Coughing is one of the most common complaints in pediatric practice, resulting in nearly 30 million outpatient visits per year.1 While many cases of cough involve the upper respiratory tract and are caused by viruses, not all are the same in terms of severity .
Upper airway obstruction — caused by inflammation and swelling in the larynx, trachea, and bronchi — causes a loud “barking” cough that’s a telltale sign of croup. While the treatment of many diseases has evolved over the years, not much has changed when it comes to croup. However, the COVID-19 pandemic has increased awareness – and paranoia – surrounding respiratory infections.
Here’s the latest guideline for managing croup and how to differentiate this condition from other respiratory illnesses.
What is croup?
Croup is a respiratory illness based on clinical findings, such as hoarseness, barking cough, or stridor. The condition is most common in the fall and winter, and 80% of cases are responsible for viruses.2 The most common viral causes of croup are2:
Parainfluenza virus 1Parainfluenza virus 2 and 3Influenza AInfluenza BAdenovirusRespiratory syncytial virusRhinovirusEnterovirus
Less commonly, bacterial infections such as Mycoplasma pneumonia and Corynebacterium diphtheria can also lead to croup.
Most cases (85%) are mild, but about 1% become severe. In severe cases, croup can lead to stridor and hypoxia. Up to 5% of all children with severe croup may end up in hospital, but only between 1% and 3% ever need intubation.2
Symptoms often get worse at night, especially when a child is emotionally upset by their symptoms. The disease usually peaks within 24 to 48 hours and resolves within about a week in most cases
Making a diagnosis
The sudden onset and loud nature of a croup cough can be concerning, especially now, when concerns about COVID-19 variants are at an all-time high. However, there is no definitive test to diagnose croup. Croup is usually diagnosed by clinical signs, although infection with a particular virus or bacteria can be confirmed with lab tests.
In most cases, though, it’s less of a matter of what’s causing that croup than how bad it is, says Mike Patrick, MD, an emergency medicine and primary care physician at Nationwide Children’s Hospital in Columbus, Ohio. Patrick has covered croup and several other issues in his podcast, PediaCast, a pediatric podcast for parents.
The first step in diagnosing croup is to assess the child’s symptoms and determine how severe the croup has been, he says. The increased use of telehealth since the COVID-19 pandemic can help with this, as it is now easier than ever for pediatricians to visually connect with their patients at home.
If it’s a patient you know, Patrick suggests making a judgment about their individual health history and reports from health care providers. Children who present only with hoarseness or a barking cough can usually be treated at home, but those who experience stridor or difficulty breathing should be seen immediately in an emergency room or emergency department in most cases.
Management and Treatment
Supportive care is the hallmark of croup treatment and is the primary treatment at home in most cases. For years, the advice has been to use humidified air to help manage symptoms of croup, Patrick says, but recent research has been unable to prove this works.
“Often kids sound bad at home, and by the time they get to the emergency department, they sound better because they were out in the cool night air,” says Patrick. “That’s traditionally what people have been told to do for croup, but the most recent studies suggest that humidified air doesn’t do as much as we’d hoped.”
But if it helps caregivers and children feel better, or like something is being done, it won’t hurt, he adds.
Other supportive care methods that can help manage symptoms include emotional support, adequate hydration, and treating pain or fever with things like acetaminophen.
Supportive care is sufficient for some children, but clinical guidelines also support the use of oral corticosteroids in any child with croup, regardless of severity.2 According to Patrick, children typically receive a single dose of oral dexamethasone (0.15-0.6 mg/kg) ). )2 if they have a violent cough or intermittent stridor with their croup. Some facilities may also choose to use an intravenous formulation.
This one-time dose will work in the body for a few days to help reduce inflammation, but some children will need to return for additional doses days after they were first seen, says Patrick.
When a child presents with severe croup – with constant stridor, shortness of breath, or other signs of hypoxia – or if oral corticosteroids have not provided relief, the next step is to administer epinephrine in aerosol form. The American Academy of Family Physicians (AAFP) suggests the following doses2:
Up to 0.5 ml 2.25% racemic epinephrine Up to 5 ml L-epinephrine 1:1000
With this treatment, it is important to remember that as the treatment wears off, the inflammation may return and become more severe. If it’s given on an outpatient basis — or even in an emergency room or emergency department — the child should be monitored for at least a few hours for a rebound reaction or to see if another dose is needed, explains Patrick.
