A child who wakes at night with a harsh cough that sounds like a bark and struggles to catch their breath: croup is frightening to watch, and common before the age of six. It is usually mild and responds well to treatment. Here is how to recognise croup, calm an attack and spot the signs that mean you should call 101.
Croup warning signs: call 101 immediately
Call 101 (Magen David Adom) straight away if a child with croup shows any of these signs:
- they are struggling to breathe at rest, even when calm, not only when crying;
- the skin sucks in below the ribs or at the base of the neck with each breath in;
- their lips or face turn bluish;
- they are drooling or can no longer swallow their saliva;
- they sit upright, leaning forward, with the chin pushed forward, and refuse to lie down;
- they are unusually drowsy, hard to wake, or instead extremely agitated;
- they have a high fever and look very unwell.
While you wait for help, let your child stay in whatever position they choose. Do not force them to lie down, and do not try to look at the back of their throat.
What is croup?
Croup is an inflammation of the voice box (larynx), most often caused by a common cold virus. The lining swells just below the vocal cords. In a young child this part of the airway is narrow, so swelling of a few millimetres is enough to obstruct the flow of air.
It mainly affects children aged 6 months to 6 years. It typically starts at night, often suddenly, in a child who went to bed with nothing more than a cold.
Croup symptoms: a cough that sounds like a bark
The picture is very recognisable:
- a harsh, dry cough that sounds like a bark or a seal;
- a hoarse voice, and crying that sounds cracked;
- a high-pitched noise when breathing in, called stridor;
- often a cold, sometimes a moderate fever.
The symptoms get worse when the child cries or becomes upset. Stridor that is present at rest, in a calm child, points to more severe croup.
What to do during a croup attack
A few simple steps help:
- stay calm and comfort your child: fear and crying make breathing harder;
- hold them sitting up, against you, rather than lying down;
- let them breathe cool air, near an open window or outside, well wrapped up: it often soothes them, but it is not a treatment;
- treat a fever or discomfort with paracetamol, according to your child's weight and the leaflet.
What to avoid: breathing in hot steam over a bowl or a saucepan. It carries a risk of serious burns and has no proven benefit. If breathing is still difficult after a few minutes of calm, or if a warning sign appears, call 101.
Medical treatment for croup
The standard treatment is a steroid medicine (corticosteroid), given as a single dose by mouth, on a doctor's prescription. It reduces the swelling in the voice box and works within a few hours. It is often prescribed even for mild croup. In more severe cases, a nebulised treatment is given in the emergency department, under observation.
Antibiotics do not help in ordinary croup: it is caused by a virus, and they do not speed up recovery. They are only considered if the doctor suspects a secondary bacterial infection, which is rare.
How long does croup last?
Symptoms are usually at their worst for one or two nights, then ease over a few days. Attacks tend to come back at night, so keep a close eye on your child the following evening.
Croup, epiglottitis or an inhaled object?
Two rare but serious conditions can look like croup.
Epiglottitis is a bacterial infection at the top of the voice box, now very rare thanks to vaccination. The child has a high fever, looks very unwell, drools and cannot swallow. They sit leaning forward and cough little. This is a life-threatening emergency: call 101, and do not lay the child down.
Inhaling a foreign body, such as a piece of food or a small object, causes a cough or breathing difficulty that starts suddenly, without a cold or fever, often during a meal or while playing. In this setting the child needs urgent assessment, even if they seem to be getting better.
When to see a doctor the same day
If there are no warning signs, see a doctor the same day if:
- it is your child's first episode of croup;
- your child is under 6 months old: noisy breathing at this age should always be examined;
- the barking cough or stridor comes back every night or lasts more than a few days;
- the fever persists or appears later on;
- your child is drinking little, eating poorly or seems very tired;
- the attacks keep recurring, or your child has a known lung or heart condition.
Croup and video consultation
Croup lends itself well to a remote consultation, provided the child is breathing comfortably at rest. On video, the doctor hears the cough and the voice, and sees the breathing, including any sucking in below the ribs. Together with a few careful questions, this is often enough to recognise mild croup and treat it.
On the other hand, a child who is struggling to breathe at rest needs to be examined without delay: call 101 if there is a warning sign, otherwise arrange a home visit. A baby under 6 months, or any suspicion of an inhaled object, also calls for an examination.
Seeing Dr Nathalie Gozlan
Dr Nathalie Gozlan, a general practitioner and a specialist in emergency medicine, sees children with a barking cough or croup — as a home visit in the Sharon region (Netanya, Kfar Saba, Raanana, Kadima-Tzoran, as well as the moshavim and kibbutzim of the area), or by video consultation anywhere in Israel, in English, Hebrew and French.
A child who is struggling to breathe at rest, drooling or whose lips are turning blue cannot be assessed remotely: call 101.
Frequently asked questions
Is croup contagious?
Croup itself is not passed on, but the virus that causes it is. It spreads within families and daycare, and in older children and adults it usually causes nothing more than a cold. Hand washing helps limit its spread.
Why does croup mostly happen at night?
Part of the explanation lies in the body's natural rhythm: the level of cortisol, the body's natural anti-inflammatory hormone, is at its lowest at night, which makes swelling more likely. Waking suddenly and feeling frightened then make the breathing difficulty worse. That is why you should stay watchful for several evenings in a row.
Do you need to go to the emergency department for every attack?
No. Mild croup, with a barking cough but calm breathing at rest, can be managed with a doctor, through a home visit or a video consultation. 101 and the emergency department are for warning signs: difficulty breathing at rest, skin sucking in below the ribs, bluish lips, drooling, drowsiness or extreme agitation.
Can croup be treated by video consultation?
Yes, for mild croup in a child who is breathing comfortably at rest: on video, the doctor hears the cough, watches the breathing and can prescribe treatment. A child who is struggling to breathe at rest, a baby under 6 months, or any suspicion of an inhaled object calls for an examination, at home or in the emergency department depending on how serious it is.
