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Generally occurring in children, Croup is a condition characteristic of a barking cough and labored breathing. Although the coughing and wheezing are terrifying for a parent, croup is rarely a medical emergency. It typically resolves in a few days, and a single dose of medication is usually enough to get over the worst of it.
What is croup?
Croup is a respiratory system infection that primarily affects children up to the age of six. Most croup cases involve an upper airway infection of the voice box (larynx) and windpipe (trachea), a condition called laryngotracheitis. However, croup can also involve the airways in the lungs (laryngotracheobronchitis) and, in the most serious cases, cause fluid build-up in the lungs (laryngotracheal bronchopneumonitis).
The larynx is a rigid structure at the front of the neck that serves as the entryway to the windpipe, or trachea. It primarily protects the respiratory system from breathing in food while eating, but also contains the vocal cords. The common symptoms of croup—barking cough, high-pitched wheezing, and hoarseness—are due to swelling of the larynx and the vocal cords. Adults also get larynx infections, but croup is limited to small children because their larynx is small and more easily closed off with swelling.
Four out of five croup cases are due to viral infections, predominantly parainfluenza virus. Cold and flu viruses make up most of the remaining cases. Bacterial croup, which is rare, is mostly caused by diphtheria or chest cold bacteria. Some cases, called spasmodic croup, involve no infection whatsoever.
Around three out of 100 children in the United States come down with croup each year, most between the ages of six months and three years. Most cases (85%) are mild and resolve in three to seven days even without treatment. Mild croup is treated by corticosteroids to reduce swelling.
Severe croup—about one in a hundred cases—is diagnosed when the child cannot adequately breathe due to airway obstruction or pneumonia. The most rare and severe cases will require hospitalization and possibly mechanical ventilation.
How is croup diagnosed?
Croup is diagnosed from the symptoms. The defining symptoms of croup are a barking cough, high-pitched wheezing (stridor), and hoarseness. A low-grade fever may also be present. If, in addition to croup symptoms, the child is drooling or has difficulty swallowing, those may be signs of a more serious condition, such as epiglottitis, and require immediate medical attention.
Most cases start as an upper respiratory infection, so croup is typically preceded by one to three days of runny nose, nasal congestion, and fever, so a patient’s recent history can help with the diagnosis.
The severity of croup depends on how well the child can breathe. An emergency room physician or pediatrician will check for signs of difficult breathing or oxygen deficit (hypoxia). Alarm signs are retractions (the area between the ribs and the neck sinks when taking a breath), fast breathing, blue skin, confusion, fast heartbeat, and loss of consciousness.
The healthcare provider will also check for other conditions that obstruct breathing, such as epiglottitis, swelling of the tissue that covers the entrance to the larynx to prevent aspirating food or water. X-rays, cultures, or blood tests will only be used if the physician suspects another condition is causing the symptoms.
Croup treatment options
Most croup cases will resolve in three to seven days without treatment. Once a diagnosis is made, however, the goal of croup treatment is to decrease problems with breathing.
Medications
Medications are used in most cases to reduce swelling in the larynx and trachea. Nearly all patients will receive a corticosteroid which will reduce swelling for several days. More severe airway obstruction will be treated with nebulized epinephrine. Its effects are immediate but last for only a few hours.
Supplemental oxygen
Children with difficulty in getting enough oxygen will be hospitalized and put on supplemental oxygen. The doctor may use a special oxygen mixture that is less dense than normal air. Called heliox, its lower density makes it easier to breathe into the lungs. About one in five hundred cases will require mechanical ventilation to prevent respiratory distress.
Croup medications
Croup typically resolves in a few days. Medications are used to reduce swelling in the larynx and trachea. Antibiotics do not work against the viruses that cause croup. For that reason, they are only used in the small number of cases involving a bacterial infection.
