A variety of respiratory illness in children can cause what we cause croup. We see children with croup in the urgent care frequently, mostly during the winter months. It occurs mostly in infants and young children between 6 months and 3 years of age. We don’t see it often in kids that are older than 6 years of age. Most of the time croup is mild and can be treated at home, but sometimes it can become serious and need immediate medical care.
When to seek help: A child with severe or worsening croup should be evaluated immediately because croup can be a life-threatening illness . Some features of worsening or severe croup include:
1) Drooling or difficulty swallowing
2) Difficulty breathing
3) Inability to speak or cry due to difficulty taking a breath
4) A whistling sound when breathing, or noisy-high pitched breathing while sitting or resting
5) Sucking in of the skin around the ribs or abdomen with breathing
6) Pale or blue-tinged skin
It’s important for parents not to attempt to drive their children to their medical provider if they are struggling to breath or are having severe croup symptoms. Instead, calling 911 and having emergency medical care assist in the treatment on the scene where the child is located and help with transport is critical in this potentially life-threatening situation.
Causes: A viral infection with influenza or para-influenza are the most frequent causes although most of the time these viruses people with these viruses don’t get croup. The infection can lead to swelling of the voice box and windpipe and as the infection progresses, this can cause the windpipe to become swollen and narrow.
Bacterial infection can also cause croup or trachiitis but this is usually more severe and requires a different treatment than a viral infection.
Symptoms: Usually it starts with congestion and runny nose and then can progress to a characteristic “barking cough,” and hoarseness. Symptoms seem to be worse at night in most children. Fever can develop in patients as well as a rash and redness to the eyes. Swollen lymph nodes are common. As the upper airway narrows due to swelling from the infection, high-pitched, noisy breathing (called stridor) can develop. If the child becomes anxious, the breathing often becomes more difficult because the agitation can increase the narrowing. The effort to breathe faster and harder is tiring and some children become exhausted and in severe cases, they might not be able to breath on their own.
A blue-tinge to the skin (called cyanosis) can develop if airflow to the lungs is restricted. Cyanosis may first be noticed in the fingers and toenail, ear lobes, tip of the nose, lips and tongue. This is uncommon in croup, but can happen in severe cases.
Severity: Croup is often graded in terms of severity as mild, moderate or severe. A brief description of these grades is listed below:
1) Mild: Child is alert and may have a barking cough. Stridor (high-pitched noisy breathing) is not present at rest, but may be notable as the child coughs or cries. There are not retractions (severe abdominal or chest movements with breathing)
2) Moderate: Children with moderate croup may have stridor at rest. They may also have retractions (severe abdominal or chest movement as they breath). They may look uncomfortable.
3) Severe: Child with this grade of croup has stridor and chest/abdominal retractions at rest. The child struggles to take each breath and may appear anxious, agitated or fatigued. A patient with severe croup should generally not be seen in the primary care or urgent care and be seen in the emergency room. These patients may be transported to the hospital by ambulance.
Diagnosis: Usually the diagnosis is made clinically and is based on the child’s symptoms including barking cough, and stridor. X-ray or other laboratory work is rarely needed.
Treatment: The type of treatment generally depends on the severity of symptoms. Generally moderate to severe symptoms suggest the child should be seen by a healthcare provider.
Mild croup: most often is able to be treated at home without difficulty. Use of a mist humidifier or sitting in the bathroom with parents with the shower running (to produce steam) may be helpful. Other treatments such as allowing the child to breathe cold air during the night by opening a window or door, treatment of fever with Tylenol or Ibuprofen, and elevating the child’s head slightly may also be helpful.
Moderate to severe croup: Usually moderate to severe croup should be evaluated by a healthcare provider who is able to handle an urgent respiratory illness. Severe croup can be life-threatening, and treatment should not be delayed. We will use humidified air or oxygen as needed, intravenous fluids if there are signs of dehydration, and even place a breathing tube or assist in oxygenation by applying a non-rebreather mask over the child’s mouth so the oxygen is delivered in a higher concentration. We also monitor the child’s oxygen levels, breathing rate, heart rate, skin color and the alertness of the child closely.
Medications for croup: In the clinic, we often prescribe a single to multiple doses of dexamethasone which is a steroid medication that decreases the inflammation of the airway (windpipe and voice box area). If there is stridor or the croup is severe, we will sometimes give nebulized treatments of racemic epinephrine (aka adrenaline). This also reduces swelling in the airway and actually starts working faster than dexamethasone. Racemic epinephrine works for a short period of time (two hours or less) and may be given every 15-20 minutes for severe symptoms.
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO