Croup - What is it?

Croup is a respiratory illness of childhood, usually contracted during the winter and autumn months. It generally affects children between the ages of six months and three years but has been seen in those as little as three months of age and as old as 15 years. It is due to a number of viruses that affect the upper part of the wind pipe causing it to become irritated, sore and swollen.

It is characterised by a typical 'barking', seal-like cough with or without noisy breathing on inspiration in particular (known as stridor, sounding as if the child were breathing through a straw), and with or without differing levels of difficulty in breathing.

It typically occurs in the evening or at night, and the onset is sudden. It often (and frustratingly!) gets better by the time the child has been taken to the Emergency Department, and this is thought to be because of the cool outside air reducing the swelling and irritation of the upper airway. Still, it can fluctuate so don't be lulled into a false sense of security half way to the hospital and don't be tempted to turn back. You might find that symptoms recur as soon as you set foot through your front door!

A child with croup will nearly always need treatment, whether the symptoms are mild, moderate or severe - so here is a quick guide telling you what to look out for:

Mild croup: Occasional barking cough, no evidence of stridor or any difficulty in breathing (seen in sucking in of the chest wall or of the notch in between the collar bones)

Moderate croup: Frequent barking cough, stridor that is easy to hear when the child is calm, some sucking in of the chest wall but no distress or agitation on behalf of the child.

Severe croup: Frequent barking cough, marked stridor (with occasionally the presence of expiratory stridor, i.e. noisy breathing on expiration), marked sucking in of chest wall and notch in between the collar bones, as well as distress and agitation on behalf of the child.

It is important to realise that the signs of croup can also vary according to how calm or frightened the child is, so it is always very important to keep the child's environment as calm as possible, even if you parent are feeling frightened or panicky. NO CHILD should ever be at home with signs of moderate or severe croup: although overall croup is quite benign, it can deteriorate very rapidly and quickly become life-threatening. If you have any doubt, bring your child to casualty.

How is croup treated?
The old wives' tales will dictate keeping your child in a steamy bathroom at home, but the truth is this has very little or no effect. The mainstay of treatment in hospital is the administration of a steroid called Dexamethasone (given by mouth as syrup). It is also possible to give other medicines via a nebuliser; these are Adrenaline, usually used in a real emergency as a stop-gap, as well as another steroid called Budesonide. The latter may be just as effective as Dexamethasone but is certainly no better, and with it comes the disadvantage that many children will get distressed by the use of a nebuliser. This puts them at risk of worsening croup and increased respiratory distress.

It is important to realise that once the initial croupy episode is over, it is possible for it to recur the following night - so it is best to be prepared. Equally, after the croupy symptoms have settled children often develop generalised upper respiratory tract symptoms of cough, cold, runny nose. This is quite normal and represents the viral infection taking its course. Unless the child is very unwell it is usually not necessary to bring the child to hospital.

When croup-like symptoms aren't croup

It is also important to recognise that very occasionally a child may have signs similar to croup that aren't croup, but could be due to other factors that need swift medical attention. Here are a few pointers:

• if the child has a very high fever, looks very unwell and does no respond to conventional treatment, think of a bacterial tracheitis, or in other words a bacterial infection of the wind pipe
• if the child has a high fever, is quiet, is drooling and finding difficult to swallow and sitting forward looking anxious, think of epiglottitis. Epiglottitis is a real emergency and can be life-threatening. Make sure you know whether your child has had the Hib vaccine, and if he/she hasn't then don't wait any longer to get the jab!
• other causes to think of are the inhalation of a foreign body that is lodged in wind pipe, an abscess behind the back of the throat, or other conditions that would cause the upper airway to swell up.