Croup

Croup is an infection of the larynx, trachea, and the bronchial tubes usually caused by viruses, less often caused by bacteria.
Croup is contagious, especially during the first few days of illness.
A cough that sounds like a barking seal and a harsh raspy "Darth Vader" sound during inhalation are symptoms of croup.
Treatment of croup can include cool moist air, saltwater nose drops, pain and fever medication, fluids, and very rarely antibiotics. Over-the-counter decongestants, cough and cold medications, and aspirin should not be given.
The major concern in croup is progressive breathing difficulty as the air passages narrow.
Close monitoring of the breathing of a child with croup is important, especially at night.

What is croup? What causes croup?

Croup is an infectious illness of the respiratory system involving the vocal cords (larynx), the windpipe (trachea), and the upper airways of the lungs (bronchial tubes). The majority of a child's symptoms reflect involvement of the larynx. Croup is usually a viral infection and maybe caused by many different viruses, including those responsible for the common cold and influenza. Rarely, croup is caused by a bacterial infection. Croup is more common in children between 6 months and 3 years of age and rarely occurs in children over 6 years of age. It is more commonly seen from late fall through the early winter months. It has a slightly higher frequency in boys than girls. Bacterial croup is an infection of the same structures that are affected during the viral process. Therapy varies depending on whether there is a viral or bacterial cause.
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Is croup contagious?

Croup is contagious and is usually spread by airborne infectious droplets sneezed or coughed by infected children. When a healthy child inhales infectious droplets, symptoms can develop in two to three days. The infection can also be spread by infected mucus deposited on doors, furniture, toys, and other objects. A healthy child can become infected by accidentally touching the infectious mucus and transferring the infection into his/her mouth.

What are croup symptoms?

Viral croup may have two distinct presentations both of which are a consequence of swelling of the vocal cords and therefore narrowing of the airway. The more common variety causes symptoms of fever (100 F-103 F), mild hoarseness, and sore throat two to three days after virus exposure. The characteristic dry "barking seal" cough is soon to follow. The barking cough may be associated with a harsh, raspy sound during inspiration. (This sound, called "stridor," has been noted to resemble the breathing of the Star Wars character Darth Vader.) The symptoms commonly last for four to seven days.

A less frequent form of croup is called "acute spasmodic croup." Children with this form of croup will appear totally well when put to bed at night only to awaken their parents in the middle of the night with the above described barky cough and stridor. Fever and sore throat are not noted in these children, and the symptoms completely resolve within eight to 10 hours from onset. The child then appears totally well until this same acute onset recurs the following night. This on/off pattern may occur over three to four nights in a row and then transition into symptoms similar to the common cold -- mucoid nasal discharge and a "wet" cough for several days.

These two different forms of croup are the result of which particular virus has infected the child. Manifestations of croup may vary from mild (common) to life-threatening (rare). The severity of symptoms is proportional to the amount of relative narrowing of the breathing airway. The more severe the vocal cord narrowing the more effort is required to inhale. A severely sick child will refuse to lie down and demand to remain in an upright position. They will show retractions of the skin above the collarbone and between the ribs with inspiration and may develop facial blueness (cyanosis). Apparent exhaustion and decreased respiratory effort are indicators of impending respiratory failure and are cause for immediate paramedic evaluation and transport to the emergency department of the closest hospital.

What is the treatment for croup?

Croup can be frightening for both children and parents. Therefore, comforting and reassuring the child is the first step. Breathing difficulties can develop and worsen rapidly. Close monitoring of the child is important during the early phases of the illness.

To help the child breathe more comfortably, a cool or warm mist vaporizer can be placed near the child. The humidified air promotes reduction of vocal cord swelling and thus lessens symptoms. To avoid accidental burns, hot water vaporizers should be out of the reach of infants and toddlers. Also effective is having the child breathe in a bathroom steamed up with hot water from the tub or shower. When cough or stridor worsens at night, 10 or 15 minutes sitting or driving in the cool night air can also help the child breathe.

In infants and children, blockage in the nasal passages from mucus can further impair breathing. Careful instillation of saltwater nose drops (¼ teaspoon of table salt in 1 cup of water) into the nasal openings every few hours, followed by gentle suction using a bulb syringe, can be helpful in opening nasal passages.

The American Academy of Pediatrics recommends avoiding most combination cough and cold medicines. Several studies show that these medicines are ineffective in children. They can potentially cause side effects that could lead to more serious symptoms. Acetaminophen (Tylenol) and ibuprofen (Motrin, Advil) are helpful for pain relief and fever. Acetylsalicylic acid (Aspirin, Ecotrin) is avoided in the treatment of croup and other viral illnesses since aspirin is suspected as being related to Reye's syndrome in children. Reye's syndrome is a serious illness causing kidney, liver, and brain damage, which can lead to the rapid onset of coma. Occasionally, cortisone medications are prescribed for more severe cases of croup. Because a virus usually causes croup, antibiotics are reserved for those rare occasions when bacterial infections cause croup or become superimposed on the viral infection.

Even though plenty of fluids are encouraged to avoid dehydration, forcing fluids is generally unnecessary. Popsicles are a popular means of providing fluid. Activity should be restricted to quiet play during the first days of the illness.

Children with croup are most contagious during the first days of fever and illness. Infection spreads easily in a household. Other children in the family will often develop a sore throat or a cough, without necessarily developing the croupy cough and stridor seen in croup. Infants and children may return to school or day care when their temperature is normal and they feel better. A lingering cough can last another two weeks but should not be the reason to keep them at home.

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