Oh, Croup!

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crying breastfeeding pictureI suspect the diagnosis as they walk in the door. I can hear them across the ER. “Croupers,” as we call them, have a very distinctive hoarse cough and a noisy breathing sound called stridor.  It’s very scary for both the child and the parent, which is why croup is probably the most common diagnosis that I make in the ER during the winter months. Here’s the good news: croup looks scary, but is usually not dangerous. Sometimes it can be treated at home.

Croup is caused by a viral infection of the voice box or larynx and the lungs. It’s the inflammation in the voice box that causes that distinctive stridor sound. The medical name for croup is laryngotracheobronchiolitis, which means inflammation of the larynx (voice box), trachea (windpipe), and bronchioles (airways of the lungs). There are many different kinds of viruses that can cause croup, but common causes are parainfluenza and influenza.

But it started so fast…
Croup classically comes on very fast and usually at night, “like a thief in the night.” Infants seem fine all day, perhaps with just a little clear runny nose, and go to bed normally. Then they awake with stridor and that barking cough that some people say sounds like a seal.

Croup can occur any time of day, but it is usually worse at night because the body’s natural steroid levels fall at night, making the swelling of the voice box worse.

What is the home treatment for croup?
We treat croup by treating the inflammation of the voice box. The easiest way to treat a swollen voice box is to use cool or moist air. Try cracking the window open and turning on the ceiling fan, or rocking your child outside in the cool night air. Some people like to go for a ride in the car with the windows down. A cool mist humidifier can also help. Many people recommend turning on the shower and closing the bathroom door until the bathroom gets steamy and humidified, then sitting in the steam with your baby. I find this might help a bit, but no one wants to sit in the bathroom all night.

Often patients are much improved by the time they get to the ER. It’s not a coincidence– the trip to the ER in the cool night air is therapeutic.

Stay calm and cheerful.  Anxiety makes croup worse. If you seem scared, your child will be scared.

Ibuprofen is helpful, especially if your child has a fever. I recommend ibuprofen over Tylenol for croup because ibuprofen is an anti-inflammatory.

If your child is still having trouble breathing, you may need to go to the ER. Consider calling your pediatrician’s exchange if you are not sure what is best to do.

What’s the ER treatment for croup?
Dexamethasone is a steroid given by mouth that reduces inflammation. It is a one-time dose given in the ER that is effective for about four days, so no further doses are needed at home.  Dexamethasone takes several hours to really kick in, so we often use another medicine in the ER called racemic epinephrine. Racemic epinephrine is an inhaled medicine given with a nebulizer machine that also reduces the swelling of the voice box. It is the most effective medicine for bringing immediate relief for stridor.

Isn’t that wheezing?
Wheezing is a different sound than the stridor associated with croup. Wheezing is usually caused by asthma or reactive airway disease. Wheezing is caused by a narrowing of the airways of the lungs.

We tried a breathing treatment and it did nothing.
Albuterol breathing treatments don’t help the voice box swelling caused by croup, and hence don’t make the stridor better. Albuterol is effective for treating the wheezing associated with asthma or reactive airway disease.

Occasionally, patients with a history of asthma or reactive airway disease will have both wheezing and stridor when they get a viral infection, in which case albuterol can help the wheezing but not the stridor. Most of the time croup has only stridor.

When can my child return to school/daycare?
When he or she is fever- and symptom-free for 24 hours. This means 24 hours without a barking cough, stridor or fever.

Is it contagious?  What about our baby? Can I get it?
Croup is very contagious, and is spread by airborne droplets. Try to teach your child to cough into his or her elbow. Make hand sanitizer your best friend. Infants are at especially high risk for becoming seriously ill with croup. If your older child has croup and you are worried about a young infant, keep hand sanitizer everywhere and consider trying to keep the two children in separate rooms.

Adults can catch the viruses that cause croup, but adults don’t usually get the stridor and trouble breathing. In adults, croup viruses usually cause laryngitis. This is because adults have larger voice boxes, so when the voice box swells a few millimeters they just get a hoarse voice or laryngitis, not stridor.

How long does croup last?
Croup usually lasts three to seven days, occasionally longer. The second night is known to be the worst.

Can you get croup twice?
Yes, the viruses that cause croup generally change a little bit every year, so your child can get croup again every year. You can also get more than one episode of croup in one calendar year by catching different viruses that both cause croup.

Not sure it’s croup?
Here’s how to identify and treat winter’s most common childhood illnesses. 

Copyright 2014 Kathleen Berchelmann, MD

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