Corticosteroids
In the emergency room or clinic, a healthcare professional will nearly always administer a single dose of dexamethasone, a glucocorticoid that reduces swelling in the airway for up to four days. If the diagnosis is made during an office visit, however, a pediatrician may instead prescribe a three-day regimen of oral prednisolone.
Racepinephrine
Moderate croup is diagnosed when a child shows some problems with breathing. In those cases, a healthcare professional will administer nebulized racemic epinephrine, called racepinephrine. The drug, similar to adrenaline, signals the muscles in the airway to relax, widening the airway to allow more air through. The effects are immediate but wear off in about three hours. Nebulizers work by using air pressure to break up liquid drugs, like epinephrine, into tiny aerosol droplets that can then be breathed into the airway through a mask or mouthpiece.
Pain relievers
Discomfort is best handled with over-the-counter analgesics such as acetaminophen or ibuprofen. Topical medications or remedies such as saltwater, lozenges, throat syrups, or teas will not help.
What is the best medication for croup?
While there is no “best” medication for croup, treatment of croup usually involves a single dose of dexamethasone and, if there are problems with breathing, nebulized racepinephrine. Treatment will depend, however, on the severity of the case and the patient’s tolerance for specific medications.
| Best medications for croup | ||||
|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects |
| Dexamethasone | Corticosteroid | Oral | Dose depends on weight. Single oral dose administered by a healthcare provider | Behavior and mood changes, fluid retention, trouble sleeping |
| Orapred (prednisolone) | Corticosteroid | Oral | Dose depends on weight. Tablet or liquid taken orally for three days | Behavior and mood changes, fluid retention, trouble sleeping |
| S2 (racepinephrine) | Adrenergic agonist | Nebulizer (inhaled) | Dose depends on weight | Anxiety, fast heartbeat, restlessness |
| Tylenol (acetaminophen) | Analgesic | Oral | Two tablets every four hours | Nausea, stomach pain, loss of appetite |
| Advil (ibuprofen) | NSAID | Oral | One 200 mg tablet every four to six hours | Nausea, bleeding, stomach pain |
Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA) and the National Institutes of Health (NIH). Dosage is determined by your doctor based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.
What are the common side effects of croup medication?
All medications have side effects, but these side effects will vary depending on the type of medication. This is not a complete list of possible side effects, so consult with a healthcare professional about possible side effects and drug interactions.
Corticosteroids commonly produce side effects even when taken in a single dose. The most common are mood and behavior changes, aggressiveness, and difficulty sleeping.
Racepinephrine is a chemical similar to adrenaline, a hormone naturally produced by the body. Many of its side effects, then, are similar to an “adrenaline rush,” including anxiety, restlessness, nervousness, trouble sleeping, fast heartbeat, shakiness, and sweating. The most hazardous side effect is elevated blood pressure, often marked by a headache and a pounding feeling in the neck.
Over-the-counter pain relievers are widely-used and safe. The most common side effects of acetaminophen are nausea, headache, or stomach pain. Acetaminophen is toxic to the liver in high doses and overdose is a medical emergency. NSAIDs, such as ibuprofen, decrease the body’s ability to form blood clots and its ability to protect the digestive system from stomach acid. The most common side effects, then, are stomach pain, gastrointestinal bleeding, bleeding problems, and bruising. Aspirin, a well known NSAID, should never be given to children or teens with a viral infection such as croup because it may trigger Reye’s syndrome, a potentially fatal reaction to a viral infection.
What is the best home remedy for croup?
In the vast majority of children, croup goes away after three to seven days as the body battles the infection. Home treatment should focus on reducing discomfort, keeping the airways open, and monitoring.
Monitor breathing
Monitor the child to make sure their breathing remains untroubled. You may need a trip to the urgent care or emergency room if you notice fast breathing, a fast heartbeat, or nostril flaring. Blue skin, altered mental status, or passing out are alarm symptoms signaling the need for immediate medical care.
As another sign of breathing problems are retractions. Normally, when a person breathes, their diaphragm expands to draw air into the lungs. When breathing becomes difficult, the muscles at the top part of the chest contract to push air into the lungs. The top part of the chest looks like it’s collapsing inwards at every breath.
