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Croup ˈkrüp

(Laryngotracheobronchitis)

by John T. McBride, MD

Croup (laryngotracheobronchitis) is an inflammation of the windpipe (trachea) and voice box (larynx) typically caused by a contagious viral infection that causes cough, a loud squeaking noise (stridor), and sometimes difficulty with breathing in (inspiration).

  • Croup is caused by viruses.

  • Symptoms include fever, runny nose, and a typical bark-like cough.

  • The diagnosis is based on symptoms.

  • Most children recover at home, but those who require hospitalization receive fluids, oxygen, and drugs.

Croup primarily affects children 6 months to 3 years of age.

Croup is caused by a viral infection that leads to swelling of the lining of the airways, particularly the area just below the voice box (larynx). Parainfluenza viruses are the most common cause, but croup can be caused by other viruses, such as respiratory syncytial virus (RSV—see Respiratory Syncytial Virus (RSV) Infection and Human Metapneumovirus Infection) or an influenza virus. Croup caused by an influenza virus may be particularly severe and may occur in a broader age range of children.

Although croup occurs throughout the year, seasonal outbreaks are common. Croup caused by parainfluenza viruses tends to occur in the fall, and croup caused by RSV and influenza viruses tends to occur in the winter and spring. The infection usually is spread by breathing in airborne droplets containing viruses or by having contact with objects contaminated by these droplets.

Most children have only a single episode of croup, but a few have repeated episodes (called spasmodic croup) caused by viral infections that gradually decrease in frequency and severity.

Symptoms

Croup usually starts with symptoms of a cold—runny nose, sneezing, mild fever, and some coughing. Then the child develops hoarseness and a frequent, unusual-sounding cough, which is described as brassy or barking. Croup ranges widely in its severity. Sometimes swelling of the airway causes difficulty breathing, which is most noticeable when breathing in (inspiration). In severe croup, there may be a loud squeaking noise (stridor—see Stridor) heard with each inspiration. About 50% of children have a fever. All symptoms are typically much worse at night and may awaken children from sleep. Symptoms often seem to lessen in the morning and worsen again the next night.

The worst of the symptoms usually lasts 3 to 4 days, and the cough continues but changes to a looser-sounding cough. This change can cause concern for parents who think the infection has moved to the chest. However, it is the normal progression of the illness.

Diagnosis

  • Sound of the cough

  • Neck x-rays

A doctor distinguishes croup by its characteristic symptoms, especially the sound of the cough.

X-rays of the neck and chest help the doctor make a definitive diagnosis.

Prognosis

Most children with croup recover completely.

Treatment

  • For mild illness, fluids and humidified air

  • For severe illness, hospitalization, oxygen, epinephrine, and corticosteroids

If a child develops a croupy breathing pattern, the parents should contact the doctor because children with croup can become very ill very quickly.

Mildly ill children may be cared for at home and usually recover in 3 to 4 days. The child should be made comfortable, given plenty of fluids, and allowed to rest because fatigue and crying can worsen the condition. Home humidifying devices (for example, cool-mist vaporizers or humidifiers) may reduce drying of the upper airways and ease breathing. The humidity can be raised quickly by running a hot shower to steam up the bathroom. Carrying the child outside to breathe cold night air or to the kitchen to breathe cold air from the freezer also may open the airways significantly.

Did You Know...

  • Breathing cool air from the freezer can help lessen croup symptoms.

For sicker children, the doctor may recommend a single dose of a corticosteroid to prevent worsening of symptoms. Children with continuous croup should be seen immediately by a doctor who will likely recommend corticosteroids and may hospitalize the child for observation and care.

Children who have increasing or continuing difficulty in breathing, rapid heart rate, fatigue, dehydration, or bluish skin discoloration need to be given oxygen, as well as fluids by vein. Doctors usually treat children with epinephrine given in a nebulizer and corticosteroids given by mouth or injection. These drugs help shrink swollen tissue in the airways. Children who improve with these treatments may be sent home, but children who are very ill should remain in the hospital.

Antibiotics are used only in the rare situation when a child with croup also develops a bacterial infection. Rarely, a ventilator is needed.

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