Croup
by Doctor Laurence H. Miller on 06/17/11
A pediatrician races across night-time Central Park in New York, a desperately ill
three year old struggling to breathe in the back seat of his car. The little boy's
voice is croaking, raspy with stridor as they begin their journey on the West Side.
Now as they approach the East 67th Street exit, the doctor hears the excited tyke
happily pipe up: "Oh! Look! The Zoo!" The doctor who took this hair-raising ride
was my mentor and eloquently gives color to the dramatic relief the damp evening
air often gives to a child whose throat has nearly closed.
Croup is one of the emergencies that puts fear in the hearts of parents and sometimes
doctors as well. The sound of its cough is best compared to the bark of a dog or a seal.
Sometimes parents mistakenly describe the difficulty the child has breathing as
"wheezing", but actually it's called stridor. Wheezing is the sound made when one
has trouble exhaling. Imagine stridor as trying to take a breath in through an
old-fashioned paper straw that's nearly collapsed. Think of "wheezing" as the sound
a balloon makes when you let the air out of it while pinching off the neck most of the
way. I usually explain croup as a severe laryngitis in little children. While irritation
might just cause a hoarse voice in a bigger person, the comparable swelling in a tiny
toddler's voicebox (larynx) and/or upper windpipe (trachea) can cause real breathing
difficulty. According to the laws of physics, resistance to flow of a liquid or a gas
through a tube is increased exponentially as the radius becomes smaller.
That explains why a little swelling in a little windpipe is such a big deal and just an
annoying hoarseness in a grown-up.
The most common cause of croup is a viral infection of the upper respiratory tract
(URI). It can also happen from allergy. Fever may or may not be present. The nose is
quite often stuffed or running. But the most predictable features are the time of day:
evening; and the time of year: the autumn and winter months. This is probably
because the insult of the viral inflammation is added to the dryness of the air that time
of year and household heating which is also aggravating.
I recommend a cool-mist humidifier in the child's room at the first sign of hoarseness
or noisy breathing. Warm or hot steam vaporizers are a terrible idea. The potential
danger of a scald burn makes them unacceptable. If the child seems to be getting worse
over the evening, it's often quite helpful to have him sit on a parent's lap in a bathroom
that's been steamed up by a hot shower running. Ten or fifteen minutes are the maximum
time limits for the treatment; I've heard horror stories of misguided folks causing severe
heat prostration in their baby by prolonged use of this steam treatment.
If the situation is not improving, it's time to get moving. Put the child in the car seat
and taking a leisurely drive around the block with the car windows open two or three
inches. If the parent doesn't see rapid improvement at this point, they should be
headed for the nearest emergency room.
I remember bundling up my eighteen-month-old daughter on a November night
about ten PM. She was having just mild stridor, but I didn't want to fool around so I put
her in her stroller and slowly ambled up the middle of our suburban street. She stared
up fascinated by the night sky and the trees blowing. She wondered aloud, "Daddy,
what are we doing?" "We're just taking a little walk honey. Isn't it beautiful out now?"
But in less than ten minutes outside, her breathing was basically normal and totally comfortable.
Having croup as a child doubles a person's odds of having allergies later.
The best news is that pediatricians have proven conclusively that if a child suffering
from moderate or severe croup is treated with a drug from the "steroid" family, the distress
is reduced in a dramatically shorter time than with mist alone. This could spare a child from
being hospitalized. The actual name of the medicine might be Decadron (dexamethasone),
Prelone (prednisone), or hydrocortisone. The medicine can be given orally or as an injection
for a day or two and then stopped without a recurrence of the illness.
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