Croup

Is this your child's symptom?

• Barky cough and hoarse voice caused by a virus
• Croup is a viral infection of the voicebox (larynx)
• The croupy cough is tight, low-pitched, and barky (like a barking seal)
• The voice or cry is hoarse (called laryngitis)
• Some children with severe croup get a harsh, tight sound while breathing in. This is called stridor.

Stridor: Another Health Problem of Croup

• Stridor is a harsh, raspy tight sound best heard with breathing in
• Loud or constant stridor means severe croup. So does stridor at rest (when not crying or coughing).
• All stridor needs to be treated with warm mist
• Most children with stridor need treatment with a steroid (such as Decadron)
• For any stridor, see First Aid for treatment

Causes of a Croupy Cough

• Viral Croup. Viruses are the most common cause of croup symptoms. Many respiratory viruses can infect the vocal cord area and cause narrowing. Even influenza (the flu) can do this. A fever is often present with the barky cough.
• Allergic Croup. A croupy cough can occur with exposure to pollens or allergens in a barn. A runny nose, itchy eyes and sneezing are also often present.
• Inhaled Powder. Breathing in any fine substance can trigger 10 minutes of severe coughing. Examples are powdered sugar, flour dust or peanut dust. They can float into the lungs. This is not an allergic reaction.
• Airway Foreign Object (Serious). Suspect when there is a sudden onset of coughing and choking. Common examples are peanut and seeds. Peak age is 1 to 4 years.
• Food Allergy (Serious). Croup symptoms can also be caused by a food allergy. This can be life-threatening (anaphylaxis). Examples are nuts or fish.

When to Call for Croup

Call 911 Now

• Severe trouble breathing (struggling for each breath, constant severe stridor)
• Passed out or stopped breathing
• Lips or face are bluish when not coughing
• Croup started suddenly after bee sting, taking a new medicine or allergic food
• Drooling, spitting or having great trouble swallowing. Exception: drooling due to teething.
• You think your child has a life-threatening emergency

Call Doctor or Seek Care Now

• Stridor (harsh sound with breathing in) is heard now
• Trouble breathing, but not severe
• Lips or face have turned bluish during coughing
• Breathing is much faster than normal
• Can't bend the neck forward
• Severe chest pain
• Had croup before that needed Decadron
• Weak immune system. Examples are: sickle cell disease, HIV, cancer, organ transplant, taking oral steroids.
• High-risk child (such as cystic fibrosis or other chronic lung disease)
• Fever over 104° F (40° C)
• Fever in baby less than 12 weeks old. Caution: do NOT give your baby any fever medicine before being seen.
• Your child looks or acts very sick
• You think your child needs to be seen, and the problem is urgent

Contact Doctor Within 24 Hours

• Stridor (harsh sound with breathing in) occurred but not present now
• Nonstop coughing
• Age less than 1 year old with a croupy cough
• Earache or ear drainage
• Fever lasts more than 3 days
• Fever returns after being gone more than 24 hours
• You think your child needs to be seen, but the problem is not urgent

Contact Doctor During Office Hours

• Coughing causes vomiting 3 or more times
• Croup is a frequent problem (3 or more times)
• Barky cough lasts more than 14 days
• You have other questions or concerns

Self Care at Home

• Mild croup (barky cough) with no stridor

Care Advice for Croup

1. What You Should Know About Croup:
   • Most children with croup just have a barky cough.
   • Some have tight breathing (called stridor). Stridor is a loud, harsh sound when breathing in. It comes from the area of the voicebox.
   • Coughing up mucus is very important. It helps protect the lungs from pneumonia.
   • We want to help a productive cough, not turn it off.
   • Here is some care advice that should help.
2. First Aid for Stridor (Harsh sound with breathing in):
   • Breathe warm mist in a closed bathroom with the hot shower running. Do this for 20 minutes.
   • You could also use a wet washcloth held near the face.
   • Caution: do not use very hot water or steam which could cause burns.
   • If warm mist fails, breathe cool air by standing near an open refrigerator. You can also go outside with your child if the weather is cold. Do this for a few minutes.
3. Calm Your Child if He or She has Stridor:
   • Crying or fear can make stridor worse.
   • Try to keep your child calm and happy.
   • Hold and comfort your child.
   • Use a soothing, soft voice.
4. Humidifier:
   • If the air in your home is dry, use a humidifier.
   • Reason: dry air makes croup worse.
5. Homemade Cough Medicine:
   • Goal: decrease the irritation or tickle in the throat that causes a dry cough.
   • Age 6 months to 1 year: give warm clear fluids to treat the cough. Examples are apple juice and lemonade. Amount: use a dose of 1-2 teaspoons (5-10 mL). Give 4 times per day when coughing. Caution: do not use honey until 1 year old.
   • Age 1 year and older: use Honey ½ to 1 teaspoon (2-5 mL) as needed. It works as a homemade cough medicine. It can thin the secretions and loosen the cough. If you don't have any honey, you can use corn syrup.
   • Age 6 years and older: use Cough Drops to decrease the tickle in the throat. If you don't have any, you can use hard candy. Avoid cough drops before 6 years. Reason: risk of choking.
6. Non-Prescription Cough Medicine (DM):
   • Non-prescription cough medicines are not advised. Reason: no proven benefit for children and not approved under 6 years old (FDA).
   • Honey has been shown to work better for coughs. Caution: do not use honey until 1 year old.
   • If age 6 years or older, you might decide to use a cough medicine. Choose one with dextromethorphan (DM) such as Robitussin Cough syrup. DM is present in most non-prescription cough syrups. Follow the instructions on the package.
   • When to Use: give only for severe coughs that interfere with sleep or school.
   • DM Dose: give every 6 to 8 hours as needed.
7. Coughing Fits or Spells - Warm Mist and Fluids:
   • Breathe warm mist, such as with shower running in a closed bathroom.
   • Give warm clear fluids to drink. Examples are apple juice and lemonade.
   • Age less than 6 months. Only give breast milk or formula
   • Age 6 - 12 months. Give 1-2 teaspoons (5-10 mL) each time. Limit to 4 times per day.
   • Age over 1 year. Give as much warm fluids as needed.
   • Reason: both relax the airway and loosen up any phlegm.
8. Fluids - Offer More:
   • Try to get your child to drink lots of fluids.
   • Goal: keep your child well hydrated.
   • It also loosens up any phlegm in the lungs. Then it's easier to cough up.
9. 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.
   • For all fevers: keep your child well hydrated. Give lots of cold fluids.
10. Sleep Close by to Your Child:
    • Sleep in the same room with your child for a few nights.
    • Reason: stridor can start all of a sudden at night.
11. Avoid Tobacco Smoke:
    • Tobacco smoke makes croup much worse.
12. Return to School:
    • Your child can go back to school after the fever is gone.
    • Your child should also feel well enough to join in normal activities.
    • For practical purposes, the spread of croup and colds cannot be prevented.
13. What to Expect:
    • Most often, croup lasts 5 to 6 days and becomes worse at night.
    • The croupy cough can last up to 2 weeks.
14. Call Your Doctor If:
    • Trouble breathing occurs
    • Stridor (harsh raspy sound) occurs
    • Croupy cough lasts more than 14 days
    • You think your child needs to be seen
    • Your child becomes worse

And remember, contact your doctor if your child develops any of the 'Call Your Doctor' symptoms.

Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.

Last Reviewed: 10/11/2023

Last Revised: 12/30/2022

Copyright 2000-2023. Schmitt Pediatric Guidelines LLC.