The barky cough of croup is distinctive. It’s not a typical wet or congested cough. It’s like a seal bark. The good news is we can often treat it at home.
Many parents get scared when they hear the barky cough of croup. I’ve even been scared when my own children have it. I know what it is, but their breathing gets so labored that it’s scary.
Sounds of coughing
Parents describe many coughs as “croupy” but most of the time they’re mistaking a wet, mucous-filled cough for croup.
It can be difficult to sort out all the various sounds of coughing, which is why I previously gathered a number of videos into one blog.
The barky cough of croup is distinctive. It’s not a typical wet or congested cough. It’s like a seal bark. The good news is we can often treat it at home.
What is croup?
Croup is a distinctive set of symptoms that occur due to inflammation around a young child’s voicebox in the larynx and trachea.
Many people describe a croupy cough as a seal bark sound. They often make a hoarse or squeaky sound called stridor when they inhale.
Croup often starts suddenly in the middle of the night.
What causes croup?
Croup is usually caused by viruses and tends to be most common in the Fall. The viruses that cause croup are common and usually cause runny nose or congestion and sometimes cause a fever.
One child may get full-blown croup, but another will get a simple cold with the same virus. Some kids seem to get croup often, while others may never get it.
Can older kids get croup?
Croup is most common in kids less than 5 years of age, but older kids can occasionally get it.
Older children and adults tend to get laryngitis with the same viruses that cause croup. Their airways are bigger, so the swelling that occurs near the voicebox isn’t as severe.
Croup is tricky
Croup often looks like a simple upper respiratory tract infection or cold during the day. Nothing to worry about…
In the middle of the night you will hear a sudden barking sound, much like a seal barking. A child with croup looks distressed and very sick at night, but seems much better the next day.
For many kids, it’s just one night of this scary cough, but it can last several nights in others.
Some kids continue to have what is called stridor or trouble talking during the day. Stridor is a hoarse sound that you can replicate by breathing in while tightening your vocal cords. It sounds like a squeak or wheeze as kids breath in. Stridor is due to the swelling near the vocal cords that’s found in croup.
This is a simple yet very helpful video to hear the sound of croup and for management tips.
How is croup diagnosed?
Croup is what we call a clinical diagnosis. No lab or x-ray is needed.
A doctor or nurse will ask questions about various symptoms, and if we hear the classic cough or stridor, it supports the diagnosis.
How is croup treated?
If you recognize croup, there are many at home treatments you can try.
Taking kids outside into the cool night air often helps soothe the airway.
If the weather isn’t appropriate, you can open your freezer door and let them breathe in that air. (This has never been my favorite advice because it means a sick kid will be breathing on the frozen food and then there’s the wasted energy…)
The airway can also be soothed by taking kids into a bathroom, closing the door, and turning the shower to the hottest setting. Just sit in the bathroom – not in the shower.
Usually after 10-15 minutes breathing normalizes.
One thing I learned when my son first had croup: don’t leave the bathroom as soon as breathing calms down. Turn off the shower and just sit there for awhile. We had a rebound croup that was less scary, but unnecessary, when we tried to get him back to bed quickly. Letting the room get closer to the home’s normal air quality before going back into the hall and bedroom is time well spent.
Humidifiers and vaporizers
When we’re sick in the dry weather months, I always recommend adding a vaporizer or humidifier to the bedrooms. This is especially helpful if a child is at risk for croup due to age.
What about medicine?
If kids are uncomfortable, you can use acetaminophen or ibuprofen as a pain reliever. These do not help the cough, but they can help with comfort.
Since steroids decrease inflammation, they are often used when kids get croup. These can only be used with a prescription and your doctor’s instructions. See your doctor if you’re interested in any prescription medicine.
Croup is often mistaken for wheezing, but it is not treated with a bronchodilator like asthma.
The swelling near the voicebox is much different than the smaller airway narrowing that occurs with wheezing, and the bronchodilators (albuterol or levalbuterol) work on the smaller airways.
If kids have asthma, they can wheeze from the same virus that leads to croup, and in that case their asthma medicine helps.
In the hospital or ER setting some kids will get a breathing treatment of epinepherine. This should only be done in a supervised setting so they can be properly monitored.
Croup is usually caused by a virus, so antibiotics don’t help.
There is also something called spasmotic croup, but that also is not treated with antibiotics.
When should kids go to the ER or their doctor?
Since croup is worst at night, most of the kids who need to be seen end up in the ER. If your child has stridor during the day, they can be seen at their usual doctor’s office.
If the above home treatments don’t work after about 15-20 minutes, you should take your child to be seen.
Kids who seem very anxious due to breathing difficulties will also benefit from a proper medical exam and treatment.
