Ask the Pediatrician: Dr. Molly

Category: Cold and flu

Croup season is here!

It is 2 a.m. and you hear your 3-year-old in her bedroom awake and coughing. This cough doesn't sound like any cough you have heard before.

Your child is agitated, sounds like she is gasping for air and even when she is just breathing you can hear her air moving in and out. When you look at her chest and neck they seem to cave in oddly as she tries to breathe more deeply. Her voice is hoarse and she may even have a fever. The amount of distress you are seeing as she breathes is very concerning and you call your doctor who encourages you to calm her down and perhaps take her outside where the cool air can help her swollen airway.

Once you calm down and she does, too, her breathing is still noisy. When she coughs it sounds like a seal barking, but otherwise the distress and agitation are improved and both of you can return to sleep.

This is the classic presentation of croup. Croup is caused by swelling in the airway just below the vocal cords in response to a viral illness or more rarely a bacterial illness. Occasionally croup swelling can be the result of allergy, but this, too, is very uncommon. The fall viruses, parainfluenza viruses and adenovirus, and the winter influenza and RSV are the most common causes of croup. I am seeing a fair amount of it and I suspect adenovirus is the cause.

When the virus causes swelling, the airway that is usually wide open (like a wide hose) gets constricted to a narrow tube (like a straw) and as a result there is a lot of distress, noise and work to get the air through the smaller tube into the lungs. If you suck hard on a straw, especially if you are having a milkshake, the tube will collapse due to the negative pressure. When croup causes swelling, the airway doesn't collapse but it takes a lot more negative pressure to move the air past the area that is narrow. This work to breathe deeply is what causes the distress and the retractions seen as the chest seems to cave in against the narrowed airway.

The swelling of the airway is worse at night (isn't everything?!) and as a result, kids will appear to have a hoarse voice and a cold during the day, but at night the symptoms escalate. Older kids and adults who get infected with these viruses get laryngitis and a very sore throat along with a harsh cough, but because the airway is much wider to begin with, the swelling doesn't compromise the air movement as much. Older kids and adults report the sore throat feels like they have swallowed glass and unfortunately there is little more than pain relievers, cool liquids and time to cure this illness.

There are lots of strategies to use when the symptoms get bad at night to relieve the symptoms of croup: steamy showers, going outside in the cool air and running humidifiers. Few of these actually make much difference. What is the biggest help is remaining calm and helping your child relax. Sometimes cool air or steamy air can help and they are not harmful so try those, too, but getting your child to relax and realize she can breathe is most important. It may take up to an hour to calm down your child enough to return to sleep, but hang in there; calming and soothing and most often the cough and agitation will lessen and you can all rest again. You may need to go to the ER during the night if your child is turning blue or cannot seem to relax despite your help and the breathing distress continues.

After a bad night and the noisy breathing is still present during the day, even if the child isn't agitated, I know it will be even worse at night so I often will prescribe a three-day course of an oral steroid to help shrink the swelling in the airway more quickly.

The good news is that croup symptoms are bad for only about three nights and then within 10 days the cold symptoms that accompany it are gone and the child feels back to normal.

Croup is contagious and as such if kids have fevers or are having really rough nights due to the cough, they shouldn't go to school or daycare the following day.