing. By the morning, symptoms often improve, and you think that your child may be in the clear. Unfortunately, as most parents that have cared for a child with croup will tell you, the symptoms often reappear in full force the following night. This is common in croup, as the cough peaks on night 2 or 3 and then progressively improves. The good news is that symptoms of croup are usually mild and typically resolve in a week.
How do I know if my child has mild vs. moderate-to-severe symptoms of croup? Below is a cheat-sheet that differentiates characteristics of children with mild, moderate, and severe croup. Parents can often manage mild croup at home, while a medical provider needs to evaluate moderate and severe croup.
Croup Severity Cheat-sheet
|Behavior||Barky Cough||Chest wall retractions||Stridor|
|Mild Croup||No agitation||Occasional barky cough||Either no or mild retractions||No stridor at rest (may be present when upset)|
|Moderate Croup||Little or no agitation||Frequent barky cough||Mild-to-moderate retraction||Stridor at rest|
|Severe Croup||May appear anxious, agitated, or pale and fatigued||Frequent barky cough||Severe/marked retractions||Stridor at rest|
“Chest wall retractions” is just the medical word to describe those extra muscles along the ribcage and around the neck sucking in when kids work hard to breathe.
Is Croup Contagious?
Croup is contagious. Kids get it by breathing in airborne droplets. That means one person can pass it to another through coughing, sneezing, and close contact. So pretty much you’re telling me not to breathe or touch anything, right? Frequent hand washing with soap and water is the single most important tool in infection control – a few seconds at the sink can save you a trip to the doctor’s office.
Children are contagious for three days after the onset of the illness or until the fever has subsided.
Why Do Children Get Croup and Not Adults?
There are some benefits of being an adult. One of them being that our airways are approximately 4x the size of an infant’s in diameter. What does that mean in layman’s terms?
Pull out your wallet and compare a dime to a quarter – which is larger? At this point you may be asking yourself, is this a trick question? Obviously the quarter! Well think of the dime being the size of an infant’s airway, while the quarter is the size of an adult’s airway – minimal swelling of the larynx/trachea will have a much more dramatic impact on an infant’s airway than an adult’s. While inflammation of an infant’s and child’s upper airway may lead to the trademark barky cough, stridor, and difficulty breathing, adults are much more likely to have symptoms of a common cold and hoarse voice, or laryngitis.
Basically, kid airways are floppy. Adult airways are more rigid and thus less likely to close up when irritated and swollen.
What Can I Do To Make My Child More Comfortable?
Croup can be successfully managed at home for most children. Here are a few tips that can help ease your child’s breathing:
*Try to remain calm. If your child sees that you are upset, it will likely increase his/her anxiety and lead to crying which can cause labored breathing.
*At nighttime, stay in close proximity to your child. That way you can comfort and monitor him/her.
*Cool, humid air seems to do the trick. If you don’t have a cool-mist humidifier at home, please don’t run to the store in the middle of the night to buy one. If it is a cool night, cover your child in a blanket and take him/her outside to breathe in the cold air. You could even open the freezer and have your child breathe in the cold air! Just remember, kids can’t get sick from being outside. They won’t “catch pneumonia,” if you take them outside to breathe soothing cold air.
*Keep your child’s head elevated. Prop an extra pillow under your child’s head while he is in bed or place your infant in her car seat. Do not use pillows with infants younger than 12 months of age.
*Encourage warm or cold, clear fluids. Fluids not only help loosen mucus on the vocal cords, but can also soothe a sore throat and make sure the child stays hydrated.
*If your child has a fever (100.4F), you can give acetaminophen (Tylenol) or ibuprofen (Motrin) > 6 months. KidMed even has a dosing chart for Tylenol and Motrin, based on your child’s weight.
What NOT to do:
*Do not give your child over-the-counter cough or cold medicines. A cough is a protective reflex that aids in clearing secretions or irritants from your throat and airway.
*Avoid smoking in the home or around the child. Smoking can make your child’s cough worse.
When To Seek Medical Care?
Most cases of croup are self-limited and can be treated at home. Children with moderate to severe croup should be seen by their pediatrician, or after hours by a pediatric provider at KidMed.
Tip: Bring a video clip of your child having croup symptoms – that way your provider can see what your child looks and sounds like. Croup often improves during the day, so by the time you’ve reached your PCP’s office or KidMed, they may have few symptoms.
Croup is viral, so antibiotics are not helpful. There is no magic pill to make a virus disappear. There are certain medications that can reduce swelling of the upper airway and make your child breathe more easily.
The most effective treatment for all types of croup is dexamethasone, or Decadron, a type of corticosteroid. It is a safe medicine that reduces airway swelling. When children hear the term medicine, they quickly ask, “Does this mean I have to get a shot?” Unless oral intake is not possible, oral steroids are the preferred route of administration.
Parents often ask, “When should I start to see a difference in my child’s symptoms?” The medication should kick-in within 2 hours, but it can take up to 4-6 hours for you to notice a difference in your child’s breathing. During this time, do what you can to keep your child calm – help distract him/her by reading stories or watching television.
While we can’t promise you that this will knock out the cough completely, steroids are known to take the “bark” out of croup. They can also soothe sore throats. We recommend 2 doses of Decadron, 24 hours apart. The combined benefit of the 2 doses allows for a therapeutic steroid effect over the 2-3 day peak period of croup.
Who doesn’t want that, right?
If your child has stridor (that whistling breathing noise we talked about earlier) at rest AND symptoms of moderate to severe croup, nebulized epinephrine is an effective treatment. Racemic epinephrine is an inhaled medication that is administered via breathing mask; it also assists in reducing airway inflammation. At 30 minutes post-treatment, there is a significant reduction in symptoms of croup.
Your child will need to be observed for at least 1-2 hours, because the effects of epinephrine are usually brief. Children with recurrent, or worsening symptoms, may need an additional treatment or admission to the hospital.
When Should I Take My Child to KidMed or the Emergency Room (ER)?
When in doubt, call your child’s health care provider.
Do not hesitate to go to KidMed or the ER, if your child:
*Is having difficulty breathing (sucking in between their ribs or above their collarbone with each breath, flaring out the nostrils, or making a grunting noise when breathing)
* Has repeated episodes of stridor or trouble breathing
* Can’t catch his or her breath, or has trouble swallowing
* Seems excessively sleepy while making croupy sounds
* Has a pale or bluish discoloration around his/her mouth or lips
* Stops drinking or has a noticeable decrease in urination (or diapers)