Croup

Symptoms Of Croup

• Cough that sounds like a barking seal

• Stridor (an abnormal, high-pitched, harsh, raspy sound during inspiration)

• Hoarseness of voice

• Sore throat

• Runny nose

• Fever (100-103 F)

• Difficulty in breathing or shortness of breath

• Congestion

• Difficulty in swallowing

• Increase in respiratory rate

• Increase in heart rate

• Nasal flaring (widening of nostrils while breathing)

The symptoms of croup usually become worse at night.

In some cases, children may also experience:

• Cyanosis - a condition in which skin, lips or nails turn blue. 

• Skin rashes

• Conjunctivitis

• Dehydration

The symptoms of croup last for within 4-7 days, but can prolong for as long as 2 weeks.

Interesting facts!

The name “croup” is derived from the word “kropan” which refers to crying out in a hoarse voice. 

The sound, called "stridor," has been noted to resemble the breathing of the Star Wars character Darth Vader.

Causes Of Croup

Croup is majorly a viral infection though some bacteria are also reported to cause it. The various causes are discussed as follows:

1. Virus

The common viruses that can cause croup include:

• Parainfluenza virus

• Influenza A and B

• Measles

• Adenovirus

• Respiratory syncytial virus (RSV)

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2. Bacteria

Croup mostly begin as viral infection which later becomes complicated due to secondary growth  of bacteria like:

• Corynebacterium diphtheriae

• Staphylococcus aureus

• Streptococcus pneumoniae

• Hemophilus influenzae

• Moraxella catarrhalis

What do these viruses and bacteria do?

These bacteria and viruses cause swelling of the larynx (sound box), trachea (windpipe) and large airways. The swelling causes partial obstruction of the airway which leads to difficulty in breathing and the other characteristic symptoms of croup. 

How does the infection spread?

Viral croup can be spread through coughing, sneezing, and other respiratory secretions such as droplets and mucus from coughing. Children can catch croup through:

• Contact with the virus in the air after an infected person has coughed or sneezed

• Handling infected person

• Touching contaminated surfaces

Children with croup are contagious for at least 3 days after the infection.

Types Of Croup

The type of the croup depends upon the level of difficulty faced by the children to pull air into lungs. The size of the windpipe and the degree of its narrowing determines its severity. Based upon the severity of croup, it can be divided into three types:

1. Mild

Children with mild croup do not generally have symptoms at rest. Children may experience stress but not at rest. The high pitched noisy breathing is usually felt when the child cries or coughs. 

2. Moderate

Children with moderate croup may be slightly disoriented or agitated, and may have moderate difficulty breathing.

3. Severe

Croup is considered severe if the symptoms such as stridor and difficulty in breathing are experienced by the individual even at rest.

The presence of retractions –  inward movement (sucking in) of the sternum (breast bone) or skin between the ribs as the child struggles to take a breath is a characteristic sign of severe croup.

Note: Approximately 85% of cases of croup are mild and less than 1% are considered severe.

Quick byte!

There is one more rare form of croup known as spasmodic croup. It occurs suddenly, often in the middle of the night, making the child wake up suddenly gasping for breath, with a hoarse voice, and stridor while breathing in. It occurs in the absence of any viral infection. It is believed to be caused by inflammation caused by allergies from pollen, bee sting etc or reflux from a child's stomach.

Risk Factors For Croup

1. Age

Almost all of the cases of croup are seen in children between the age group of 3 months to 5 years due to the small diameter of the windpipe. 

2. Season

Children are more likely to develop croup during late autumn or early winter due to occurrence of more viruses, such as colds and flu at this time of year.

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3. Family history

Children with a family history of croup or other respiratory illness such as asthma have higher chances of developing it. 

4. Gender

Males are more prone to croup than females. 

5. Geographical location

Individuals living in densely populated areas have higher chances of developing croup due to its highly contagious nature. 

6. Traveling

Frequent traveling increases the risk of croup because of the more exposure at closed overcrowded places like play groups, schools, offices, bus, and flight. 

7. Poor hand hygiene

Since, croup is majorly a viral illness, poor hand hygiene increases its risk. 

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8. Passive smoking

Children who are exposed to passive smoking are more prone to develop croup.

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9. Inadequate vaccination

Children who are not vaccinated for influenza are at higher risk of contracting croup infection.

Here are 5 things that should be kept in mind while vaccinating your child.
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Low immunity

Children with low immunity are more prone to bacterial, viral infections that can cause croup. 

Diagnosis Of Croup

Croup is majorly diagnosed with its clinical symptoms and physical findings. 

The doctor may listen to your child's breathing with a stethoscope for wheezing and decreased breath sounds. Visual examination of the throat may reveal redness in the upper airway.

The following tests can be performed as per the need of the situation:

1. Complete blood count

Blood tests do not confirm croup but give an indication of the disease. Complete blood count (CBC) is used to assess the infection. The white blood cell count of the CBC may suggest the presence of a virus. 

2. Pulse oximetry

It is used to measure oxygen level of the blood. This is usually done by placing a clip-like device called a probe on a body part, such as a finger or ear lobe.

This monitoring is helpful in assessing the need for supplemental oxygen. 

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3. Laryngoscopy 

It involves examination of the voice box and vocal cords using a camera. It is not used for routine examinations. The circumstances in which this examination is used include:

• Failure of other diagnostic methods

• Presence of acute distress in child

• Confirmation of bacterial tracheitis (complication of croup)

4. Neck X-ray

The X-ray of the neck can also be considered for observing features like tapering of the upper windpipe or thickened trachea. However, it is not routinely used.