If another dose is needed, there’s a good chance the child will still need to stay in the hospital for at least one night, he adds. AAFP recommends monitoring children who have received epinephrine breathing treatments for at least 4 hours
Considerations with COVID-19
There are many concerns about respiratory symptoms as the COVID-19 pandemic continues to develop. The emergence of new variants continues to pose a challenge to control the virus and properly diagnose other respiratory diseases.
Patrick says his organization does not universally test all children for COVID-19 when they have respiratory symptoms. Instead, testing is done when the situation warrants it. For example, if a child stays at home with vaccinated parents while they recover, testing will not affect treatment and may not be necessary. When kids have to return to a school or daycare center, testing may be more necessary for isolation purposes than anything else, he says.
There have been a few known cases where COVID-19 and croup have occurred together3, but Patrick says this isn’t all that surprising.
“If they are positive [for COVID-19], children can have several viruses at once. Whether COVID-19 is with croup or other viruses is not the issue,” says Patrick. “Which virus is less important than tackling the matter based on the severity of the croup.”
What may be more important than which virus causes croup symptoms is what other illnesses or conditions the child may have. Certain groups are at higher risk for both COVID-19 and croup, he says. This group usually includes children who are immunocompromised by immune disorders or medications, such as chemotherapy. Interestingly, Patrick says there doesn’t seem to be much of a connection between children with asthma and the severity of COVID-19, but children who already have breathing problems may need special attention when it comes to croup.
As for croup and at-risk kids, Patrick says he’s trying to get a sense of how severe their symptoms are before making a recommendation on where to get care.
“You don’t want to miss the child who is deteriorating, but you also don’t want to increase exposure,” he says.
Children with a history of respiratory problems or who are immunocompromised are best left home with mild croup symptoms, but a worsening clinical picture may outweigh any infectious disease risks encountered in the emergency department or office-based care, says Patrick.
One of the ways COVID-19 may increase risk — at least anecdotally — is elevated respiratory disease in general, he adds. This may be more a result of COVID-19 mitigation strategies, such as masking and social distancing, than the virus itself, he adds, pointing to a drop in flu cases last year.
“It’s bizarre how much cough we see now [in early August] in bronchiolitis,” says Patrick. “The pandemic in general has shifted epidemiology for viruses.”
Decreased exposure — especially in young children, within the past 18 months — can limit their natural immune defenses against respiratory viruses and make them more susceptible to infection the more people they interact with.
Recovery and Prevention
Just as masking, social distancing and hand hygiene have been used to prevent the spread of COVID-19 — and possibly other respiratory diseases — croup can be avoided with the same strategies. Families should be encouraged to avoid areas where sick people are close, to stay home if they are sick themselves, and to be vigilant with personal hygiene and hand washing when seasonal viruses are rampant.
Recovery from croup usually takes several weeks, and Patrick warns that parents and caregivers may need some reassurance. It’s not uncommon for a cough to last for several weeks after a viral illness, he says, and the key is for the cough to gradually improve over time. If the cough worsens or lasts too long, clinicians may want to re-examine the child to rule out pneumonia or other differential diagnoses.
While new research may question age-old remedies like steam, when it comes to croup, there’s not much that can hurt in terms of supportive care. The primary method of treating croup is to treat the child based on their clinical presentation. Hospitalization and medications, such as corticosteroids and epinephrine, can help in mild to severe cases, but treatment is based largely on the severity of symptoms, not the source of infection, regardless of whether there is an ongoing respiratory virus pandemic.
Therefore, in most cases, reassurance from the healthcare provider and education about emergency symptoms is enough to manage croup.
1. Kasi AS, Kamerman-Kretzmer RJ. Cough. Pediatrician Rev. 2019;40 (4): 157-167. doi: 10.1542/pir.2018-0116
2. Smith DK, McDermott AJ, Sullivan JF. Croup: diagnosis and management. Ben Family Arts. 2018;97(9):575-580.
3. Venn AMR, Schmidt JM, Mullan PC. Pediatric croup with COVID-19. Ben J Emerg Med. 2021;43:287.e1-287.e3. doi:10.1016/j.ajem.200.09.034