Croup is common, and has been around for hundreds of years. Yet, parents may be unfamiliar with croup's striking presentation, often without warning in the middle of the night. Pediatrician and "Today" contributor Mark Widome brings viewers up to date on this common childhood disease, and discusses how parents can combine old and new treatments to manage the symptoms.
What is croup? In its most common form, croup is a viral illness that causes inflammation and swelling in the throat, particularly in the larynx (voice box) and trachea (windpipe). Another name for common croup is acute laryngotracheitis. The illness usually occurs sometime between 6 months of age and three years, though older children can occasionally come down with the croup, as well. Croup most commonly strikes toddlers, with as many as twenty percent of children getting the disease in the second year of life. More boys get the croup than girls.
Croup is mostly an illness of late fall and winter, though it can occur any time of the year. One of several viruses can cause the illness, including the parainfluenza virus, RSV, and influenza A. During outbreaks of the flu, as we have seen this winter, young children with croup most often are having their own special form of the flu.
What are the symptoms of croup? Viral croup starts out very much like the common cold. There may be low-grade fever, runny nose, mild cough, and sore throat. But after two or three days, this illness that starts in the nose and throat, works its way down to the vocal cords and to the relatively narrow opening to the windpipe just below the cords. Children with croup become hoarse or may temporarily lose their voice, and then develop the "croupy" cough. Parents hearing the croup for the first time are struck by how different it is from any other cough they have ever heard. The cough is loud and is described as "sharp" or "brassy," and is often compared to a seal's bark. (The origin of the word "croup" is disputed, but probably comes from an old Germanic word meaning "to cry out.")
If inflammation and swelling causes sufficient narrowing of the airway, the child may develop stridor. Stridor is a harsh high-pitched sound heard with each breath on inspiration (breathing in). It is the sound of air rushing past the narrowed opening at the top of the windpipe. Some children will be distressed and have retractions: sucking in of the skin between the ribs with each breath.
While the distinctive cough and stridor of croup can occur anytime during the day, croup symptoms often appear in the middle of the night, and for several nights the symptoms may return, only to improve each morning. Sometimes the cold symptoms and fever are absent, and croup appears suddenly in the middle of the night without warning. In such cases the illness is called spasmodic croup.
How is croup treated? For over 100 years, physicians have recommended warm moist air for the treatment of croup. In the 19th century, parents and doctors noticed that the steam from tea kettles often provided relief. (Unfortunately, it often resulted in scald burns, as well.) While modern studies have disputed the value of moist air, there is plenty of anecdotal evidence to continue to recommend it, to at least see if it helps.
Today, mild croup is usually treated by turning on the hot water in the shower, steaming up the bathroom, and then taking the child in their for 10 or 15 minutes. If the steam is going to help, the cough will be calmed and any stridor will disappear. (One school of thought argues that it is the close and reassuring presence of a parent, not the steam, that calms both the child and his cough.)
If the croupy cough and stridor are not quickly relieved in the steamy bathroom, taking a warmly bundled child with the croup out into the cold night air for a few minutes is often beneficial. Here, it would seem, that the cold air passing into the swollen windpipe reduces the swelling. If neither steam nor night air brings relief, the physician has some additional remedies to offer, either in the office or in the emergency room.
Epinephrine, given as a mist with an electric nebulizer, can bring rapid relief to a child who is having breathing difficulty because of the croup. Also, a single dose of the steroid, dexamethasone, given either by mouth or injection, has been shown to be very effective in preventing or shortening hospitalizations. It is not as rapidly acting as epinephrine, but it's beneficial effect lasts much longer. While neither of these medicines is necessarily needed in mild croup, they can make a big difference in moderate or severe croup.
Some children with croup require hospitalization. In the United States, croup is responsible for about 40,000 hospitalizations a year. During hospitalization, children with croup may need supplemental oxygen and nebulizer treatments, as well as IV fluids if they are breathing too hard to eat or drink. The hospital stay is rarely more than two or three days, and otherwise healthy children recover from the croup completely.
When to call the doctor If your child has croup with stridor (noisy breathing), you should call the doctor and your child should be examined. But because croup is so different from other respiratory infections that parents are familiar with, pediatricians usually recommend that they be consulted — at least by telephone — the first time a parent experiences the illness in one of her children, no matter how mild. If croup is accompanied by high fever, or if your child seems unusually sick, irritable or lethargic, or if there is repeated vomiting, then you should call the doctor promptly. The same holds true if you are worried.
A note to viewers / readers
This health information is meant to complement, not replace, the individual advice provided by your child's physician. Every child is different. When your child is ill, your child's pediatrician is the best source of information on management of the illness.
Copyright © 2004. Mark D. Widome, MD. Dr. Widome is professor of pediatrics at the Penn State Children's Hospital and a regular contributor to the TODAY show. He writes regularly on topics of interest to parents.