Croup

Topic Overview

What is croup?

Croup is a common respiratory problem in young children. It tends to occur in the fall and winter. Its main symptom is a harsh, barking cough. Croup causes swelling and narrowing in the voice box, windpipe, and breathing tubes that lead to the lungs. This can make it hard for your child to breathe.

An attack of croup can be scary, but it is rarely serious. Children usually get better in several days with rest and care at home.

What causes croup?

Croup usually occurs a few days after the start of a cold and is usually caused by the same viruses that cause the common cold. Croup is contagious. The germs that cause it can be passed from one person to another through coughing and sneezing and through close contact. Regular hand-washing and limiting contact with others can help prevent spreading croup to others.

As children grow older and their lungs and windpipes mature, they are less likely to get croup. Getting a flu shot each year may help your child fight off some of the viruses that can lead to croup.

What are the symptoms?

Symptoms of croup are caused by narrowed airways. They include a barking cough; a raspy, hoarse voice; and a harsh, crowing noise when breathing in. The cough is very distinctive, so you'll know it when you hear it. It is often compared to the sound of a barking seal. Sometimes children breathe fast and need to sit up to breathe better.

Symptoms of croup often improve during the day and get worse at night. Sometimes children have croup attacks that wake them up in the middle of the night for a couple of nights in a row, but the illness usually improves gradually in 2 to 5 days.

How is croup diagnosed?

Your doctor will probably be able to tell whether your child has croup by examining him or her and asking about symptoms. Sometimes doctors can identify the distinctive barking cough of croup over the phone.

Because croup can make breathing harder, your doctor may place a small clip called a pulse oximeter on your child's finger, toe, or earlobe to check if enough oxygen is reaching the blood.

How is it treated?

Even though your child's coughing and troubled breathing can be frightening, home treatment usually eases the symptoms.

• Try to stay calm during an attack, and soothe your child. Crying can make the swelling in the windpipe worse and make it even harder to breathe.
• Breathing in moist air seems to help during a croup attack. Fill your bathroom with steam from the hot water faucets, and sit in the room with your child for 10 minutes. Or hold your child directly over a humidifier, and let the vapor blow directly in his or her face.
• Breathing cool night air also seems to help sometimes. Dress your child in warm clothes, and go outside for 10 minutes.
• If symptoms improve with these methods, put your child back in bed with the humidifier blowing nearby. Do not smoke, especially in the house. If the symptoms happen during the middle of the night, it is a good idea to sleep in or near your child's room until morning.
• It is important to keep your child well hydrated. Offer water, flavored ice treats (such as Popsicles), or crushed ice drinks several times each hour.

If your child’s symptoms don't get better after 30 minutes, call or see your doctor. If the attack is in the middle of the night and you are very worried, consider taking your child to the emergency room.

If your child has severe difficulty breathing, call 911 or other emergency services immediately.

If your child has severe croup or has not responded to home treatment, medicines may be used to decrease airway swelling. These are usually given in a doctor's office or an emergency room. In rare cases, a child needs to stay in the hospital for treatment.

Frequently Asked Questions

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	Croup: Managing a croup attack

Symptoms

A child who has croup may at first seem to have a common upper respiratory infection (URI), such as a cold. The first symptoms of URI, such as runny nose and congestion, usually last about 1 or 2 days. Croup symptoms usually follow and last 2 to 5 more days.

Croup symptoms include:

• Normal temperature or a slight fever.
• A loud, barking cough.
• A raspy, hoarse voice.
• Varying degrees of high-pitched crowing sounds when breathing in.
• Some trouble breathing as a result of swelling in the windpipe.

Unless the illness is severe, a child with croup is usually alert and active and doesn't appear very sick.

The coughing and troubled breathing caused by mild to moderate croup may make your child's condition seem more serious than it really is.

If your child has severe difficulty breathing, call 911 or other emergency services immediately.

Exams and Tests

A doctor usually diagnoses croup from a physical examination and a medical history. During the physical examination, the doctor listens to your child's chest and back and looks for signs of inflammation or infection in the nose, ears, mouth, and throat. You will also be asked when your child's symptoms began, whether they have changed, and whether you have noticed any fever.

