Viral croup usually has a gradual onset and course. The symptoms often get worse at night. Initially, the child gets a cold with cough, coryza and low-grade fever. In about 12 to 24 hours, the cough becomes croupy (i.e. barky) with inspiratory stridor, causing varying degrees of respiratory distress with retractions and even cyanosis.

The duration of symptoms is usually 3-7 days. Examination reveals hoarse voice, coryza, a normal or minimally inflamed larynx and an increased respiratory rate with prolonged inspiratory phase and stridor.

• Fever

  Fever Medicine: For fevers above 102° F (39° C), give an acetaminophen product (such as Tylenol). Another choice is an ibuprofen product (such as Advil). Note: Fevers less than 102° F (39° C) are important for fighting infections. [stlouischildrens.org]

  The only exception is medication used for fever. If you give medication for fever, read the instructions carefully and do not give more often than listed on the label. See your doctor if symptoms continue or worsen. [caringforkids.cps.ca]

  High-risk child (such as cystic fibrosis or other chronic lung disease) Fever over 104° F (40° C) Age less than 12 weeks old with fever. Caution: do NOT give your baby any fever medicine before being seen. [seattlechildrens.org]

  (see Fever and children, below) Has a cough or other symptoms that don't get better or that get worse Doesn't get better within a week Has a fever that goes down but he or she still “acts sick” Has a seizure Fever and children Always use a digital thermometer [urmc.rochester.edu]

• Pallor

  Marked sternal retractions, marked tachycardia, pallor, with restlessness, lethargy, or cyanosis. Breath sounds often reduced. [starship.org.nz]

  Grade 3 : respiratory distress, irritability, pallor or cyanosis, tachycardia, and exhaustion. Grade 3 croup is an emergency that necessitates immediate treatment. Your ability to promptly recognize croup and stridor can save a child’s life. [web.archive.org]

  Child Tripod position Noise Infants grunt to generate auto-CPAP; wheezing can occur with an inhaled foreign body; stridor Ineffective breathing Hypoxaemia and hypercarbia produce tachycardia, sweating, restlessness and confusion, agitation and anxiety, pallor [academic.oup.com]

  In addition to symptoms at the site of infection (sore throat), the patient may experience more generalized symptoms, such as listlessness, pallor, and fast heart rate. These symptoms are caused by the toxin released by the bacterium. [jariboti.pk]

  Moderate symptoms Severe symptoms Barking cough No stridor at rest No sternal recession or tracheal tug Normal behaviour Barking cough Audible stridor at rest Mild sternal regression +/- tracheal tug May be irritable at times Persistent stridor at rest Pallor [pch.health.wa.gov.au]

• Cough

  However, differentiation in early illness is possible by additional observation of coughing and absence of drooling in croup and by the additional observation of drooling with absence of coughing in epiglottitis. © 2010 The Authors. [ncbi.nlm.nih.gov]

  Initially, the child gets a cold with cough, coryza and low-grade fever. In about 12 to 24 hours, the cough becomes croupy (i.e. barky) with inspiratory stridor, causing varying degrees of respiratory distress with retractions and even cyanosis. [symptoma.com]

  Avoid cough medicines unless you discuss them with your provider first. [nlm.nih.gov]

  The croupy cough can last up to 2 weeks. [stlouischildrens.org]

• Hoarseness

  METHODS: Children were classified as having recurrent croup if they had had 2 or more episodes of barky cough, inspiratory stridor, and hoarseness. [ncbi.nlm.nih.gov]

  In febrile children, the presence of hoarseness, barking cough or acute inspiratory stridor is usually indicative of croup. Older children usually recover fully without any complications. [symptoma.com]

  Croup manifests as hoarseness, a seal-like barking cough, inspiratory stridor, and a variable degree of respiratory distress. [emedicine.medscape.com]

• Inspiratory Stridor

  METHODS: Children were classified as having recurrent croup if they had had 2 or more episodes of barky cough, inspiratory stridor, and hoarseness. [ncbi.nlm.nih.gov]

  Bilateral vocal-cord paralysis produces a high-pitched inspiratory stridor. (Stridor doesn’t occur in unilateral vocal-cord paralysis.) Congenital subglottic stenosis causes stridor that’s commonly biphasic or inspiratory. [web.archive.org]

  Inspiratory stridor suggests a laryngeal obstruction, whereas expiratory stridor suggests tracheobronchial obstruction. Biphasic stridor indicates either a subglottic or glottic anomaly. [emedicine.medscape.com]

• Common Cold

  Many cases come from parainfluenza viruses (the common cold). [healthline.com]

  Other croup symptoms are not dissimilar to those of the common cold and upper respiratory infections, so parents should observe their child carefully. [rd.com]

