Recurrent Croup

Recurrent Croup, when to consider other causes of stridor in children

Image: Recurrent Croup, when to consider other causes of stridor in children (I know, pic has nothing to do with croup; I just like it!)

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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Comments

  1. I completely agree with Dr Faust on this one. You child needs additional evaluation so we can avoid the use of frequent courses of steroids.

    • Russell A. Faust, PhD, MD says:

      Hi Dr. Hana,
      Thank you for visiting, and for your vote of confidence!
      Best in health,
      RF (boogs)

  2. Dawn Kellogg says:

    My grandson who will be 3 in May and who has Down Syndrome has recurring croup. It has been suggested that there may be an underlying cause….hemangioma,narrowing in the throat, a flap (????). He has been referred to a Pediatric ENT. Are we on the right path?

    • Russell A. Faust, PhD, MD says:

      Hi Dawn,

      Recurrent croup occurs because there is a baseline narrowing of the airway below the larynx or voice-box. Then, whenever there is added narrowing due to swelling – can be caused by simple allergies or a viral ‘cold’ – the narrowing becomes limiting. Whenever the child coughs, pressure narrows the airway further, causing the classic “seal-bark cough” known as croup. It is rarely caused by hemangioma, and if so, nearly always requires intervention during infancy – rarely waits until age 3 to be addressed.

      As the airway grows in diameter, as the child grows, the recurrent croup resolves as the airway reaches a certain size. Note that children who make it past infancy without needing tracheotomy or surgery to enlarge their airways usually do fine without further intervention – that is, they outgrow the problem.

      Children with Down Syndrome often have slightly narrow airways and other changes in their respiratory anatomy.

      If your grandson has made it to age 3 without serious troubles, he will likely do well, but it is perfectly reasonable for him to be checked out by a pediatric ENT.

      Thank you for your question!

  3. Zoe PEARS says:

    Our little boy is 6 years old. He has had recurring croup with stridor since 3 plus months. Our local hospital always just treat him with dex but he has got worse each time. Currently under specialist and will be having tonsils and adneoids removed as they are extremly large. They will be putting a camera fown while they remove his tonsils. He has Asthma also. Can you tell us what could be the cause and what to expect?

    • Russell A. Faust, PhD, MD says:

      Hi Zoe:

      Of course, the best source of information for your son’s procedures is the person recommending those procedures.

      Because the entire respiratory tract is affected by similar circulating biochemicals – inflammatory cytokines – any local site of inflammation (an ear infection, for example) can result in stimulation of the entire respiratory tract. You know the result: asthma exacerbation; croup; swelling of tonsils and adenoids; etc.

      Because the adenoids can act as a chronically-infected reservoir for bacteria (and the tonsils, too, to a lesser extent), tonsillectomy/adenoidectomy can help these children immensely. And it is certainly less painful at the age of 6 than 16.

      I’m not going to describe the technical details of tonsillectomy or bronchoscopy because there are many ways to perform these procedures. Again, it is best to ask the physician who recommended your son’s procedures.

      Thank you for visiting, and for sharing, and best success.

  4. My son is 2 was born 9 weeks premature was incubated for 24 hours and was diagnosed with laryngomalatia and during the supraglottoplasty they discovered he has stenosis of his airway at 7 months he had his tonsils and adenoids removed and he continued to had destats which we had a sleep study which showed he has severe central sleep Aponea which has since come down to normal levels and is no longer monitored.
    He has had croup 9 times out of the past 10 weeks on steroids each time it goes and then it’s back again. I have called his paed and respiratory specialist for appointments but am wondering is there other treatment I hate seeing him sick all the time and the fear of him not waking up scares the crap out of me.

    • Russell A. Faust, PhD, MD says:

      Hi Bron,
      I’m sorry to hear about your son’s struggles. That is scary for a parent. From your note, it seems that he has complicated airway issues, including laryngomalacia (and likely tracheomalacia), subglottic stenosis, a history of obstructive sleep apnea (from adeno-tonsillar hypertrophy?) and central apnea.
      Both sub-glottic stenosis and tracheomalacia (soft, collapsible trachea) can result in recurrent croup troubles.
      With the very limited information that I have I simply cannot comment on your son’s care. However, I can suggest the same thing that I tell the parents of my own patients: whenever you are not satisfied with your child’s care, seek another opinion (and another if necessary). At the very least, your current team is not explaining the situation for your complete understanding to your satisfaction, so I urge you to continue looking. If you have an academic children’s hospital nearby, that is likely your best place to start. By “academic,” I mean a children’s hospital that is associated with a good medical school; one that trains residents; and – for your son – one that trains Otolaryngology – Head & Neck Surgeons to specialize in Pediatric airway issues during a specialized Fellowship. You should be able to find out such information by searching for “pediatric otolaryngology training” and your city, or nearby large metropolis.
      In summary, infants and toddlers with your son’s history were my main focus in my own pediatric-ent practice, mostly because most doctors avoid these kids – they are extremely difficult to treat, and it is frustrating for the child, the parents and the docs. I know how difficult it is to care for your own child who struggles with a chronic condition, especially when that condition is vital – such as breathing! The more you search for the very best care, the less helpless you will feel.
      Thank you for sharing. Please keep me updated. And best success!

