Recognizing and Treating Croup
Your child has had a mild cold for the past day or two, and then around bedtime, you hear it starting. That barky, raspy cough that sounds like a seal asking for his next meal. If you have heard a “croupy” cough before, there’s no mistaking it. If your child has never had croup, it can be a frightening experience. Here is a quick lesson on croup to help you get through the night.
Should You Contact Your Doctor?
Because the doctor can’t treat croup over the phone, most croup cases do not require an urgent page to your doctor. Follow the treatment plan below. The instructions will tell you how to assess if your child is improving and doesn’t require urgent medical attention or if your child is not doing well and when to go to the ER. If your child is stable through the night, be sure to call your doctor’s office in the morning.
What is Croup?
Croup is a viral infection that affects mostly younger children (under 5-6). It causes swelling in the child’s vocal cords, which is 
what causes the barky cough. The vocal cords are already the narrowest part of the air passages, and any swelling from infection may narrow the airway enough to obstruct breathing. Croup usually lasts 5-6 days and is worse at night. The symptoms tend to peak on the second or third night. Croup may begin without warning when a child suddenly sits up in bed with a barking cough. Or it may begin as a cold that gradually escalates into a croupy cough. The main concern for parents is to recognize when croup is serious and when it is not.
Is it Contagious?
Yes, it is about as contagious as the common cold. Good handwashing is important to prevent spread.
Symptoms of Croup
- Barky cough: A child will sometimes awaken from sleep with a croupy cough, and it can be frightening for child and parent.
- Fever: Often, there will be a fever, but usually below 104.
- Hoarse voice: This is also from the swelling of the voice box.
- Stridor: This is the most concerning symptom of croup. Stridor is a harsh, raspy, whooping, gasping sound when your child breathes in.
- Symptoms of the common cold can precede the croup, or they can linger afterward.
Signs it is Not Serious
The features to observe are the behavior of your baby and how the croup is progressing. If your child is smiling, happy, playful, looking around, interested in the environment, and not obviously bothered by the croup, these are good signs. He may have a barky cough but is not having stridor (see above). As a final reassurance, if your barking child can lie down and sleep without repeated interruption, his breathing is not jeopardized.
Signs of Serious Croup
Here’s when to be concerned but not to panic. The child whose airway is obstructed and unable to get enough air has a worried look on his face and is not interested in any play or interaction as if concentrating all his energy on getting air. The child won’t lie down; he just sits up and barks, and he can’t sleep. When you watch the little dent in a child’s neck just above the breastbone, it caves in with each labored breath. This sign is called indrawing. Stridor (see above) is another sign to watch for. The stridor will sound worse when your child is agitated or crying. When the child is resting calmly, the stridor usually lessens or goes away. If your child is calm but still has stridor, this is a sign that the croup is worsening and requires immediate treatment; see below.
Treating Croup
Calm your child. Croup can be frightening for your child. Crying will make the stridor sound much worse. It is important to keep your child relaxed by cuddling and staying calm. Sit baby upright in your lap, play soft music, sing lullabies, read a story. If breastfeeding, offer the great pacifier.
Steam up the bathroom. Humidity helps clear a child’s breathing passages. Turn on the hot shower in your bathroom and close the door. While keeping your child calm, sit with them on your lap in the steamy bathroom. You should see some improvement in about ten minutes.
Inhalation of cool mist. If you have a cool-mist humidifier or vaporizer, let your child breathe directly in front of the stream of mist. Once the child improves, keep the mist flowing near the bed for the rest of the night. If you only have a hot mist vaporizer, you can still use it, but don’t get too close, as a child can get burned.
Cool night air. If necessary, bundle-up your child, take him outside into the cool night air for 10-20 minutes or take a slow car ride with the windows open. The misty night air is why babies with croup often improve en route to the ER.
Treat the fever. Using Acetaminophen or Ibuprofen. Click on each for dosing help.
Important:
The above suggestions usually work well within about twenty minutes (an hour for the fever), and the child can settle back to sleep. You should observe your child closely by sleeping in the same room for the rest of the night, as another croup attack is likely, and the above treatments will need to be repeated.
When to go to the Emergency Room (or Doctor’s Office)
After trying the preceding treatment, assess in which direction your child is going. If indrawing and stridor is lessening, color is returning to child’s pale cheeks, or he initiates some interaction or wants to drift off to sleep (though still breathing noisily), continue with the steam and a watchful eye and ear. If you feel your child is getting worse despite the above treatments, go straight to the Emergency Room. Your doctor won’t be able to treat this over the phone, so it may be best to go to the ER instead of paging your doctor and waiting for a callback.
When to Move Quickly
Watch for the following emergency signs, and if any of them occur, take baby directly to the nearest Emergency Room.
- The indrawing is becoming more labored, and your child’s inhaling changes from low-pitch stridor to a whistling sound.
- Your child becomes paler.
- Child can’t speak or cry from lack of breath.
- Child is struggling more to get each breath.
- Your child begins drooling excessively or has difficulty swallowing.
- The indrawing is increasing, but the sound of breathing is decreasing.
Emergency Room Treatment
What will they do for you in the ER? As they evaluate your child, they should encourage you to hold him in your lap, remember to keep him calm. They might measure his blood oxygen level with an oximeter or “pulse-ox.” This uses a small light source that is wrapped around a finger or toe and helps determine how your child is breathing. They might have you blow cool mist in front of your child’s face. If your child’s croup is severe enough (which is why you’re in the ER), they may give him vaporized Epinephrine to breathe with the cool mist. This works quickly to open the airways.
Depending on the situation, the ER physician may recommend a short course of steroids. Don’t worry; this is not the “body-building” type of steroids. These will help keep the air passages open over the next few hours to days. Your child will only be on the steroids for a few days. There are no side effects to worry about when used for this short time. The first dose often needs to be given as an injection since the child with severe breathing difficulty is in no mood to take oral medication, or he may throw it up.