Does your child have a bark-like cough? Here’s what you need to know about croup

If you’ve ever heard it, you will never forget it: the sound of a child with a croup cough, which has a very distinctive sound. The sound is often described as “barky” or sounding like a sea lion. Unfortunately, you’ll typically hear it in the middle of the night, so you are going to need to know what to do to alleviate your child’s symptoms when it happens.  But first…

What is croup?

Croup (or laryngotracheobronchitis) is caused by a viral infection of the upper airway. The infection causes swelling of the vocal cords (the larynx) and windpipe (the trachea), which narrows a child’s airway.

Sometimes the narrowing limits the air that can pass through the airway, causing a hoarse voice, a noise with each inhalation (called inspiratory stridor), and that harsh, sea lion like cough. Think of a sea lion show at Sea World or in a movie, and you understand the sound.

What causes croup?

The most common cause of croup is Parainfluenza, a family of respiratory viruses similar to the influenza viruses. However, adenovirus, influenza, respiratory syncytial virus (RSV) and measles can also cause croup. Even different variants of the SARS-CoV2 virus can cause croup. Most often occurring during peak cold and flu season in fall and winter months, a child catches one of these viruses from exposure to respiratory droplets from the sneeze or cough of an infected person. These droplets can also live on surfaces like toys and desks, so when a child touches these surfaces and then touches his/her mouth, nose, or eyes without washing their hands first, they can become infected.

These viruses are not childhood-specific illnesses. In older children and adults they cause typical common cold symptoms. So why do they lead to croup in children? The answer comes down to size. Children 6 months to 3 years have smaller airways, increasing their risk of croup.

What are the symptoms of croup (besides ‘barking’)?

The initial stages of croup will present like a typical cold. Children often have a fever along with a runny and/or stuffy nose. As inflammation increases, the cough starts and the classic symptoms of croup develop. These symptoms will persist until the inflammation decreases, around 2-3 days later. Typically children will continue to have cold symptoms for 7-10 days like the common cold, even after the swelling goes down.

A word of caution, though. Parents frequently confuse the sound of stridor (a high-pitched noise made while breathing in) with wheezing (a high-pitched sound while breathing out). Though they both are distressing and sometimes loud, they are not the same.  Whooping cough is also a loud respiratory illness, but is not related to croup.

Croup’s barking noise comes from a cough forcing air into a more narrow (upper) airway.  Wheezing, like we see in asthma, comes from forcing air out over a swollen and inflamed (lower) airway. I usually describe wheezing like this; imagine a balloon filled with air and you are pinching the opening and squeezing the balloon at the same time. That high-pitch whine the air makes as it comes out is similar to wheezing. Since croup is from an inflamed upper airway, medications used for lower airway constriction and wheezing, like albuterol, will not work for it.

A small percentage of children develop swelling so severe that their airway can become compromised. Please call 911 immediately if your child is struggling to breathe, is tiring out, or is looking grey or blue.

What should I do if my child has croup?

Antibiotics (used for bacterial infections) will not work for the viral infections causing croup. Therefore, treatment is mostly supportive. Sometimes medications are used so make an appointment with your child’s pediatrician if you are worried they may have croup.

• Keep your child calm and comfortable.
• Steam from a shower or humidifier helps soothe the airway and decrease the symptoms of croup.
• Cool air can also be helpful so walk your child outside.
• Because symptoms are frequently worse at night, sit in a steamy bathroom before bed and either crack a window in your child’s room or run a cool mist humidifier (never use a hot steam humidifier because of the risk of burns).
• Treat fever or discomfort with acetaminophen (a medication like children’s Tylenol, but check the dosing with your pediatrician first).

Sometimes, the swelling gets so bad from croup that children will have stridor at rest, as opposed to just with coughing or crying.  In these cases an oral dose of a steroid or anti-inflammatory medication (like dexamethasone) can be given in your doctor’s office. This reduces the swelling in the airway, making it easier for your child to breathe. Children who are really struggling to breathe should be taken to the emergency room and may receive a nebulizer treatment. This is a device that goes over their nose and mouth and helps them inhale medication. Racemic epinephrine is used for croup to relax the smooth muscle of the airway, making breathing more comfortable.  Children who receive a nebulized treatment of racemic epinephrine need to be observed for at least 3 hours following treatment to watch for a return of airway constriction.

Fortunately, even if a child had a rough few days with croup, they should recover from the most severe symptoms of it within the first 2-3 days, and the remaining runny nose and cough should resolve within 7-10 days.

As always, if you have questions or concerns about your child’s illness, visit your child’s doctor.