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Prevention Of Croup

1. Practice hand hygiene

Most cases of viral croup can be prevented by washing hands with soap and water for at least 30 seconds both for the child as well as the parents:

• After going to the toilet

• Before and after eating food

• After handling vomiting of an infected patient

• After changing the diapers of the child.

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2. Maintain hygiene

Bacterial croup spreads through contaminated surfaces. Practicing good hygiene is the best way to prevent infection. The following measures can be taken to ensure the cleanliness:

• Keep the nails short and avoid wearing false fingernails, nail extenders and nail polish, and jewelry as they restrict adequate cleaning of hands.

• Clean the surfaces or objects that have been exposed to vomits or feces.

• Wear disposable gloves and masks while handling feces or vomit of infected individuals. 

• Use disposable paper towels to dry your hands. Clothes towels should be avoided as bacteria can survive on objects. 

• Keep kitchen tops, toys, toilet seats, nappy change tables clean to avoid the growth of bacteria and viruses. 

3. Isolate the patient 

As croup is highly contagious, isolation of the patient prevents the spread of the infection. 

Children who have experienced symptoms such as stridor (an abnormal, high-pitched, musical breathing sound), hoarseness, rhinorrhea (runny nose), and sore throat should not return to childcare until 24 hours after symptoms have resolved.

4. Ensure vaccination

Croup is caused by several viruses and bacteria. Some of the viral infections causing croup such as influenza can be prevented by ensuring proper vaccination. 

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Specialist To Visit  

Parents should immediately consult to the doctor if the child is developing the following the symptoms of croup:

• Whistling sound with breathing or noisy, high-pitched breathing while sitting or resting

• Difficulty in breathing

• Severe cough

• Drooling or difficulty swallowing

• Inability to speak or cry due to difficulty taking a breath

Parents/caregivers should contact to emergency medical services instead of driving their children to the hospital if he/she:

• Is severely agitated

• Has blue-tinged skin

• Is struggling to breathe

• Is excessively drowsy
  
  

You can consult the following specialists:

• General physician

• Pediatrician

• ENT specialist
  
  

A general physician can examine the symptoms and initiate treatment.

A pediatrician specializes in medical treatment for children and adolescents.

Croup infects the throat so an ENT(Ear, Nose, Throat) specialist can also help in its management.

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Treatment Of Croup

The treatment of croup generally depends upon the severity of the condition. 

• Antibiotics are usually ineffective as the condition is majorly caused by viruses. 

• There is no proven role of cough medicines and decongestants.
  
  

The medications used in managing symptoms include:

1. Saltwater nose drops

This is an excellent remedy for symptomatic relief. The salt water nose drops help in losing the mucus and clears the airways. 

2. Non-steroidal anti-inflammatory drugs (NSAIDs) 

These drugs are used to control fever. The common examples include paracetamol and ibuprofen. 

3. Steroids

Steroids work by decreasing swelling of the larynx due to its antiinflammatory action. They can be given intravenously (IV), intramuscularly (IM), or orally (PO) depending upon the condition. Examples include:

• Dexamethasone

• Prednisolone

• Budesonide

4. Epinephrine (adrenaline)

This drug is given by nebulizer (through inhalation) to the children. It works by dilating the muscles of the airway. This increases the supply of oxygen which helps in managing symptoms. The effect with epinephrine is very immediate (usually within the first 30 minutes) of administration. 

5. Oxygen

Children with severe croup may need supplemental oxygen. It is administered through a mask or nasal cannula. 

6. Intubation

It involves insertion of a tube into the trachea (windpipe) for respiratory support. It is used in children with life threatening symptoms experienced by the child due to narrowing of airway as a result of excessive swelling. 

7. Heliox

It is a mixture of oxygen and helium that is usually delivered to the individual through a nasal cannula and face mask. It is used if the children are facing excessive difficulty in breathing.

Helium aids in the movement of oxygen and decreases the load of respiratory muscles.

8. Antibiotics

They are given in bacterial croup. Vancomycin and cefotaxime are two most common drugs used in case of secondary bacterial infection. 

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Home-care For Croup

1. Inhale steam

The use of inhaled hot steam or cool moist humidified air is proven to be beneficial for managing symptoms of croup. 

Caregivers should sit with the child during mist treatment. It is also important to keep the child calm as anxiety and crying can worsen the symptoms. This can be done by engaging in activities such as reading a book, playing, and listening to music.

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2. Encourage fluid intake

Children should be encouraged to drink warm clear fluids. This helps in loosening mucus and keep the child relaxed. 

3. Minimize passive smoke

Parents and caregivers of the infected child should avoid smoking as it can worsen the child’s cough. 

4. Keep the child's head elevated

The head of the child should be kept elevated. This can be done by using extra pillows. It prevents the accumulation of mucus in the throat. 

Note: Pillows should not be used with infants younger than 12 months of age.

5. Stay in close proximity to the child

Parents/caregivers should stay close to the ill child so that they can immediately assist the child in case of difficulty in breathing. 

6. Keep the child calm

Anxiety and crying may cause agitation, respiratory distress, and lead to increased oxygen requirements. Children should be kept as comfortable as possible. 

7. Avoid self-medication

Do not give medications for cold and cough without prescription as it can cause side effects.

Most of the cases of the croup are mild and can be treated at home. Children with mild croupy cough just need parental guidance, reassurance, and proper care. 

Complications Of Croup 

Most of the cases of croup are resolved within a few days. The complications include:

• Bacterial tracheitis (infection of the trachea)

• Pneumonia

• Pulmonary edema (accumulation of fluids in the lungs)