  The largest study (n=1314) reported common cold symptoms lasting 1.8 weeks (SD 1.3) for children aged 7 or younger. 46 Fig 8 Proportion of children with symptoms of common cold. [doi.org]

  “Often trigged by a virus such as the common cold, croup in younger children creates a cough that is described as a seal-like bark, which can be scary for families to hear,” said Dr. [reuters.com]

• Dyspnea

  A nine-month-old girl was admitted to our hospital because of abrupt onset dyspnea and unconsciousness. From clinical and laboratory findings, she was diagnosed as having bacterial croup. [ncbi.nlm.nih.gov]

  ‘In children, fever associated with dyspnea usually implies an infectious cause, such as pneumonia, croup, or bronchiolitis.’ ‘Bronchiolitis was the most common diagnosis, followed by pneumonia and croup.’ [en.oxforddictionaries.com]

  Indication for hospitalization Cyanosis Not improving or getting worse Decreased alertness Family anxious about the child's condition No guarantee of follow-up References Ramboud-Cousson, Annie Bacterial Tracheitis among Children Hospitalized for Severe Dyspnea [pedclerk.bsd.uchicago.edu]

  Croup usually is self-limiting; dyspnea and stridor typically arise as the patient starts to recover from the illness. Respiratory distress from croup varies from mild to moderate; it rarely progresses to upper airway obstruction. [web.archive.org]

• Tachycardia

  Marked sternal retractions, marked tachycardia, pallor, with restlessness, lethargy, or cyanosis. Breath sounds often reduced. [starship.org.nz]

  Tachycardia and other adverse effects may occur. This drug is recommended mainly for patients with moderate to severe croup. [msdmanuals.com]

  Nebulised epinephrine may result in dose-related adverse effects including tachycardia, arrhythmias and hypertension and its benefit may be short-lived. [ncbi.nlm.nih.gov]

• Areflexia

  After admission, she developed progressive muscle weakness and areflexia. Flexible laryngoscopy showed bilateral vocal cord paralysis. Finally, she was diagnosed with Guillain-Barré syndrome (GBS). [ncbi.nlm.nih.gov]

Diagnosis is usually made on the basis of complete history and clinical examination. Usually, baseline investigations such as complete blood count are of no great significance as the results are non-specific.

Procedures: Laryngoscopy may be required in when any uderlying anatomic or congenital anomaly is suspected. Bronchoscopy is indicated in cases of recurrent croup when other respiratory disorders have to be ruled out [5].

Radiography: Plain X-ray films can help confirm the diagnosis of croup. The posterolateral and lateral neck films show funnel-shaped subglottic region with normal epiglottis. This is known as Steeple's sign and is present in 40 to 60% of the cases [6]. It is also known as hour-glass or pencil point sign.

• Subglottic Narrowing

  Subglottic hemangiomas most commonly cause eccentric narrowing of the subglottic airway. Typically, croup causes symmetric subglottic narrowing. [emedicine.com]

  Lateral x-ray films of the airways showed subglottic narrowing and often these suggested the presence of radio-opaque foreign material in the tracheal lumen. [ncbi.nlm.nih.gov]

  narrowing Studies Making the diagnosis based on clinical presentation Differential Acute epiglottitis distinguishing factors patients typically have muffled voice, drooling, high fever, and have dysphagia a medical emergency absence of barking cough [step2.medbullets.com]

  The lateral view may show subglottic narrowing or loss of the air shadow. The complete blood count or CBC is generally unremarkable except for a lymphocytosis. Bronchoscopy would show mild subglottic edema. [virtualpediatrichospital.org]

• Mediastinal Shift

  Depending on the predominant symptoms and signs, a child presenting to the clinician can be divided into six groups, viz., stridor; cough, fever and difficulty in breathing or fast breathing; wheezing; mediastinal shift with severe respiratory distress [ncbi.nlm.nih.gov]

The treatment depends upon the severity of symptoms and degree of the respiratory distress. For mild disease, reassurance in addition to maintenance of oxygenation and fluid homeostasis is sufficient.

Children that present with significant respiratory distress and stridor may require 100% oxygen supplementation and ventilator support.

• Mist therapy: It is given by hot steam from a vaporizer or cold steam from a nebulizer [7].
• Oxygen (cold and humidified) must be provided. Pulse oxymetry and arterial blood gas analysis are important in assessing the adequacy of air exchange.
• Nebulizer recemic epinephrine (2.5% solution) if available may improve air exchange [8].

• Dexamethasone (0.3-0.5 mg/kg administered once and repeated in 2 hours) shortens the course of illness but should be used with caution to prevent the occurrence of side effects [9] [10].

