Croup Symptoms and Treatment

A Common Childhood Viral Infection With a Distinctive Cough

Sick child in bed

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Croup is a common childhood viral infection that is easily recognized because of several of its distinctive characteristics. Croup, also called laryngotracheobronchitis, most commonly affects children between the ages of 6 months and 3 years, usually during the late fall, winter, and early spring. Symptoms, which often include a runny nose and a brassy cough, develop about two to six days after being exposed to someone else with croup (this is the incubation period).

Signs and Symptoms of Croup

One of the first distinctive features of croup is the abrupt or sudden onset of symptoms. Children will usually be well when they went to bed, but will then wake up in the middle of the night with a croupy cough and trouble breathing. The sound of the cough is also distinctive. Unlike other viral respiratory illnesses, which can cause a dry, wet, or a deep cough, croup causes a cough that sounds like a barking seal.

Another common sign or symptom of croup is inspiratory stridor, which is a loud, high-pitched, harsh noise that children with croup often have when they are breathing in. Stridor is often confused with wheezing, but unlike wheezing, which is usually caused by inflammation in the lungs, stridor is caused by inflammation in the larger airways.

The pattern of croup symptoms is also characteristic. In addition to beginning in the middle of the night, symptoms are often better during the day, only to get worse again the next night. Symptoms also become worse if your child becomes anxious or agitated.

The symptoms of croup are caused by inflammation, swelling, and the buildup of mucus in the larynx, trachea (windpipe) and bronchial tubes. Since younger infants and children have smaller airways, it makes sense that they are the ones most affected by croup. In contrast, older children will often just develop cold symptoms when they are infected by the same virus.

Other croup symptoms can include a hoarse voice, sore throat when your child coughs, decreased appetite and a fever, which is usually low grade but may rise up to 104 F.

Assessing Kids with Croup

Because of the characteristic symptoms of croup, the diagnosis is usually fairly easy to make. If a doctor hears a child cough, she can often tell the child has croup while they are still in the waiting room or before the doctor enters the exam room. Therefore, testing is usually not necessary.

Specifically, an X-ray is usually not required and is usually only done to rule out other disorders, such as ingestion of a foreign body. When an X-ray is done, it will usually show a characteristic "steeple sign," which shows a narrowing of the trachea.

When assessing a child with croup, it is important to determine if he is having trouble breathing. Fortunately, most children have mild croup and have no trouble breathing, or they may only have stridor when they are crying or agitated. Children with moderate or severe croup will have rapid breathing and retractions, which is a sign of increased work of breathing. They may also have stridor when they are resting.

The croup score is an easy and standardized way to figure out if a child has mild, moderate, or severe croup, which can help to dictate what treatments are necessary. The croup score is based on a child's color (presence of cyanosis), the level of alertness, the degree of stridor, air movement, and degree of retractions, with zero points given if these findings are normal or not present, and up to three points given for more severe symptoms.

In general, children with a croup score of less than four have mild croup, five to six indicates mild/moderate croup, seven to eight points to moderate croup, and greater than nine shows croup.

Croup Treatments

Like most viral infections, there is no cure for croup, there are many treatments that can help improve the symptoms and make your child feel better.

Mild croup symptoms can usually be safely treated at home. Common treatments include using humidified air, which can be delivered by a cool-mist humidifier. Using a hot steam vaporizer is usually discouraged because of the risk of your child getting burned if he touches it. Instead, warm steam can be delivered by turning on all of the hot water in the bathroom, including from the shower and sink, close the bathroom door and holding your child as he breathes in the steamy, humidified air.

On cool nights, exposure to the cool nighttime air may also help symptoms, and this phenomenon is responsible for another characteristic finding of croup, the fact that children often get better on the way to the emergency room. To take advantage of this, it may help to bundle your child up and walk around outside for several minutes. It is probably not a good idea to keep his window open, as you don't want him to get too cold.

Other treatments can include using a fever reducer (products containing acetaminophen or ibuprofen) and/or a non-narcotic cough syrup (although they probably won't suppress the cough of croup) if your child is over 4 to 6 years old.

Since symptoms worsen if your child is crying and agitated, trying to keep your child calm may also improve his symptoms.

Children with moderate or severe croup, or who aren't quickly responding to home treatments, will need medical attention for further treatments, which usually includes administering a steroid to help decrease swelling and inflammation and improve breathing. An injection of dexamethasone has been the standard way of administering this steroid, but new studies have shown that an oral steroid (Prelone, Orapred, etc.) or steroid delivered by a nebulizer (Pulmicort) may also be effective.

For children with severe respiratory distress, treatment, in a hospital setting may include a breathing treatment with racemic epinephrine. Because there is a risk of a rebound and worsening breathing, children are usually observed for two to four hours after receiving racemic epinephrine. Children who continue to have difficulty breathing, or who require more than one treatment, are usually hospitalized.

A newer treatment that is being researched is the use of a helium-oxygen mixture for children with severe croup.

What To Know About Croup

In addition to these tips on recognizing and treating croup, other things to know about croup include:

  • Your child can get croup more than once, as there are many viruses that can cause croup, including parainfluenza, adenovirus, respiratory syncytial virus (RSV) and influenza (the flu virus), and there are multiple subtypes of each virus.
  • If your child is getting croup very often, then he may have spasmodic croup (acute spasmodic laryngitis), which can be triggered by viruses, allergies, or reflux. Although they may have trouble breathing, children with spasmodic croup often don't have a fever and get better quickly after several hours.
  • Kids who get diagnosed with croup multiple times each year might also need to be evaluated for asthma.
  • Unless your child has a secondary bacterial infection, such as an ear infection, antibiotics will not be effective against the viruses that cause croup.
  • The main symptoms of croup typically last only 2 to 5 days, but more rarely, they can last several weeks. Once the barking cough and difficulty breathing improve, your child may continue to have cold symptoms for 7 to 10 days.

Although there is no vaccine (except for the flu vaccine) or medication that can prevent your child from getting croup, you might decrease the chance that your child will get croup by decreasing his exposure to other people who are sick. Also, encourage strict hand washing and avoiding sharing foods and drinks can help to lessen your child's chances of getting sick.

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Article Sources
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  1. MedlinePlus. Croup. Updated February 7, 2019.

  2. Bjornson CL, Johnson DW. Croup in childrenCMAJ. 2013;185(15):1317–1323. doi:10.1503/cmaj.121645

Additional Reading
  • Mandell GL, Douglas RG, Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennetts Principles and Practice of Infectious Diseases. New York: Elsevier/Churchill Livingstone; 2015.