Croup (cont.)

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The infection starts with a cold, cough, and low-grade temperature lasting two to three days. Then the typical barking cough (sounds like a seal) is usually present by day three and is more likely to be worse at night. The presence of stridor (wheezing on inspiration), hoarseness, difficulty swallowing, and respiratory distress are common but may or may not be severe.

Call your doctor if the following conditions develop:

• Your child has a high fever.
• The child is breathing faster than normal or has noisy breathing.
• The child has signs of dehydration, including increased sleepiness, dry mouth, or decreased urination.
• The child starts having loud, high-pitched wheezing while breathing.
• The child begins to struggle to breathe or speaks in short sentences because of lack of breath.
• The child has difficulty swallowing or is drooling excessively.
• The child is having signs of restlessness or sluggishness either from respiratory distress or dehydration.
• The child has signs of respiratory distress, including retractions of skin around the ribs from deep breathing, nostril flaring, or rapid breathing; these symptoms suggest a medical emergency.

Cyanosis, which is a bluish color to the skin, lips, or nail bed, indicates severe lack of oxygen in the body and should be considered an emergency, and 911 should be called.

The great majority of children with croup can be diagnosed from the history of the present illness and a physical examination that show croup symptoms described above. Studies are not routinely required and should be reserved for those children who present with atypical symptoms or with extremely severe symptoms that are not obviously associated with croup. However, an anteroposterior neck X-ray may show a steeple or pencil sign indicating narrowing of the trachea.

• A pulse oximeter may be used to determine if the child is getting an adequate amount of oxygen. This is a skin sensor, placed on the finger, toe, or ear, connected to an oximeter machine by a wire. Normal levels would be above 95% on room air.
• X-rays of the neck may be ordered to differentiate croup from epiglottitis, which is a more serious condition. Children with croup typically have visible upper airway narrowing, called a steeple sign that can be seen on X-rays.
• Blood tests are usually not necessary.
• Viral cultures and antibody tests are not recommended.

• Although mist or humidified air and exposure to cold air have not been proven effective in treating the symptoms associated with croup, they are still routinely recommended by physicians since they are generally not invasive and have been described anecdotally as helping some children with moderate symptoms.
• Consider substituting water or juice for milk products. Frequent sips of clear liquids can loosen mucus and prevent dehydration, which often occurs with croup.
• Crying can trigger spasmodic coughing. Attempt to comfort your child to prevent agitation.
• Acetaminophen (Children's Tylenol) or ibuprofen (Advil, Motrin) may be given for fever or sore throat. Aspirin-containing medications should never be given to children unless prescribed by a physician due to the risk of a serious liver condition called Reye's syndrome.
• Over-the-counter cough medications are not recommended. Avoid exposure to respiratory irritants such as smoke.

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