Definition.
Croup is a viral
illness, usually caused by parainfluenza virus or respiratory syncytial virus.
Croup is characterized by a distinctive cough that sounds tight,
metallic, and like a barking seal. It occurs year-round, but it much
more common during the fall and winter seasons. The virus infects and
inflames the upper respiratory tract, especially the voice box. Severe croup is
associated with a problem called stridor, which is a harsh,
raspy, vibrating sound made when the child breathes in.
Expected Course.
Croup begins a few days
to a week after exposure to the virus. Croup is quite contagious, much like
other upper respiratory viral illnesses. Mild symptoms of a cold, sore throat,
or laryngitis (hoarseness and losing
your voice) without the barky cough of croup occur in many persons with the
parainfluenza virus. Therefore, many children with croup were not exposed to
someone else with the same symptoms. Most cases of croup occur in children less
than 5 years of age, with the peak ages for infection being 6 months to 3 years
of age. We do see teenagers with croup symptoms, even stridor. Note:
during certain strains of COVID, we saw cases of COVID that presented with
croup symptoms.
Croup symptoms can begin
suddenly. Some children have no symptoms of illness prior to
awakening with the cough of croup in the middle of the night. Other children
have mild cold symptoms and perhaps a hoarse voice prior to the cough
appearing. The cough of croup is worse at night and with more
activity. Croup typically lasts about 3-5 days. A mild case may last
a night or two and some cases linger on for well over a week. It is not
unusual for the cough of croup to come and go throughout the illness. Cough
spasms can occur where the cough is nearly non-stop for some time. During the
day, many children will have long stretches without coughing.
Other symptoms
associated with croup include fever, fussiness, and a decreased appetite. A few
children will have vomiting, usually around the time of the coughing spasms.
Some children with croup, as with other respiratory illnesses, will develop a
bacterial ear infection.
Although some children
have croup once, it is not unusual to have croup more than once. Some otherwise
healthy children seem particularly prone to croup and will have it frequently.
These children typically require the same treatment as other children with
croup. Occasionally persons with asthma will present with barky coughs, we will
hear wheezing in their chests, and they will respond to albuterol
(bronchodilator) treatments. This is called spasmodic croup. Most children with
frequent barky coughs do not have spasmodic croup.
Prevention.
Because croup is spread
so easily through casual contact with the virus, it is difficult to prevent.
The virus can be spread from being close-by when someone with it sneezes or
coughs. It can also be picked-up from toys, cups, door-handles, and other
objects recently in contact with someone with the virus. Older children should
be strongly encouraged to cover their mouth and nose during coughing and
sneezing (teaching children to cough into the crease of their elbow can help,
as your hands are more likely to spread the germs). Frequent hand washing or
using hand sanitizer is important.
Children should be kept
home from school or daycare on those days in which they have a fever or
frequent cough. Check with your child's daycare or school for their
specific policy on returning there with symptoms of croup, as these may vary.
Treatment.
Croup will run its
course without special treatment. Because it is caused by viruses, antibiotics will not help with croup. However,
certain treatments can be helpful.
-- Dry air makes the cough of croup worse and increased moisture
in the air helps decrease the swelling and inflammation around the voice box.
Therefore, the most effective treatment for croup is humidified air. Run a cool
mist vaporizer (recommended over the warm mist vaporizers because some
children burn themselves on the warm mist and studies show that either cool
mist or steam vaporizers help equally) or a humidifier in the child's
room. If the child is having their sleep disrupted by the cough and the
vaporizer is not helping, run a hot shower in the bathroom with the door
and windows closed. Sit on the floor with your child (toys or books or
screentime can keep young children occupied). After 10-15 minutes, many
children have their cough settle down and they can return to sleep. If they
continue to cough and it is cool or cold outside, try bundling them up and
taking them outside. The cool night air often helps the cough if the
steamy shower did not. This also usually takes 10-15 minutes to work.
-- Tylenol® or
Motrin® (acetaminophen or ibuprofen) can be given for fever or pain
(sore throat).
