Introduction: Imagine waking up at 2 AM with your child gasping for air and barking like a dog. Croup is one of the most frightening diseases for a parent but rarely is a dangerous one. Understanding what is happening to your child is essential in managing this common and mostly self limited disease
What is croup? There are really two basic types of croup. 1) Larynotracheobronchitis (LTB) - In this form of the disease, the child develops cold-like symptoms with a runny nose and some congestion. Fever may be absent or as high as 105 F degrees. Over a two-day period, the child develops the characteristic cough, which has been described as similar to a barking seal or crowing rooster. This sound, called stridor, is heard best on inspiration or breathing in, and may be accompanied by a cough. Laryngitis with loss of voice may also develop. Symptoms are present day and night although they seem to worsen at night. This form of croup is clearly caused by one of a number of viruses including parainfluenza virus and adenovirus. 2) Spasmodic croup (SC) - for parents, this is a far more frightening form of the disease. These children usually awaken suddenly in the middle of the night with significant stridor and respiratory distress. There is almost never any fever, runny nose or other evidence of cold-like symptoms. And the next day children appear otherwise healthy. The cause for this form is unclear, although it is likely to be allergic in nature.
Who gets croup? Croup is usually a disease of young children and infants with the peak incidence from three months to three years although cases have been described in older children as well. Boys tend to be affected more than girls with a ratio of 1.5:1 and 5% who have a recurrence, possibly even in the same year.
At what time of the year does croup appear? Epidemics of the LTB form of croup tend to occur in clusters during viral cold seasons in the late spring, fall and early winter with the peak incidence in the last three months of the calendar year. For unclear reasons, epidemics tend to be worse in alternate years. Spasmodic croup tends to occur more in spring and fall during high allergy times of the year.
Diagnosis: The diagnosis is a clinical one based on the history and physical examination. An x-ray will demonstrate a characteristic form of airway narrowing but it is almost never necessary. This narrowing in the area of the vocal cords causes a change in the frequency of vibration leading to the characteristic sound. There are no laboratory findings that are particularly helpful.
What should you do? In general, croup is a far more frightening disease that it is dangerous. Because it is usually of viral origin and never of bacterial origin, it never responds to antibiotics.
- Cool Mist - Ninety-five percent of children with either LTB or SC forms of croup can be managed at home with mist.
- Cool mist in the form of a cool mist humidifier in a room with the window left open a crack is the treatment of choice. Remember that even when the child is in such distress that he/she requires hospitalizations, the treatment is the same, only that hospitals frequently have steam-rooms or tents that generate large volumes of humidity.
- Sitting in a closed steamy bathroom where the hot bath or shower has been running is another effective measure especially when you open the window because exposure to cold air seems to be very effective in relieving stridor.
- Sitting in front of an open freezer is a trick that works for many. Occasionally, worried parents will rush off to the emergency room only to find that the trip from the car to the ER was sufficient to eliminate the symptoms entirely.
- Although asthma and croup are not related, for those children with asthma who have an aerosol machine at home, giving a saline aerosol using the same saline that is used for contact lenses, provides as effective a humidity treatment as any of the above.
- Along similar lines, taking your child for a walk in the stroller in the middle of the night sounds kooky but almost always is effective.
- Why does cold air help? Because it is 100% vaporized in the warm airways, providing treatment where it is needed most.
- Steroids - Steroids are medications that relieve inflammation. Since the problem with croup is inflammation around the vocal cords (causing the characteristic bark or the laryngitis), it makes sense that giving a steroid medication will rapidly relieve the symptoms.
- Inhaled medications-Vaporized adrenaline can be used quite effectively in hospital settings. Occasionally there is a rebound effect, which tends to worsen the symptoms only hours after administration and so, some children who are sick enough to get this type of treatment will actually be admitted to the hospital. Codeine and sedative medications are dangerous, for they depress the respiratory center in a patient with a very narrow airway.
When to call? At night, if you have tried the steaming in the bathroom with an open window and taken a walk outside and your child still seems in distress, then call. Remember agitated children sound worse so do everything you can to relax yourself and your child. Stridor at rest or during the day is something we usually will want to see because if it is mild during the day, it is likely to be worse that night.
Prognosis: In general, croup is a short-lived, 2-3 day (and night) disease. Recurrences are common, but the prognosis for a full recovery is excellent.