Croup in Toddlers: how to Recognize and Treat It

Laryngotracheitis, otherwise known as croup, is a common upper respiratory illness of childhood. The condition usually affects children 6 months to 3 years old. Symptoms of croup usually include:

• a hoarse, dry, barking cough (sometimes described as “seal-like”)
• inspiratory stridor (a high-pitched noise noted during inhalation)
• respiratory distress that develops over a brief period of time

A virus called parainfluenza is the most common cause (in 75 percent of cases) for croup, but respiratory syncytial virus (RSV), human metapneumovirus, influenza A and B, adenovirus, coronavirus, and a bacteria called Mycoplasma pneumoniae can also be responsible. Croup seems to be more common during the fall and winter months, but sporadic cases can occur throughout the year, as well as in older children.

Croup symptoms can occur without warning, or they may be preceded by upper respiratory tract infection symptoms like cough, congestion, runny nose, or fever. The barky cough and high-pitched wheezing noise is caused by swelling of the trachea just below the vocal cords.

Croup symptoms usually resolve within 48 hours. Most cases are mild and symptoms go away with or without treatment. Common home remedies for croup include putting the child in the bathroom and running a hot shower or letting the child breathe in the cool, misty air from a refrigerator’s open freezer door. Keeping the child calm is also helpful. Crying and agitation can make the stridor noise and respiratory distress worse.

If these conservative measures fail to improve symptoms, then the child should be taken to the emergency department. Sometimes being exposed to the cool, nighttime air while on the drive to the emergency department can improve the distressing symptoms.

Diagnosis of Croup

The diagnosis of croup usually does not require any special testing. If there is uncertainty, a neck x-ray can confirm the diagnosis (and help the doctor rule out other diagnoses like epiglottitis or the presence of a foreign object your baby breathed in). In the past, a “croup tent” would be available for hospitalized children with croup. It was hoped that the child would remain quiet and calm in this strange tent filled with cold mist. While we now know humidified mist can be helpful in the out-of-hospital setting, it has not proven to be useful for those requiring hospitalization.

A single dose of a systemic corticosteroid (i.e. oral dexamethasone) is currently the recommended treatment for croup. Either nebulized budesonide or intramuscular dexamethasone injection is preferred for mild-to-moderate or moderate-to-severe croup in a child who is vomiting or unable to take oral medications.

For those with moderate to severe croup, the addition of nebulized epinephrine (adrenaline) can greatly improve croup symptoms. Less than 5 percent of patients with croup need to be admitted to the hospital. Children with severe croup on arrival to the emergency department with signs of respiratory distress or continued distress despite corticosteroid and nebulized epinephrine treatment should be admitted to the hospital for close observation.

Sources:

• Johnson DW
• Croup. BMJ Clinical Evidence
• 2014;2014:0321.
  Nierengarten MB
• Diagnosis and management of croup in children
• Contemporary Pediatrics
• March 1, 2015.
  Marchessault V
• Historical review of croup. The Canadian Journal of Infectious Diseases
• 2001;12(6):337-339.

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