Trouble swallowing along with difficulty breathing should be evaluated by a physician.
If you notice that your child seems better leaning slightly forward while sitting, he should be seen.
Any child who is not up to date on vaccines, especially the Hib vaccine, should be seen with labored breathing. Epiglottitis is now rare, thanks to vaccines, but if a child isn’t vaccinated, it is still possible to get this. It can cause stridor, fever, difficulty breathing, and other similar symptoms to croup. Be sure the physician knows your child isn’t vaccinated!
This blog is generally about pediatric health, but sometimes the principles are similar in adult medicine, so I’m sharing a personal story.
I was visiting my parents out of town and came down with fever, chills, and a sore throat. Due to the fatigue and shaking chills, I wasn’t sure if I’d be able to drive the 4 hour trip home the following day. I decided to go to a walk in clinic to see if there was a treatment to help get me on my feet again.
Although it’s less common for adults to get Strep throat, I wanted to have my throat swabbed because I had been exposed to just about everything at work.
If it was just a viral illness, fine. I’d tough through it with fluids and a fever reducer for the body-shaking uncomfortable chills.
But a child had gagged and coughed in my face earlier that week when I was doing a throat swab – and he had Strep. If I had Strep (as I hoped), then an antibiotic would treat the cause and I’d be back in shape in no time.
I could technically call out an antibiotic for myself, but I didn’t want to do that. That is poor care and I would never recommend treating anyone with a prescription without a proper evaluation.
I followed my own advice and went to a walk in clinic since I was out of town. If I was at home, I would have gone to my primary care physician because I believe in the medical home.
The provider walked into the exam room looking at the nurse’s notes saying it sounded like I had a sinus infection. (I use the term provider because I don’t recall if he was a physician, NP, or PA.)
He hadn’t even examined me or gotten any history from me other than answers to the cursory questions the nurse asked. Not to mention that my symptoms had just started within the past 24 hours and didn’t include any form of nasal congestion or drainage.
I’m a physician and know that sinusitis must have persistent symptoms for much longer than 24 hours. But I kept that thought to myself for the moment.
He did a quick exam and started writing a script to treat my sudden onset of fever without cough/congestion.
He literally started writing the script as he was telling me, once again, that I had a sinus infection.
Now I couldn’t stay quiet any longer.
I said I really just wanted a throat swab to see if it was Strep. I didn’t want an antibiotic if it wasn’t Strep throat.
He argued for a bit about the validity of rapid Strep testing.
I argued that I did not meet the criteria for a sinus infection and that the rapid strep tests are indeed fairly reliable (not perfect).
As a pediatrician I won that argument easily. In the end I was swabbed.
The test was negative. I most likely didn’t have Strep throat after all.
He still gave me a prescription for a commonly used antibiotic called a Z-pack, which I threw away.
Did I get better?
I felt better the next day, so if I had just taken the z-pack, I would have thought it worked.
Ironically, the Z-pack is not a very good antibiotic against Strep, the one reason I would have taken an antibiotic. Resistance rates are high in my area, so unless a person has other antibiotic allergies (which I do not) I would not choose it for Strep throat.
But my body fought off an unnamed virus all by itself. That’s what our immune system does. Pretty cool, right?
No. Not cool.
Well, yes… it is cool that we can get better with the help of our immune system and no antibiotics. But not cool that a less knowledgeable person would have taken the prescription without question.
Unfortunately, I think many people trust the medical care provider, even when he or she is wrong. Even smart people don’t know how to diagnose and treat illnesses unless they’re experienced in healthcare, so anyone could be fooled. Especially since we’re vulnerable when we’re sick. Even more so when our kids are sick. We want to do anything to help them.
False security in an unnecessary treatment.
Many parents come into my clinic wanting an antibiotic for their child because the child has the same symptoms as they have and they’ve been diagnosed with a sinus infection, bronchitis, or whatever. They’re on an antibiotic and are getting better, so they presume their child needs the same.
Most of the time they both likely have a viral illness, and the natural progression is to get better without antibiotics, but it’s hard to get buy in to that when a parent’s worried about a child. Even harder when the parent is certain that their antibiotic is fixing their viral illness.
Confirmation bias is the tendency to process information by looking for, or interpreting, information that is consistent with one’s existing beliefs.
A false belief is reinforced when we think we get better due to an antibiotic. It doesn’t prove that the antibiotic worked, but our minds perceive it as such.
We want to believe something works, and when it appears to work, it affirms our false belief.
The wrong treatment plan.
In my example, not only did I not have a sinus infection, but if I did have a false negative Strep test and actually needed an antibiotic for Strep, the Z-pack wasn’t a good choice.