• Antibiotics are used only if there is suspicion of secondary bacterial infections.

The prognosis of croup is excellent. Almost all of the cases of croup recover completely without any sequel of complications. Most of the patients can even get treated in the outpatient settings, whereas few of the cases might require hospitalization. Although the overall mortality rate in not exactly known, however a 10-year study shows the mortality rate to be less than 0.5% in intubated patients [4].

About 80% of the total cases of croup are caused by Parainfluenza viruses (type 1, 2 and 3), out of which about 66% of the cases are caused by types 1 and 2. Parainfluenza type 3 virus mostly causes bronchiolitis and pneumonia in young infants. Not much is known about parainfluenza type 4 virus. It may be the cause of minor childhood illness.

The remaining 20% of the cases of croup are caused by adenovirus, respiratory syncytial virus (RSV), enterovirus, coronavirus, rhinovirus, reovirus, influenza virus A and B and metapneumovirus [1] [2]. Other rare causes of croup are measles virus, herpes simplex virus and varicella virus.

These viruses can spread through inhalation of infectious agents in the cough or sneeze of an infected person. They can also spread by contamination of hands with fomites or through touching of mucosa of eyes, mouth and/or nose.

Croup is primarily a disease of infants and younger children and is the most common cause of acute stridor in this age group. It is slightly more common in the male gender, the male-to-female ratio being 1.5:1.

It is common in children aged 7 months to 3 years. After 6 years of age, the occurrence of croup is very rare [3].

In North America, the peak incidence is in the second year of life affecting 5-6 cases per 100 children.

The common ports of entry of the virus are nose and nasopharynx. From there, the virus then spreads to the larynx and trachea resulting in inflammation and edema in these areas. The inflammatory infiltrate contains lymphocytes, histiocytes, plasma cells and neutrophils. An increased chloride secretion and decreased sodium absorption results in edema, thus narrowing the lumen of the air passages by accumulation of fibrinous exudates.

Endothelial damage and loss of ciliary function occurs which decreases the mobility of vocal cords thus resulting in hoarseness.

As croup is a contagious disease, contact with the affected individuals must be made as minimally as possible.

• Proper hand washing technique must be taught to the children and have them wash their hands more often to avoid the spread from one child to another.
• Children should increase their fluid intake.
• Exposure to respiratory irritants (such as smoke) should be avoided.
• Treatment should be promptly obtained when the respiratory symptoms appear.
• Hygienic conditions must be ensured.
• Covering the mouth while coughing or sneezing helps prevent the spread to other children.

Croup or laryngotracheobronchitis is a common respiratory tract viral illness affecting the pedriatic population. It generally affects the larynx and trachea; and sometimes even the bronchi.

In febrile children, the presence of hoarseness, barking cough or acute inspiratory stridor is usually indicative of croup. Older children usually recover fully without any complications. In infants however, this might be a life-threatening condition.

Croup refers to infection of the airways that causes them to swell up. It is caused by a virus and usually affects male children under the age of 4 years. Symptoms are more common in winter months. The child develops flu-like symptoms with cough that sounds like a bark. Croup is usually not fatal and almost all children recover from it.

1. Sung JY, Lee HJ, Eun BW, et al. Role of human coronavirus NL63 in hospitalized children with croup. The Pediatric infectious disease journal. Sep 2010;29(9):822-826.
2. Williams JV, Harris PA, Tollefson SJ, et al. Human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children. The New England journal of medicine. Jan 29 2004;350(5):443-450.
3. Sobol SE, Zapata S. Epiglottitis and croup. Otolaryngologic clinics of North America. Jun 2008;41(3):551-566, ix.
4. Segal AO, Crighton EJ, Moineddin R, Mamdani M, Upshur RE. Croup hospitalizations in Ontario: a 14-year time-series analysis. Pediatrics. Jul 2005;116(1):51-55.
5. Chun R, Preciado DA, Zalzal GH, Shah RK. Utility of bronchoscopy for recurrent croup. The Annals of otology, rhinology, and laryngology. Jul 2009;118(7):495-499.
6. Huang CC, Shih SL. Images in clinical medicine. Steeple sign of croup. The New England journal of medicine. Jul 5 2012;367(1):66.
7. Moore M, Little P. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Family practice. Sep 2007;24(4):295-301.
8. Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized epinephrine for croup in children. The Cochrane database of systematic reviews. 2011(2):CD006619.
9. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. The New England journal of medicine. Sep 23 2004;351(13):1306-1313.
10. Cetinkaya F, Tufekci BS, Kutluk G. A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup. International journal of pediatric otorhinolaryngology. Apr 2004;68(4):453-456.