Croup
Croup is swelling of the airway just below the vocal cords. It gives a child a harsh barking cough and a noisy intake of breath, and gives parents the…
On this page
Medicines commonly prescribed for Croup
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: PULMONARY INHALATION, 0.12% w/v SALBUTAMOL SULFATEActive substance: salbutamolManufacturer: Laboratorio Aldo Union S.L.Prescription requiredDosage form: PULMONARY INHALATION, 500 mgActive substance: salbutamolManufacturer: Glaxosmithkline S.A.Prescription requiredDosage form: PULMONARY INHALATION, 2.5 mg/2.5 mlActive substance: salbutamolManufacturer: Neutec Inhaler Ireland LimitedPrescription required
Croup is swelling of the airway just below the vocal cords. It gives a child a harsh barking cough and a noisy intake of breath, and gives parents the feeling that the child is suffocating. An ordinary virus is almost always behind it, and it almost always settles within a couple of days. Two things are worth knowing in advance, though: croup responds beautifully to a single dose of medicine, and a handful of other conditions sound exactly like it while needing an ambulance.
A cough you will not mistake for anything else
It starts like any cold: a day or two of a runny nose, a low fever, a bit of coughing. Then, usually in the evening or in the middle of the night, the voice goes and the cough changes. It turns dry, abrupt and hollow, and people compare it to a barking dog or a seal. Once you have heard it, you will recognise it next time.
- a barking cough audible from the next room;
- a hoarse, worn-out voice, or a rasping cry in a baby;
- a whistling or creaking noise on breathing in, known as stridor; at first it appears only when the child cries or runs about;
- faster breathing than usual, and a preference for sitting up rather than lying down.
Two features throw families off. The first is that croup flares sharply at night and eases during the day, so at a morning appointment the child often looks perfectly well. That does not mean you imagined it; describe to the doctor what happened. The second is that the harder a child cries, the narrower the airway becomes and the louder the noise, which makes a calm adult in the room part of the treatment.
It mostly affects children between six months and three years, less often up to five or six. The acute phase lasts two or three nights, while the hoarseness and the leftover cough drag on for about a week.
Why the airway gets tight
A virus is nearly always responsible: parainfluenza most often, though influenza, respiratory syncytial virus and the ordinary cold viruses can all do the job. The swelling develops at the narrowest point of the airway, below the vocal cords, inside a ring of cartilage that cannot stretch.
That is the whole difference between an adult and a child. In an adult the same degree of swelling would produce hoarseness at worst. In a three-year-old the passage there is about as wide as a pencil, so a millimetre of swelling takes away almost half of it: air starts moving noisily and every breath in takes effort.
There is also a variant known as spasmodic croup. The child goes to bed well, wakes in the small hours with a barking cough and stridor, has no fever, and is fine again by morning. These episodes recur readily, are more common in children with an allergic tendency and are just as frightening, but they behave and are treated in the same way.
Getting through the first night at home
If a doctor has seen the child and the attack is mild, the rest is managed at home. What genuinely helps:
- hold the child upright or prop them up on pillows, since breathing is easier sitting than lying flat;
- keep them calm, distract them and speak in an even voice; stopping the crying often removes half the noise;
- offer small drinks often, whether warm water, diluted juice or whatever they will accept;
- give paracetamol or ibuprofen in a children's formulation for fever or discomfort, using the weight-based dose on the packaging;
- sleep in the same room for the first night and get up to check how the child is breathing.
What not to do:
- do not shut yourself in a steamy bathroom with the child or have them breathe over a pan of hot water. This advice has never been shown to work, and scalds after it happen regularly;
- do not try to inspect the throat with a spoon or a finger and do not force the mouth open; in rare but dangerous cases that triggers a complete blockage of the airway;
- do not give cough syrups or antihistamines, which do nothing for swelling under the vocal cords, and cough suppressants are unsuitable for small children in any case;
- antibiotics have no role in croup, because the cause is a virus. Cool air by an open window, on the other hand, soothes many children: there is no solid evidence for it and no harm in it, provided the child does not get cold.
