Croup in newborns
Croup is the most common cause of upper airway obstruction in babies and children aged 6 months to 3 years.1 Medically it is inflammation of the upper airway passages- the larynx, trachea and the bronchi. The inflammation can be caused due to various factors- the most common being viruses. This term is collectively called laryngotracheobronchitis.
Despite its complicated name, laryngotracheobronchitis it isn't as daunting. It resolves on its own in most children, leaving little to no complications. The risk of airway obstruction is the main call for attention in babies affected with croup. That being said, parents or carers must be able to recognise the symptoms of croup to enable immediate treatment, resulting in better outcomes, both immediate and long-term.
Read on to understand more about croup, the viruses that cause it, and how children with croup present. This article will take you through all the above and untangle this mouthful of disease into bite-sized, palatable portions so you will be well-equipped to identify the symptoms of croup, what causes it when to take your child to a hospital, and the treatment options available.
What causes croup?
Viruses are the main cause of croup.1 They settle and multiply in the upper air passages. They are -
- Parainfluenza, which is known to be the most common cause, accounts for >75% of croup infections.
- Respiratory syncytial virus RSV
- Rhinovirus
- Enterovirus
- Influenza A or b
- Metapneumovirus
- Adenovirus
When these viruses multiply in the upper airways, they cause a release of substances that alter normal cell function and cause irritation to the tissues. The net effect of this is inflammation of the tissues hence croup.
What are the symptoms of croup?
Croup is essentially caused due to the inflammation of the upper airway- this consists of the larynx, trachea, and large primary bronchi. One or more of these parts may get swollen and result in a significant narrowing of the airway, which is seen as difficulty breathing.
The normal duration is 3-7 days, often with the symptoms worsening till day 3/4 and then start resolving. The symptoms include
- Mild fever, although it isn't always present
- Seal-like or barking cough - It is hallmarked by the peculiar cough- often described as ‘seal-like’ or ‘barking’ cough which sounds like this-
- Difficulty breathing, which gets worse at night
- A loud sound while breathing called stridor
- No drooling or difficulty swallowing
- Usually a precedent of cold, stuffy nose and sore throat
- An increased pace of breathing
Typically the disease progresses in a manner,
- Day 1: The child initially develops a stuffy nose and mild fever
- Day 2 and 3: The parent notices the child making loud sounds while breathing especially while breathing in, a loud unusual cough and chest heaving up and down while breathing.
- Day 4: The child is unwell and in bed, with a fever, stridor, difficulty breathing and weakness.
- There is a gradual improvement in symptoms over the next few days.
The loud sound called stridor is caused by the turbulent passage of air through the narrowed tubes. Increased breathing is seen as the child tries to overcome this strain by using their muscles to breathe more to ensure the necessary amount of air reaches the lungs which is seen as intercostal retractions, chest heaving, and nasal flaring.1
Severe cases can even result in less oxygen reaching the body which makes the face, tongue and body a bluish hue called cyanosis. Their breathing may be faster than usual and their voice may turn hoarse.
What to watch out for indicating respiratory failure/ severe croup:2
- Stridor
- Prominent ribs while inhaling and exhaling- called intercostal or subcostal retractions
- Heaving chest or your baby looks like they’re struggling to breathe
- Flaring of nostrils
- Cyanosis- lips/ tongue/ face appears bluish
- Lethargic, drowsy baby/ unconscious
Take your child to the hospital if you notice the above or are suspicious.
Typically a clinical diagnosis is based on symptoms and signs, supported by the nasal swab isolation of the causative viruses that are known to cause croup. The doctors will rule out other causes of upper airway obstruction like a foreign body in the airway, subglottic stenosis, angioedema, retropharyngeal abscess, and bacterial tracheitis.
Occasionally a chest X-ray may be performed which may show the characteristic Steeple sign (due to inflammation of the upper airways) - in 50% of cases only.1
How is croup treated?
The doctors will grade your child according to the Wesley score.1 This involves five criteria
- Inspiratory stridor: 0 (None); 1 (When agitated); 2 (At rest)
- Retractions: 0 (None); 1 (Mild); 2 (Moderate); 3 (Severe)
- Air entry: 0 (Normal); 1 (Decreased); 2 (Markedly decreased)
- Cyanosis: 0 (None); 4 (When crying); 5 (At Rest)
- Level of consciousness: 0 (Alert); 5 (Disoriented)
Depending on the total score, the severity of the croup will be determined.
- A total score of 2 or less- Mild croup
- 3 to 5 - Moderate croup
- 6 to 11 - Severe croup
- >12- impending respiratory failure
More than 85% of children present with mild symptoms while fewer than 1% score 6 or more.1
Does my child need to stay in the hospital?
Children with moderate to severe croup will need at least 4 hours of monitoring to ensure airway patency and no further deterioration.3 If there is severe obstruction with decreased saturations or cyanosis endotracheal intubation and further monitoring will be required.
For moderate to severe cases, guidelines recommend dexamethasone with nebulised epinephrine⁴, adding oxygen by a nasal cannula or mask if saturations drop. 0.2% of children may require intubation to secure their airway.¹
However, if the disease is not severe at home treatment is best suited for the child. Croup usually gets better on its own within 2-3 days. There are things you can do to help2
- Sit your child upright and try not to let them lie down
- Try to keep them calm (crying can make the symptoms worse)
- Hydrating them well
- Check on them regularly, including at night
- Give them paracetamol or ibuprofen to help ease a high temperature or any discomfort
Along with these, single-dose corticosteroids usually dexamethasone are recommended, while carefully watching for signs of obstruction.
Will antibiotics help my child?
Antibiotics are not used routinely in the treatment of croup since it is caused mostly by viruses. They are reserved for rare situations where a primary or secondary bacterial infection is suspected.
In such children, vancomycin/ cefotaxime are the antibiotics recommended. In case of severe infection due to influenza A or B, antivirals may be used.3
Will cough medicine help my child?
Studies have shown that there is no role of cough meds in the management of croup. This is because cough medicines act on central receptors in the brain to suppress the initiation of cough, but croup is caused by local inflammation of the passages causing narrowing and irritation which manifests as cough.
Summary
In conclusion, croup is a childhood respiratory condition characterized by inflammation and narrowing of the upper airway. Key symptoms of croup include a harsh, barking cough, stridor, respiratory distress, and fever.
Prompt recognition and management of these symptoms are essential to prevent complications and improve outcomes for affected children. Supportive care with humidified air and hydration is the mainstay of treatment, with corticosteroids and nebulized epinephrine reserved for more severe cases.
By understanding the symptoms of croup and implementing appropriate management strategies, healthcare providers and caregivers can help alleviate distress and promote recovery in children with this condition.
References
- Sizar, O., & Carr, B. (2023, July 24). Croup. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK431070/#article-20142.s4
- Johnson DW. Croup. BMJ Clinical Evidence [Internet]. 2009 Mar 10;2009. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907784/
- Leung, A. K. C., Kellner, J. D., & Johnson, D. W. (2004). Viral croup: a current perspective. Journal of Pediatric Health Care, 18(6), 297–301. https://doi.org/10.1016/j.pedhc.2004.08.004
- Rizos, J., DiGravio, B. E., Sehl, M. J., & Tallon, J. M. (1998). The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department. the Journal of Emergency Medicine/the Journal of Emergency Medicine (S.l. Online), 16(4), 535–539. https://doi.org/10.1016/s0736-4679(98)00055-9