… ask the Boogor Doctor …

Recurrent Croup

by Russell A. Faust, PhD, MD

Dear Dr. Faust,

Please help us figure out what is wrong with our son. He is 5 years old, and continues to have recurrent croup. Our doctor told us that he would outgrow it by age 3, but he keeps having problems. He requires steroids so often that they are making him fat. What should we do?

Real Croup

True “Croup” is a respiratory illness that is characterized by a “barky cough” that sounds like a seal bark. It is usually (but not always) accompanied by some mild difficulty breathing, and often hoarseness.

When it is severe, these children can have severe difficulty breathing, and the sounds that they make are scary – it can sound like they won’t be able to get enough air. Difficulty inhaling during croup will commonly be accompanied by a high-pitched noise, called “stridor”. There are many causes of stridor, but it is always associated with a narrowing of the airway.

Causes

Croup results from a virus that causes swelling of the trachea and voice box (larynx). The “seal bark” cough is caused during forced-exhalation (cough), that causes the swollen tracheal walls to contact each other – that is what makes that terrible bark sound.

Moist air (a humidifier or sitting in the bathroom with a steamy shower running) and keeping the child calm (meaning: parents remaining calm) are usually all that are needed for mile croup.

Severe croup, especially when associated with any breathing difficulties, should be evaluated in urgent care or the emergency department of your local hospital (children’s if possible). Most commonly, inhalers and steroids are used to reduce the swelling and improve the airway, reduce the croup.

Natural History – What You Can Expect

As your child grows older, their airway – their trachea and larynx – also grow larger. At about the age of three, more or less, the trachea is usually a large enough diameter that the usually amount of swelling that results from viral inflammation will no longer cause the “seal bark” cough. That is also around the age that the larynx is large enough that most common viral infections will no longer result in stridor.

When to Worry

Dial “911” or go directly to the emergency department of your nearest hospital if your child is:

• struggling to get enough air
• stops breathing
• turning blue

When to Consider Other Diagnoses

(time to see your pediatrician)

If your child has any of the following features to their “croup,” their cough or noisy breathing may not be simply from viral infection.

When you should think about other causes of “recurrent croup” – that it might NOT BE CROUP :

• stridor lasts for hours
• stridor that lasts for longer than the infection
• severe stridor that requires multiple ER visits
• severe stridor that requires hospitalization
• any respiratory distress that requires intubation
• stridor in child older than 3 or 4 years of age
• progressive stridor that worsens over time
• worsening or frequent episodes of croup
• progressive weakening of the voice over weeks
• choking or gagging before onset of stridor

Red Flags

It is time for further medical attention for ANY of these signs listed above!

Maybe not right this minute. But soon.

Premies

Children who had previously been intubated and on the ventilator (breathing machine) as newborns are at greater risk of anatomic narrowing of their airways. Intubation is common for babies that are  very premature.

Referral to Specialist

Your child may be referred to an Otolaryngologist (Ear, Nose & Throat Specialist) by your Pediatrician.

Depending on their history, signs and symptoms, the ENT doc may recommend looking at your child’s upper airway using a tiny flexible fiberoptic “laryngoscope” – essentially a way to look at the larynx and upper airway using a spaghetti-like instrument, placed into the nose.

It does not hurt. On the other hand, nobody enjoys the feeling – it is just so strange.

We won’t review all of the many, many, rare (and some scary) possible causes of “recurrent croup” in children here.

But to answer the mother’s question above:

This youngster meets a couple criteria for further evaluation: He has had multiple ER visits and is frequently treated with steroids, and he continues to have “recurrent croup” beyond the usual age of 3 or 4 years.

My recommendation is therefore further medical evaluation. Depending on the history, signs, symptoms, and exam, possibilities may include laryngoscopy in clinic, evaluation by Speech Pathologist, pH probe or other assessment of gastro-esophageal reflux, and even endoscopy under general anesthetic.

Thanks for visiting!

Visit again sometime soon for a review of the causes of airway narrowing, including some photos taken during endoscopic surgeries.

________

Resources

Image Credit: LifeART (and/or) MediClip images, copyright 2010 Lippincott Williams & Wilkins. All rights reserved.

(I just love this pic!)

1. Faust RA: An 18-month-old with progressive hoarseness. Pediatric Rounds. Hospital Physician, 39: 38-45, 2003.
2. Faust RA: Childhood voice disorders: Ambulatory evaluation and operative diagnosis. Clinical Pediatrics, 42: 1-9, 2003.

________

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Tags: childhood, cough, croup, diagnosis, dysphonia, emergency, laryngeal edema, recurrent croup, stridor, trachea, voice