Noisy breathing, stridor and croup

What is croup?

Croup (also known as laryngotracheobronchitis) is a common childhood condition caused by swelling of the voice box (larynx), windpipe (trachea), and the airways to the lungs (the bronchi).

It is associated with a characteristic barking cough, hoarseness of voice, and a whistling noise when breathing in (called stridor).

Croup is typically seen in young children and can usually be managed at home. It can affect children as young as three months or as old as 15 years, though kids under three are the most susceptible because they have smaller airways.

It tends to affect boys more than girls and is common during late autumn and early winter. Croup may occur more than once in childhood, though this isn’t common.

What happens when you have croup?

The main symptoms of croup are caused by a narrowing of the airways. When these passageways become constricted, you may hear your child breathe more loudly than usual, and they may start to cough. A croup cough is often described as a ‘barking cough’.

Stridor, which is a whistling noise when breathing in, is another common symptom of croup.

Quite often, your child will also experience some hoarseness. Other symptoms may include a sore throat, a runny nose and a fever.

What causes croup?

Croup is typically caused by a cold or flu-like infection in the larynx, trachea or bronchi. Normally this is a viral infection, generally caught by close contact with someone else with the virus.

In rare instances, more serious cases croup can be caused by bacterial infections/agents. These can result in serious breathing trouble, requiring emergency care.

Very occasionally, recurring croup can also be caused by:

• an underlying structural problem in their airways
• inhalation of a foreign body
• acid reflux
• an allergic reaction
• other serious lung problems

What should I do if I think my child has croup?

Fortunately, most episodes of croup are mild and can be managed at home, but it’s always good to seek medical advice. Your GP can confirm the diagnosis and assess whether your child would benefit from hospital care.

It is not advisable to examine your child’s throat, as this could trigger a spasm of the airway, potentially completing the blockage.

The following symptoms indicate a serious presentation of croup and you are strongly recommended to dial 999 for emergency assistance:

• severe breathing difficulties
• an increased rate of breathing (too breathless to feed or talk) or 'silent chest' (you're unable to hear sounds of breathing)
• a worsening cough or stridor
• increasing distress and agitation
• dark, blue-tinged or pale skin (cyanosis denoting a serious lack of oxygen)
• increased effort when breathing – the skin around their ribs and chest appears to be pulled in and tight, making the bones of their chest and ribs more visible (recessions and tugs)
• becoming drowsy and sleepy
• a fast heartbeat or a falling heart rate
• a very high temperature
• unable to drink fluids

How is croup treated? Is there a cure?

Most children can be managed at home, taking common medicines such as paracetamol and ibuprofen to control the pain and fever. It’s also important to drink plenty of fluids to prevent dehydration.

Keeping your child comforted is paramount, as crying and agitation worsen symptoms. Reassurance and sitting upright can go a long way to ease their distress.

A single dose of oral corticosteroid (dexamethasone or prednisolone) may also be prescribed to reduce the swelling.

It should be noted that steam treatment has no proven benefits and may cause more harm than good. The same is true of cough medicines and decongestants.

When your GP examines your child, they may check for oxygen levels and how much effort it is for your child to breathe. If they do decide that hospitalisation is necessary, treatments might include oxygen, nebulised adrenaline, antibiotics, and regular high dose steroids. In extreme cases, breathing might need to be supported using a ventilator.

Your GP may consider checking the oxygen saturations (pulse oximetry) and the effort of breathing.

Will croup go away as my child gets older?

For most children, croup is a one-off event and no further investigation is needed. Less commonly, croup can happen on a few occasions in childhood, usually triggered by viral upper airway infections.

In rare cases, a child with a serious case of croup, requiring hospital support, may develop complications (pneumonia). In this group of children, it is important to rule out other underlying conditions. You’ll be recommended investigations, in particular bronchoscopic evaluation (looking into the windpipe using a camera); allergy and immune investigations; chest x rays; and assessment of acid reflux.