Croup

Definition

• Viral infection of the voicebox (larynx)
• The croupy cough is tight, low-pitched, and barky (like a barking seal)
• The voice or cry is hoarse (laryngitis)

Cause

• Usually a parainfluenza virus

First aid advice for stridor (harsh sound with breathing in) or constant coughing

• Breathe warm mist in a foggy bathroom with the hot shower running for 20 minutes. Other options: a wet washcloth held near the face or a humidifier containing warm water.
• Caution: avoid very hot water or steam which could cause burns or high body temperatures.
• If warm mist fails, breathe cool air by standing near an open refrigerator/freezer door or taking outside for a few minutes if the weather is cold.

Return to school

• Your child can return to daycare or school after the fever is gone and your child feels well enough to participate in normal activities. For practical purposes, the spread of croup and colds cannot be prevented.

Stridor: A complication of croup

• Stridor is a harsh, raspy sound heard with breathing in
• Loud or continuous stridor means severe croup
• All stridor needs to be treated with warm mist
• See "First aid for stridor," above, for treatment recommendations

When to Call Your Doctor for Croup

• Severe difficulty breathing (struggling for each breath, unable to speak or cry because of difficulty breathing, continuous severe stridor)
• Child has passed out or has bluish lips
• Croup started suddenly after bee sting, taking a medicine or allergic food
• Child is drooling, spitting or having great difficulty swallowing (EXCEPTION: drooling due to teething)

Call your doctor now (night or day) if

• NOTE: For any stridor, difficulty breathing, or severe coughing, see FIRST AID
• Stridor (harsh noise with breathing in) is present now
• Your child looks or acts very sick
• Child choked on a small object that could be caught in the throat
• Difficulty breathing (age under 1 year old) not relieved by cleaning the nose
• Difficulty breathing (age over 1 year old) present when not coughing
• Ribs are pulling in with each breath (retractions)
• Child can't bend the neck forward
• Fever over 104° F (40° C) and not improved 2 hours after fever medicine
• Fever greater than 105 by any route
• Age 3 years or younger with a croupy cough
• Continuous (nonstop) coughing
• Age under 12 weeks with fever above 100.4° F (38.0° C) rectally (Caution: Do NOT give your baby any fever medicine before being seen.)
• Severe chest pain
• Age less than 6 months with any stridor

Call your doctor within 24 hours (between 9 a.m. and 4 p.m.) if

• Had croup before that needed Decadron
• You think your child needs to be seen
• Stridor (harsh noise with breathing in) occurred but not present now
• Age 1 to 3 months with a cough for over 3 days
• Earache is also present
• Fever present for more than 3 days

Call your doctor during weekday office hours if

• You have other questions or concerns
• Croup is a recurrent problem (has occurred 3 or more times)
• Barky cough present over 14 days

Parent care at home if

• Mild croup with no complications and you don't think your child needs to be seen

Home Care Advice for Croupy Cough

1. Reassurance:
   • Most children with croup just have a barky cough.
   • Some develop tight breathing (called stridor).
   • Remember that coughing up mucus is very important for protecting the lungs from pneumonia.
   • We want to encourage a productive cough, not turn it off.
2. Humidifier: If the air is dry, run a humidifier in the bedroom. (Reason: Dry air makes croup worse.)
3. Homemade Cough Medicine
   • From 3 months to 1 year of age, only use warm clear fluids (e.g., water or apple juice) to thin the secretions and loosen the cough.
   • Honey for coughing (recommended at bedtime only in the following amounts: 2-5 years 1/2 tsp, 6-11 years 1 tsp, 12-18 years 2 tsp).
   • After age 6, use COUGH DROPS to coat the irritated throat. (If not available, can use hard candy.)
4. OTC Cough Medicine (DM):
   • OTC cough medicines are not recommended. (Reason: no proven benefit for children). Never use them under 4 years of age. (Reason: risk of serious side effects and not approved by FDA)
   • Age 4-6 years do not recommend Dextromethorphan (AAP recommendation reason lack of proven benefit)
   • Honey has been shown to work better for coughs.
   • If you decide to use a cough medicine from your drugstore and your child is over 6 years, choose one with Dextromethorphan (DM). It's present in most OTC cough syrups.
   • Indication: Give only for severe coughs that interfere with sleep, school or work.
   • DM Dosage: See dosage table. Give every 6 to 8 hours for severe coughs that interfere with sleep, school or work.
5. Coughing Spasms:
   • Expose to warm mist (e.g., foggy bathroom).
   • Give warm fluids to drink (e.g., warm water or apple juice) if over 3 months of age.
   • Reason: both relax the airway and loosen up the phlegm.
6. Fever Medicine: For fever above 100.4 F (38° C), may give acetaminophen (e.g., Tylenol) or ibuprofen.
7. Observation During Sleep: Sleep in the same room with your child for a few nights. (Reason: can suddenly develop stridor at night)
8. Avoid Tobacco Smoke: Active or passive smoking makes coughs much worse.
9. Contagiousness: Your child can return to day care or school after the fever is gone and your child feels well enough to participate in normal activities. For practical purposes, the spread of croup and colds cannot be prevented.
10. Expected Course: Croup usually lasts 5 to 6 days and becomes worse at night.
11. Call Your Doctor If:
    • Stridor (harsh raspy sound) occurs
    • Croupy cough lasts over 14 days
    • Your child becomes worse

And remember, contact your doctor if your child develops any of the "When to Call Your Doctor" symptoms.

References

1. Bjornson CL, Johnson DW. That characteristic cough: when to treat croup and what to use. Contemp Pediatr. 2001;18(10):74-82.
2. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med. 2004; 351: 1306-1313.
3. Britto J, Habibi P, Walters S, Levin M, Nadel S. Systemic complications associated with bacterial tracheitis. Arch Dis Child. 1996;72:249-250.
4. Brown J, Klassen TP. Croup. In: Moyer V, Davis RL, Elliott E, et al, eds. Evidence Based Pediatrics and Child Health. London, England: BMJ Publishing Group; 2000. p. 214-227
5. Cherry JD. Croup. N Eng J Med. 2008;353:384-391.
6. Custer JR. Croup and related disorders. Pediatr Rev. 1993;14:19-29.
7. Hopkins A, Lahiri T, Salemerno R., et. al. Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics. 2006;118(4):1418-1421.
8. Kaditis AG and Wald ER. Viral croup: Current diagnosis and treatment. Contemp Pediatr. 1999;16(2):139-153.
9. Klassen TP. Croup: A current perspective. Pediatr Clin North Am. 1999;46(6):1167-1178.
10. Malhotra A and Krilov LR. Viral croup. Pediatr Rev. 2001;22:5-12.
11. Scolnik D, Coates A, Stephens D, et al. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments. JAMA. 2006;295:1274-1280.
12. Wenger JK. Supraglottitis and group A streptococcus. Pediatr Infect Dis J. 1997;16:1005-1007. 

Disclaimer

This information is not intended be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.

Author and Senior Reviewer: Barton D. Schmitt, M.D.

Last Reviewed: 1/4/2010

Last Revised: 11/12/2009 2:58:36

Copyright 1994-2010 Barton D. Schmitt, M.D.