Special exams or tests usually are not needed to diagnose croup. But because the condition may cause difficulty breathing, a pulse oximeter may be placed on your child's finger, toe, or earlobe to check the amount of oxygen in the blood. In rare cases, an X-ray may be needed to look at the throat.

Treatment Overview

Home treatment, such as using a humidifier, can help treat mild to moderate croup. Regardless of treatment, symptoms usually improve gradually within 2 to 5 days.

If your child has severe croup or has not responded to home treatment, medicines may be used to reduce airway swelling. These are usually given in a doctor's office or an emergency room. Medicines usually include:

• Glucocorticoids, such as dexamethasone or budesonide (for example, Pulmicort).
• Epinephrine.

If your child needs extra oxygen, it is given through a nasal cannula or delivered through an oxygen mask placed over the nose and mouth.

If breathing improves after one or more of these measures, your child will be observed for a short time and sent home. If symptoms do not improve, your child may need hospitalization and further testing.

What to Think About

Over-the-counter cough and cold medicines are not helpful for treating croup. Don't give these medicines to your young child unless you've checked with the doctor first. They can be harmful to children.^{1, 2} Experts say not to give them to children younger than 2.

Antibiotics, such as amoxicillin (Amoxil and Trimox) or cefpodoxime proxetil (Vantin), are not effective treatments for croup. These are only used if a secondary bacterial infection, such as a middle ear infection, develops.

Home Treatment

Home treatment usually is all that is needed to treat croup. You can help prevent major episodes, or attacks, as well as use techniques to manage attacks if they occur.

Wash your hands often and stay away from others to help prevent spreading croup. Keep your child home from day care or school if he or she has croup.

Preventing croup attacks

You may be able to prevent croup episodes, or attacks, of intense troubled breathing and coughing. If your child has croup:

• Offer plenty of fluids to drink. Always have water available and try offering other beverages, frozen ice treats (such as Popsicles), or crushed ice drinks several times each hour.
• Do not smoke, especially in the house.
• Consider using a humidifier in your child's room. Do not use a hot vaporizer, and make sure you put only plain water in the humidifier. Although research has not consistently shown that croup symptoms improve with humidifier use, using one poses very little risk.³ To prevent mold growth, be sure to empty, clean, and completely dry out the humidifier between each use.

Managing attacks of croup

It is important for you and your child to keep calm during an attack of croup, even though it can be frightening. If your child is upset, crying, and anxious, the swelling and narrowing of the airway can become worse. Usually, symptoms sound worse than they are.

Taking measures to manage an episode of croup, such as adding moisture to the air and keeping your child calm and comfortable, can help keep symptoms under control. If coughing and difficulty breathing do not improve within about 30 minutes despite your efforts, call or see your child's doctor. Because attacks often occur in the middle of the night, you may need to visit a hospital emergency room.

Over-the-counter cough and cold medicines are not helpful for treating croup. Don't give these medicines to your young child unless you've checked with the doctor first. They can be harmful to children.^{1, 2} Experts say not to give them to children younger than 2.

For more information on how to deal with croup at home, see:

Croup: Managing a croup attack.

If your child has severe difficulty breathing, call 911 or other emergency services immediately.

Other Places To Get Help

Organizations

Related Information

• Coughs, Age 12 and Older
• Fever, Age 3 and Younger
• Hand-Washing
• Respiratory Problems, Age 11 and Younger

References

Citations

1. Schaefer MK, et al. (2008). Adverse events from cough and cold medications in children. Pediatrics, 121(4): 783–787.
2. Kuehn BM (2008). Debate continues over the safety of cold and cough medicines for children. JAMA, 300(20): 2354–2356.
3. Johnson D (2007). Croup, search date November 2006. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.

Other Works Consulted

• Bjornson CL, et al. (2004). A randomized trial of a single dose of oral dexamethasone for mild croup. New England Journal of Medicine, 351(13): 1306–1313.
• Cherry JD (2004). Croup (laryngitis, laryngotracheitis, spasmodic croup, laryngotracheobronchitis, bacterial tracheitis, and laryngotracheobronchopneumonitis). In RD Feigin et al., eds., Textbook of Pediatric Infectious Diseases, 5th ed., vol. 2, pp. 252–265. Philadelphia: Saunders.
• Moore M, Little P (2006). Humidified air inhalation for treating croup. Cochrane Database of Systematic Reviews (3). Oxford: Update Software.

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