  5. My son is about to turn 7. He has had recourant croup about 2 to 3 x’s per year since 3mths.
    The first episode required ER and dex and a trip to FL from MI age 4 required ER but an RX for dex would have covered.
    He has seasonal allergies. The croup tends to be once in summer and once in winter.
    He has been evaluated by speech due to ASD and some executive functioning issues since age 2 which are well managed with early interventions.
    Cool mist, rest, essential oil in mist to avoid steroids unless absolutely necessary usually works great and symptoms gone in 2 days.
    I noticed this time that he had (new) symptoms of reflux x 2 weeks. Dr visit scheduled but pending.
    I have always felt his croup is an allergy related event. Given presence with warm weather and cold. He is healthy without other symptoms aside from croup itself. No ear infections or frequent cold or flu.
    Dad had adenoids removed
    Mom (me) had recurrent croup until age 10ish. I also developed vocal cord paralysis at age 30 that did not resolve. I wound up having surgery.

    • Russell A. Faust, PhD, MD says:

      Hi Kimberly:

      I like your approach. And I agree with you that the symptoms are linked with allergies or seasonal inflammation.

      Recurrent croup is always suspicious for a narrow airway, usually below the level of the vocal cords, in the trachea: known as “sub-glottic stenosis.” If the narrowing does not cause life-threatening symptoms, and does not cause “failure-to-thrive,” time usually solves the problem. That is, nearly all children with slightly narrow airways will outgrow the problem.

      Agree with you on minimizing use of steroids – “unless absolutely necessary!”

      Note that many, in my experience, even children with “obvious” allergy symptoms will often be “negative” on allergy testing. That is, standard allergy testing is notoriously inaccurate for children. The only benefit of the testing is that injection sera or allergy “drops” (for sub-lingual application) can be customized for tests that are positive for certain allergens. Otherwise, in my opinion the child whose allergy tests are negative should be treated exactly like the child with a positive allergy test: treat the symptoms; emphasize prevention and avoidance (to suspected allergens).

      Thanks so much for sharing, and best success. Please do keep me updated.

  6. We have 2 children who wake at night with severe stridor. They are ages 2 and 4 and we have had this problem for 3 years. Both girls have had tonsils and adenoids removed and have had repeat aryepiglottoplasty procedures. Both girls require adrenalin top open there airways. We have had chest xrays, laryngoscopy, bronchoscopy, barrium swallow testing, immunology testing, sleep studies and have regular check ups with there ENT and GP. The girls have had 81 attacks between them and we now believe it is vocal chord dysfunction.

  7. Sarah Burgess says:

    At 2.5 my daughter had her first case of croup that sent us to the ER. A week later, my son, then 10 months came down with it. Every time our family has gotten a cold since, we may all get runny noses and a cough, but our girl always gets that difficulty breathing and seal-like cough at night for 1-2 days. It’s happened 3 times now in the last year. We have easily been able to treat her with cold air for a few minutes until she starts to breath normally again. My question is whether she is actually getting the croup virus each time or whether her airway gets restricted due to prior damage or memory from that first croup episode? It seems unlikely that she would get the croup virus so many times and her brother would just get a normal cold.

    • Russell A. Faust, PhD, MD says:

      Hi Sarah:

      Any child with a small airway – that is, small diameter trachea – can have ‘croup’ cough if anything causes swelling of their airway. Because it is small children (infants and toddlers) who have the smallest airways, they are the ones who get croup. You rarely see a child of four or five years (or older) with a croup, seal-like, barking cough.

      As long as those children don’t experience real respiratory distress (struggling to breathe, stopping breathing, or turning blue), they can usually be monitored during these episodes and will recover fully. You are doing the right thing: ANY time you are worried about their safety, the ER is the place to be. They will have tools to measure oxygen levels, and they are equipped with medications and skills to manage a true respiratory emergency.

      The good news: they will outgrow this. The bad news: you may have more sleepless nights ahead.

      In my experience, the only children with croup who required surgical intervention were those with such severe respiratory distress early in life (within their first few weeks) that they required intubation (placement of breathing tube and mechanical ventilation). It doesn’t sound like that is the case with your little ones, though that does little to assure you when it’s your baby with croup!

      Thank you for visiting, and for sharing. Please feel free to contact me any time.

  8. Hello, my 2yr old son has had 9 cases of spasmodic croup in the last 11 months following rsv/bronchitis at 14 monthes when he had to be hospitalized. He also has asthma. His doctor wants to do a scope and remove adenoids as every bout of croup ends in an er visit with steroids and sometimes racemic epi depending on the severity. Is removing adenoids for this issue generally helpful even if they aren’t very enlarged???