-- Although the cough of croup does not usually respond well to cough medicines (the medications will
not change the cough of croup significantly), it is okay to try an
over-the-counter cold and cough medicine for children 4 years old and above. If
it does help, it is fine to continue the medicine throughout the illness.
However, if it does not help after a dose or two, stop.
-- Coughing spasms can be due to the sticky mucous of croup.
Drinking clear fluids (water, apple juice, lemonade, etc.) can help
relax the vocal cords and loosen the mucous.
-- The laryngitis (losing your voice and sounding hoarse) gets
better over a few days with resting your voice. Little kids do not rest their
voice on request, even with encouragement. Their laryngitis will gradually get
better without special treatment.
-- IF THE CHILD HAS STRIDOR OR OTHER SEVERE BREATHING
DIFFICULTY:
Some children with
croup will develop the harsh, raspy, vibrating sound of stridor when
they breathe in. This is caused by a narrowing of the airway in your voice box.
Stridor gets worse with crying, coughing, and other activity. It needs
treatment right away. Stridor often frightens both children and parents. Do
your best to remain calm. Stridor is often worse in the night.
If you hear stridor,
the breathing becomes more difficult, or the breathing becomes tighter:
ð
Sit in the bathroom with your child with the door and windows
closed. Run a steamy shower. It may
take 10-20 minutes to help. If better, put back in bed with the vaporizer
running in their room. This steamy shower treatment can be repeated as often as
needed.
ð
If that has not helped, bundle up your child and take them outside into the cold/cool night air
(it is not as effective, but standing right in front of the open freezer door
also can help) for 10-20 minutes. If that helps, put back in bed with the
vaporizer running in their room. This cool night air treatment can be repeated
as often as needed.
ð
If not better and after office hours, your child needs to be seen
right away at Nationwide Children’s Hospital Emergency Department or Urgent
Care. If during walk-in hours at 8 a.m., we want to see your child at that
time. During routine office hours, call for an appointment.
CALL 911 (THE RESCUE SQUAD) IF YOUR
CHILD TURNS BLUE OR DUSKY, PASSES OUT, OR STOPS BREATHING.
A few notes on "steroids":
Some children seen in the office with more severe croup will need to be treated
with steroids. These help the naturally occurring steroids in our body fight
the inflammation in the respiratory tract caused by the croup virus. It has
been shown that these steroids decrease the chances that the croup will worsen.
They also seem to help decrease the worst of the symptoms of croup. They are
given as either a shot (injection) of Decadron® (dexamethasone) or a few days
course of a liquid called Orapred®, Prelone®, or Pediapred® (prednisolone) or a
one-time oral dose of dexamethasone.
Most cases of croup seen in our office do not need these steroids. But,
for those children that do, it is important to remember a few things:
-- Either the shot or the liquid take a
few hours to begin working in your child's system.
-- The shot keeps working for few days
after just the one dose.
-- Continue having your child take the
liquid medicine as instructed, even if they seem much better before they are
done.
-- Let your doctor know if your child has
never had chicken pox but has been directly exposed to it in the last month
(this is
because the steroids could cause a worse
case of chicken pox).
-- Although there are no longer-term side
effects from the steroids given for croup, some children get headaches,
grouchiness, moodiness, an increase in appetite, or stomachaches while they are
taking them or for a few days after the shot.
-- If the liquid forms of the medicine do
not taste good to your child, the liquid can be mixed with something to drink
(such as a small amount of juice or chocolate milk) to make it taste better.
Many pharmacists recommend flavoring this medication.
Cough and Cold Medicines:
If you choose to try a cough and cold medicine, here is one you may find
helpful. Please realize more coughs of croup will not be better with
these medicines. All of these have a cough suppressant (dextromethorphan,
usually called "DM").
Other cough medications are discussed on
the Coughs, Colds, Allergies, and Sinus Infections protocol.
Delsym® Children’s 12 Hour Cough Liquid 4-5
yrs.: 2.5 ml.; 6-11 yrs.: 5 ml.; 12 years and above: 10 ml. Every 12 hours.
--
Dr. Tim Teller, M.D. -- Hilliard Pediatrics, Inc. – 8/2023
