CROUP - Full extract 

One night several years ago our three-year-old daughter developed a noisy cough and difficulty breathing.

After a couple of coughs the cause was fairly obvious. When you have seen and heard a lot of croup you recognise it quickly - that noisy breathing followed by a dry rasping cough, like a small dog's bark.

We picked her up but she couldn't be consoled. She felt hot and her voice was husky. As she became more upset the noisy breathing became worse.

We brought her into our bedroom and she gradually settled. However, after another hour or so she woke up coughing and struggling for breath, so we headed into casualty at the Royal Children's Hospital.

After being seen by the casualty doctors, she was observed for a few hours and then allowed to go home. No specific treatment was needed. She started coughing again the following night but was not distressed. It was a couple of weeks before her cough finally cleared.

Croup is a very common upper respiratory infection in young children. It can be caused by a number of different viruses, the same types that might cause symptoms like a cold or sore throat. Croup leads to inflammation and swelling in the larynx (voice box) and the large airways.

The concern with small children is the relative narrowness of the breathing tube just below the larynx. Swelling in this area can cause the airway to become blocked. Although this is very uncommon, croup has to be regarded as a potential cause of respiratory obstruction in children.

Croup tends to occur in predictable outbreaks each year, especially in autumn and early winter, with a smaller peak in spring. Because it is caused by a few different viruses, there is no way of preventing children from getting croup. Likewise, there is no vaccine available.

The main symptoms are the dry barking cough and difficulty breathing. The noisy sound when breathing in is called stridor. When this noise is present at rest, the croup should be regarded as severe and the child observed in hospital. Another clue to the severity of croup is the amount of work that the child is doing to breathe. When the child is working hard, the small spaces between the ribs and in the front of the neck become drawn in with every breath. The child's nostrils might also flare with breathing. All these signs suggest that the croup is severe and the child should be in hospital.

Signs such as a bluish discoloration in the lips or the child becoming pale and drowsy are ominous indications that the airway has become severely narrowed. Emergency transport to hospital by ambulance is the best step.

There is no diagnostic test for croup. It is a clinical diagnosis based on history and examination. Other causes of a blocked upper airway, such as severe allergies or an inhaled foreign body, need to be kept in mind. Another condition called acute epiglottitis can cause a similar picture. This potentially fatal condition comes on without warning and the child is extremely sick, drooling saliva. It is caused by Haemophilus Influenza type b (Hib), the same organism that can cause one type of bacterial meningitis. With routine immunisation these conditions are now very rare.

Most cases of croup can be managed very well at home. Paracetamol may help if the child is upset with a fever or sore throat. In some cases a doctor may prescribe a day or two of an oral cortisone preparation called prednisolone to reduce the amount of swelling in the larynx. Because croup is a viral infection, antibiotics have no role to play in treatment. In days gone by some people found that humidifiers and steam seemed to be of benefit, although it is difficult to know whether these measures help at all. Fortunately, croup usually runs a mild, short course.

In more severe cases admission to hospital is necessary. Again, the vast majority of these children settle down without treatment. Sometimes special adrenalin type medications administered by nebulisers are used to reduce the swelling in the child's airway, but this occurs only in a hospital where intensive-care staff are on hand.

Health Tip:
* If a child with croup is having increasing difficulty breathing, err on the safe side and go to casualty for advice, regardless of the hour. 

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: December 11, 2004