One dose that changes how the illness runs
Croup is treated with a steroid, and it works extremely well. A single oral dose of a glucocorticoid, usually dexamethasone and sometimes prednisolone, brings the swelling down within hours, shortens the illness and greatly reduces the chance of admission to hospital.
It is not kept in reserve for severe attacks: the benefit shows in mild ones too. So a child with their first ever barking cough and stridor should be seen the same day rather than left until "Monday, if it hasn't cleared". This is one dose, not a course, and the usual worries about steroids do not apply to it.
When the swelling is severe, hospitals add nebulised adrenaline. It works within minutes but wears off quickly, so the child is watched for a while afterwards rather than sent straight home. Oxygen is given if needed. Only a minority of children are admitted, and a single night is usually enough.
When to call an ambulance
Call the emergency number (112 across Europe) or take the child to an emergency department if any of the following appears:
- the child is struggling to breathe: the spaces between the ribs and the hollow below them suck in, the nostrils flare, the abdomen heaves;
- the stridor is audible while the child is calm and not crying; or, conversely, the noise has grown quieter while breathing has clearly become harder, since a fading stridor alongside rising effort means very little air is getting through;
- the skin, lips or tongue look blue, grey, pale or blotchy; on darker skin this is easier to see on the palms, the soles and the lining of the mouth;
- the child is unusually sleepy, hard to rouse, floppy and not responding as they normally would;
- the child is oddly quiet and still, which in croup is more worrying than screaming;
- the child is extremely agitated, cannot breathe comfortably and cannot be settled;
- there is more drooling than usual, swallowing hurts or is impossible, and the child sits leaning forward and refuses to lie down.
Do not drive yourself in that situation: nobody would be watching the child on the way. Ask someone to take you or call an ambulance, and bring along every medicine the child is taking. Separately, a barking cough in a baby under six months always warrants medical advice, even when the attack looks mild.
What looks like croup but is not
Most "croup" really is croup, but a few conditions disguise themselves as it, and those must not be missed.
- Epiglottitis, inflammation of the flap that covers the entrance to the voice box. The child deteriorates fast, with a high fever, severe sore throat, drooling, an inability to swallow and a muffled voice, and notably without a barking cough; they sit upright, leaning forward with the neck extended. This needs an ambulance immediately. It is rare nowadays thanks to the Haemophilus influenzae type b vaccine, given in all our countries during the first year of life;
- An inhaled foreign body. Coughing and noisy breathing begin suddenly in a well child with no cold and no fever, often while eating or playing. Do not wait; this is an emergency;
- Bacterial tracheitis. It begins like croup, but the child keeps getting worse, the fever is high, and neither the steroid nor adrenaline brings the usual relief. It is treated in hospital with antibiotics;
- Allergic swelling. It comes on within minutes of a food, a medicine or an insect sting, often with a rash and swollen lips and eyelids. That is anaphylaxis and needs an ambulance;
- Whooping cough and bronchiolitis also start with cold symptoms. Whooping cough brings bouts of coughing to the point of vomiting with a gasping breath at the end of each bout; bronchiolitis in a baby brings wheezing on breathing out, fast breathing and refusal to feed.
One more situation is rarely discussed: croup that keeps coming back. If a barking cough with stridor recurs many times, particularly beyond the age of six or in a child who needed a breathing tube in the first days of life, the larynx deserves a proper look, because a congenital or scarred narrowing may lie behind it rather than a run of viruses.
Online consultation
Two questions are well suited to a remote appointment. The first is what this cough actually is: the doctor will ask you to hold the phone near the child, listen to the cough and the breathing in, ask how it all began, and say whether this is croup or something else. The second is what to do next: whether the child needs to be seen today for a dose of steroid, which signs to watch overnight, and at what point to call an ambulance. Recurring night-time attacks are also easy to review this way. Difficulty breathing, blue colouring, drowsiness or an inability to swallow, on the other hand, are not for a consultation: those mean calling the emergency number straight away.
This material is for information only and does not replace medical advice.
Consult with a doctor about Croup
Discuss your symptoms and possible next steps with a doctor online.
Online doctors for Croup
Discuss your symptoms and possible next steps for Croup with a doctor online.
