Croup

This entry was posted by Monday, 17 January, 2011
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What is Croup?

Croup is a common childhood viral illness that is easily recognized because of the distinctive characteristics that children have when they become infected. Like most viral illnesses, there is no cure for croup, but there are many symptomatic treatments that can help the child to feel better faster.

croup

Croup, also called laryngotracheobronchitis, most commonly affects children between the ages of six months and three years, usually during the late fall, winter and early spring. Symptoms, which often include a runny nose and a brassy cough, develop about 2-6 days after being exposed to someone with croup.

One of the distinctive characteristics of croup is the abrupt or sudden onset of symptoms. Children will usually be well when they went to bed, and will then wake up in the middle of the night with a croupy cough and trouble breathing. The cough that children with croup have is also distinctive. Unlike other viral respiratory illnesses, which can cause a dry, wet, or 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, which are often better during the day, worsen at night, although they are usually less intense each night. Symptoms also become worse if the 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.

Children with croup will usually also have a hoarse voice, decreased appetite and a fever, which is usually low grade, but may rise up to 104 degrees F.

Croup Assessment

Because of the characteristic signs and symptoms of croup, this diagnosis is usually fairly easy to make. You can often tell a child has croup while they are still in the waiting room or before you enter the exam room, therefore, testing is usually not necessary.

Specifically, an xray is usually not required, and is usually only done to rule out other disorders, such as ingestion of a foreign body. When an xray 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, level of alertness, degree of stridor, air movement, and degree of retractions, with 0 points given if these findings are normal or not present, and up to 3 points given for more severe symptoms.

  • Inspiratory Stridor
  • None (0 points)
  • When agitated (1 points)
  • On/off at rest (2 points)
  • Continuous at rest (3 points)
  • Retractions
  • None (0 points)
  • Mild (1 points)
  • Moderate (2 points)
  • Severe (3 points)
  • Air Movement/Entry
  • Normal (0 points)
  • Decreased (1 points)
  • Moderately decreased (2 points)
  • Severely decreased (3 points)
  • Cyanosis (Color)
  • None (0 points)
  • Dusky (1 point)
  • Cyanotic on room air (2 points)
  • Cyanotic with supplemental oxygen (3 points)
  • Level of Alertness (Mentation)
  • Alert (0 points)
  • Restless or anxious (1 points)
  • Lethargic/Obtunded (2 points)

In general, children with a croup score of less than 4 have mild croup, 5-6 have mild/moderate croup, 7-8 have moderate croup, and greater than 9 have severe croup.

Treatments

Although, like most viral infections, there is no cure for croup, there are many treatments that can help improve the symptoms and make the 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 the 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 the 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 the child up and walk around outside for several minutes. It is probably not a good idea to keep his window open though, as you don’t want him to get too cold.

Other treatments can include using a fever reducer (acetaminophen or ibuprofen containing products) and/or a non-narcotic cough suppressant (although they probably won’t suppress the cough of croup).

Since symptoms worsen if the child is crying and agitated, trying to keep the 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 2-4 hours after receiving racemic epinephrine. Chlildren who continue to have difficulty breathing, or who require more than one treatment, are usually hospitalized.

A mist or oxygen tent has long been used to treat children who are hospitalized, but there use has been decreased because it makes it harder for the hospital staff to observe the child and notice if he is getting worse. Instead, blow by oxygen or cool mist may be used.

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

The main symptoms of croup typically last only 2-5 days, but more rarely, they can last several weeks. Once the barking cough and difficulty breathing improve, the child may continue to have cold symptoms for 7-10 days.

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