Calm down
Stay calm. Keep your child calm. Worry, fear, and tension tightens the airways and worsens the symptoms. Staying calm and settling the child down goes a long way in relieving croup symptoms.
Use steam
A cool mist vaporizer or just sitting in the bathroom with a hot shower going may be enough to calm the cough and wheezing. The body shuts down much of its anti-inflammatory activity at night, so keep a cool mist vaporizer going to relieve nighttime symptoms.
Let child breathe cool air
Most croup cases occur in the fall and winter, so there is plenty of cold air on tap. Open a window or a freezer door and let the child breathe in cool air for a few minutes to settle the symptoms.
Give warm fluids
The barking cough is often due to irritation caused by mucus in the larynx. Over-the-counter cough medicines, throat lozenges, and throat-soothing teas don’t affect the larynx. That’s because nothing you swallow goes into the larynx. However, warm drinks warm up the throat, and this warmth can help loosen mucus in the larynx, which sits right in front of the throat. When the mucus clears out, the coughing spasms settle down.
Frequently asked questions about croup
What is the best thing to do for croup?
Croup generally goes away in three to seven days. Steam, cool air, and warm drinks can help reduce symptoms such as high-pitched wheezing and coughing spasms. The most important thing to do, though, is to monitor the child carefully to make sure they are not having difficulty breathing.
What does a steroid do for croup?
The symptoms of croup—barking cough, high-pitched wheezing, and hoarseness—are caused by swelling in the larynx. Corticosteroids reduce swelling in the larynx by interfering with the body’s ability to create the substances that cause swelling.
How long does it take for steroids to work for croup?
Corticosteroids reduce croup symptoms in about six hours. The effects of single-dose dexamethasone, the standard of care for croup, lasts three to four days.
How long does it take for croup to go away?
Croup usually resolves in three to seven days.
Do you need antibiotics for croup?
Most croup cases are the result of a viral infection, so antibiotics will not be used. Some cases, however, may be due to a bacterial infection or result in a bacterial infection on top of the original viral infection. Those infections will be treated with the appropriate antibiotics.
Can croup heal on its own?
Croup usually heals on its own in three to seven days. It is important, however, to monitor the child’s breathing throughout the illness. Any signs of breathing difficulties, such as fast breathing, fast heart rate, chest retractions, blue skin, or changes in mental status are alarm symptoms requiring immediate medical care.
What helps a croup cough at night?
Croup symptoms worsen at night because the body reduces substances, called corticosteroids, which reduce airway swelling. You can help quell nighttime symptoms by using a cool mist humidifier at night or by letting the child breathe in cool air. If it’s cold outside, open the window for a few minutes. If not, hold the child in front of an open freezer door.
What essential oil is good for croup?
Essential oils should be avoided as they can worsen the symptoms of croup. Several essential oils are commonly advised as natural remedies for a normal cough, most notably eucalyptus, peppermint, clove, oregano, thyme, and cinnamon oils. They can be rubbed on a child’s back or used in a vaporizer. All contain topical counterirritants. When a counter-irritant comes in contact with irritated tissues, they “overwhelm” the nerves with a counter-sensation, reducing the irritation that causes coughing. Some of these substances, however, cause inflammation and may worsen other croup symptoms. More importantly, some, such as cinnamon, thyme, and clove oil, can be dangerous and have not been verified as safe treatments for children.
When should I go to the hospital for croup?
Most croup cases resolve without treatment. It is important, however, to closely monitor the child’s breathing. Any sign of breathing problems requires medical attention. Signs that the child needs medical help include fast breathing, nostril-flaring, and chest retractions, that is, the top of the chest below the neck collapses when the child takes a breath. Blue skin, changes in mental status, and unconsciousness are signs that the child is not getting enough oxygen. The child needs to be taken immediately to an emergency department.