    • Russell A. Faust, PhD, MD says:

      Hi Tricia:

      Recurrent Spasmodic Croup is most often a problem in younger children; most will out-grow these episodes. There are some great, insightful pediatric ENT and Pulmonology docs out there who have a very good understanding of this. It is complicated: it can be caused by reflux, and many pediatricians (even many ENT docs) don’t consider reflux as the cause of recurrent croup. Adenoidectomy is a reasonable thought, as adenoid tissue is a potential reservoir for pathogens causing recurrent bronchitis or recurrent sinusitis. But in my experience, I would not overlook the potential of reflux contributing to this clinical scenario. I am frustrated by notes from parents like yours: I feel your own deep care for your child; your own frustration with not knowing how to help; and your underlying question of whether your child’s doctors understand what is going on and have the best plan possible. And, unfortunately, I can’t truly help without being your child’s doctor myself. I can only offer this advice (advice I often gave my own patients and their parents): if you have questions that are not being answered by your doctors, get another opinion. And another after that, if necessary. Your doctors should be reassuring you; should be answering all of your questions; and you should feel as though they are truly your child’s advocate for optimal health. If not, keep looking.
      And thank you for visiting. Please keep me updated.

      • Wow, I just saw this and thank you for responding. After the ENT took a look at his adenoids he did say they were enlarged, blocking around 70% of his airway so we are going to go ahead with the adenoid removal. He’s also getting a bronchoscopy done at the same time. Curious, with the bronchoscopy would they be able to rule out reflux also or would that be a totally different scope? My son has had 2 more bouts of croup since we last spoke so we are REALLY trying to get to the bottom of things. Really appreciate this blog :)

        • Russell A. Faust, PhD, MD says:

          Hi Tricia:
          Thank you for your kind comments about this website.
          Regarding your question about finding evidence of reflux during bronchoscopy: yes, there are things that can be seen during bronchoscopy that suggest the presence of reflux.
          We published a paper on this topic about ten years ago. Here is the full-text link in JAMA:
          http://jamanetwork.com/journals/jamaotolaryngology/fullarticle/219584
          Note that you can always look for original medical literature using Google’s “Scholar” search feature: https://scholar.google.com/
          Just click-off the box that also searches “patents” to reduce the number of hits (unless you’re looking for patents, of course).
          Thanks again, and best success with your little boogor!

  9. This is a very helpful site to read. My twin girls (5 years) seem to still get croup with every cold/virus. Dex is the normal treatment but I try to wait it out first. Unfortunately, if I make the mistake of riding it out too long, the dex works less effectively especially with my one daughter. Her coughing turns into cough-sneeze spasms. I can’t see how this makes sense that croup would cause the sneezing. We saw an ENT. He barely looked at them and said he is sure we had a really bad year last year but he doesn’t see anything. I thought how do you know, he just talked to me while they sat there. In any event, my other daughter this past weekend ended up in emerg with it. I was waiting it out again. She seemed fine. Coughing but not extreme. Then she woke me at 3am, said she was dizzy and I noticed her breathing was laboured so I took her in. They kept her – gave her 5 masks. 1 epi, 4 ventolin. Heart beat was racing like crazy. Gave her dex. Sent her home. Kept fevering but now a wet cough mostly. While her twin is in the sneeze-cough spasms (post dex) not working so great today. I feel so at a loss on how to help. Esp when the dex doesn’t work. My fear is that if she didn’t wake me how would she have fared through the night. I bought an oximeter for myself. Just making myself crazy with worry non-stop.

    • Russell A. Faust, PhD, MD says:

      Hi Holly:

      Sounds like it may be time to find a physician with a better “big picture” approach…more integrative. If you have access to Doctors of Naturopathy (ND), you might start there. They are trained in a broad and integrative view of health. Chronic and recurrent croup can be a symptom of anatomic narrowing; of a super-reactive airway; of reflux; or other things.

      If your child requires steroids or inhalers but your doc (ENT, Pulmonologist, Pediatrician, whatever) doesn’t have time to assess what is going on, and doesn’t take time to discuss it with you and help educate you – it’s time to look elsewhere. In my not-so-humble opinion!

  10. My child turns 3 in couple weeks ..she was born with respitory distress at 36 weeks was intubated 2 weeks. Fast forward now.. since october she has had croup 2x and is currently starting to have that nasty cough again…btw turn into ear infec. Should i take her sooner to the ENT? She sees hers for follow up in 3 weeks but this came up…or should i take her to her pediatrian?

    • Russell A. Faust, PhD, MD says:

      Hi Luisa:

      Any time you are worried about your baby – especially if they have a history of respiratory distress with intubation – don’t hesitate to see your doc. Be safe.

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