Croup in toddlers
It’s winter in the PICU and that means more respiratory illnesses, one of them being croup. This is an ancient illness — its very name comes from the Anglo-Saxon word to croak, which is what children with croup can sound like. The characteristic brassy cough sounds more like a seal to our modern ears, though. Also characteristic is a sound we call stridor, the sound of air rushing through a narrowed tube, in this case the child’s airway.
Croup is caused by viral infection of the region just below the vocal cords. One of several viruses can do it, but the usual offenders are members of the parainfluenza group. The infection causes swelling, and the swelling causes narrowing of the airway. This makes it more difficult for the child to breath — in some ways it is like breathing through a straw — and the child has to work harder to get air in. This can make the child’s chest cave in the wrong way with each breath, something called retractions. Fever, if present, is usually mild.
As with most viral illnesses, there is no specific treatment for croup — what treatment we have is directed at relieving the symptoms of throat pain and difficulty breathing. We do have several effective ways of doing this. Simple mist, as from a steamy bathroom, is a time-honored therapy to help a child breath. Inhaling a mist of the drug epinephrine shrinks the swollen tissues, although it only lasts for an hour or two. The drug dexamethasone, either orally or by injection, has become a standard therapy for moderately severe croup and it is quite effective. Acetaminophen or ibuprofen can treat fever and throat pain.
When should you bring your child to the doctor for croup? A good rule of thumb is if your child has stridor when sitting quietly or if there are any retractions present — both of these are indications for therapy with epinephrine or dexamethasone.
We always see a few children in the PICU with severe croup, usually those who need repeated doses of epinephrine or are working very hard to breath. On very rare occasions we need to use a breathing tube and a mechanical ventilator for these children. Nearly all children, however, recover from croup with no complications.
I’ve written a more detailed discussion of croup, which includes an x-ray of what it looks like and some uncommon causes of airway obstruction, in a Google Knol here.
Sachin on 
very helpful thank you
Thank you very much. great information
Thank you for the info.
My son is 6.5 years and still suffers from severe recurrent croup. His last case in in May 2010 and he could not breathe, Oxygen level was 93%. He also gets stridor with croup. He was also diagnosed with GERD. I have doctors that do not agree on which course of treatment to take with him because when he is on a anti-reflux drug he is croup free, but when he is not on the drug he gets croup. The concern from some of the doctors is that long term use of certain drugs is not safe. Any thoughts?
Hi Juli:
I can’t give you specific advice about what to do because I’m not your son’s doctor. I can offer a few general comments, though. Recurrent breathing problems from GERD is a well-known problem, and I’m glad to read that anti-reflux therapy improves his symptoms. Among the anti-reflux drugs, we don’t have really good long-term information (meaning years) about the risks of chronic therapy with the class of drugs called proton pump inhibitors (Prilosec and Prevecid are common examples), although thus far they seem quite safe and they are very effective. However, we do have a couple of decades of experience with ranitidine, what is called an H2 blocker (an antihistimine), and this drug looks to be very safe in the long term. Like all decisions in medicine, we are always weighing the risks of using the medications against the risks of not using them. As you probably know, the real experts for GERD are the pediatric gastroenterologists and for recurrent croup the pediatric pulmonologists.
I realize this is not a specific answer to your question, but I hope you find it helpful.
Thanks for stopping by.
Just wanted to add a comment…my daughter had croup several times every year…& the “do nothing it will pass” theory was not helping…her lapses would last for weeks ( persistant harsh coughing until she was short of breath). Pulmonary specialists gave me no suggestions. Finally, I read a medical textbook on asthma for a college course & thought that she fit the description of what was termed “cough induced asthma”. I brought the chapter to her physicians & they were not familiar with it. However, after placing her on preventative steroid inhalants (Pulmocort) she really improved & when she did become ill, she was given a short course of steroids with good effect. Croup that occurs in the older child may not just be croup at all. This may be something you might want to read up on. Good Luck!
Thanks for your comment, Bonnie. I guess I’m a little surprised your doctors were unfamiliar with what we often call “cough variant asthma.” At least in my field it’s a well-known thing. As you point out, the hallmark is persistent cough, generally in a child older than a toddler. They generally improve when given albuterol and similar asthma medications, which is one way to make the diagnosis.
Thanks for your informative and helpful post. Starting at the end of last August, 2010 (15 months old then) my son had reoccurring bouts of croup through early spring of this year. In every case, he had severe stridor at rest, and ended up in the ER on 4 of those occassions. It is obviously a very scary experience… But after dealing with it, on what seemed like a bi-weekly to monthly basis, I knew what needed to be done. If it would rear it’s head in a mild manner, early enough in the afternoon, he would get a dose of orapred at home and it saved us from needing the ER in the middle of the night. We have seen an ENT, and I explained my husband suffered from it quite frequently as a toddler/preschooler bc of his anatomy. We sincerely think that is the problem with our child, but I have never had a doctor make me feel confident that a child can suffer from croup/stridor that frequently. We had no episodes this summer, one at the end of august and another one last night (likely again tonight) these episodes were 5 weeks apart. Should we evaluate seasonal allergies or something further in your opinion?
Hi Rachel:
I can’t really give you specific medical advice over the internet — I hope you understand why. It sounds as if you have already seen a relevant specialist, an ENT physician. One thing to consider in recurrent croup is if the child’s airway is just naturally a bit smaller than the average (that may have been your husband’s issue as a small child). Another is if there is something in the airway that shouldn’t be there, such as a cyst or some similar growth. An ENT physician or a pediatric lung specialist (called a pulmonologist) is the best person to evaluate that possibility.
Thank you for your helpful post. My son who’s 16 months old is currently in the hospital with croup. We have been here for the last 5 days and by this time the doctors were hoping to see any improvement but so far we aren’t seeing anything. He’s got severe stridor even when he’s sleeping. He is getting steroids on daily basis and epinephrine treatment almost every 2 hours in the last 2 days to manage his severe symptoms, but nothing is working. It seems that doctors are at a loss and don’t know what else to do to help. Is there anything else that can be done and how long can this possibly last?
Hi Viola:
I can’t really give specific patient advice over the internet, of course, because I’m not your child’s doctor. In general terms, though, I’ve seen severe croup last a week or so. If it goes on much longer than that we start to wonder if there is something else inside the airway blocking airflow. The best way to check for that is with bronchoscopy — to actually have a look with a flexible tube with a light on the end that we can look through. I’m sure your child’s doctors are also thinking about that since it’s pretty standard. Croup also has a typical appearance through a bronchoscope.
I hope this helps. Good luck and thanks for stopping by.