False negative tests mean that there is a disease, but the test failed to show it. False negative tests are the reason I usually do a back up throat culture if I really think it is Strep throat and not a virus.
If the wrong treatment is given, not only do you fail to treat the real cause, but you also take the risks associated with the treatment for no reason.
Doesn’t the doctor (or NP or PA) know the antibiotic won’t work?
Yes, they know (or should know) how antibiotics work and when they’re indicated. But unfortunately, there are other factors at work when quick fixes are chosen.
Top 3 reasons that lead to patients getting unnecessary prescriptions:
One problem is that it’s much easier to give a prescription rather than taking time trying to teach why a prescription isn’t needed.
The faster they see a patient, the more patients they can see and the shorter the waiting time is, which makes people happy.
I see many unhappy parents who follow up with me because their child is still sick and the “last doctor” did nothing. I have previously blogged about the Evolution of Illness so will not go into it in depth here.
Sometimes it’s hard for physicians, NPs, and PAs to not try something to make a sick person better. After all, that’s why we do what we do, right? We want to help. We’ve all heard of patients who get progressively ill because an infection wasn’t treated quickly and we don’t want to “miss” something.
While missing a significant illness can happen, it’s not common. Common is common. Most upper respiratory tract infections are viral. It’s knowing how to recognize worrisome symptoms that comes from experience.
Physicians (MD, DO)
Physicians spend years of not only classroom training, but also clinical training to learn to recognize warning signs of illness. Even a brand new physician has at least 2 clinical years during the total 4 years of medical school. Then they spend at least 3 years of residency seeing patients in a supervised capacity before they can work independently. That’s at least 5 years of 60-80 hour work weeks.
The physicians in my office, including myself – now 18 years in practice – still ask for help if we feel it could be beneficial. Sometimes a second set of eyes or putting our heads together helps to put things into a clearer picture.
Trust that if we say it’s a virus, it’s a virus. We know that bodies can still be significantly sick if it’s Just A Virus, but most of the time you can manage symptoms at home. Listen to what we say are warning signs that indicate your child should be reassessed. Bring your child back if symptoms worsen or continue longer than typical. Symptoms can worsen, but taking an antibiotic does not prevent that progression in most cases.
Be sure to question if you do not understand or agree with an assessment or treatment plan, as I did in my example above. It is essential to have this type of communication for the best care.
Nurse Practitioners (NPs) and Physician Assistants (PAs)
I love the NPs in my office. They do a fantastic job and make patient access easier. They see a lot of sick kids and do a great job treating when needed and giving “just” advice when that is what is needed. (That’s usually harder, trust me.)
They are always able ask questions if they don’t know what to do or for a physician to see a patient if a parent wants a second opinion.
I do not want this to become an argument if NPs and PAs are good. They are needed in our healthcare system to help patients get seen in a timely fashion. I welcome and appreciate them as part of the healthcare team.
But I do want to acknowledge that the training and background can vary widely, and I think it’s important to know the experience of your provider. It is not as regulated to become an NP or PA as it is to become a physician.
Many NPs have years of work experience before returning to school to get their advanced degree. But newer online programs do not require much clinical experience. At all.
If they then begin working independently without much supervision, they learn as they go and may or may not learn well. I’m not saying they’re not smart, but I also know how lost I felt those first months as a new physician after many supervised hours, and I know they have a small fraction of those supervised hours. I can’t imagine doing that as a new grad!
This is why I think that all new practitioners should work with others who have more experience, so they can learn from the experience of others. I worry when inexperienced people work alone in clinics, with no one to bounce questions off of.
We can’t see what your child experienced last night if we’re seeing them in the morning and symptoms changed. Many symptoms are worse overnight, which makes it difficult to assess during the day. Of course if symptoms are urgent at night, go to a 24 hour facility that can adequately evaluate the situation.
If you are able to wait until regular business hours, you must describe it so we can understand it.
If you feel uncomfortable with the treatment plan, talk to the provider. List your concerns and let them address them. That’s not the same thing as demanding a prescription or further testing. It means asking for more information about why they feel the current plan is the correct one.
Many hospitals, clinics and insurance companies are surveying patients to see if “good care” was provided. These surveys are used to place providers on insurance contracts and decide payment and salaries.
People are happier and think care is better if something was done. A lab, x-ray, or prescription (whether needed or not) is “something” people can identify.
People do not feel that information about viral illnesses and what treatments can be done at home is as worthwhile as a tangible treatment, even if it’s the correct treatment. They see the prescription as making the cost and time taken for the office visit “worth it” even if it is bad care. Leaving empty handed (but with proper treatment) doesn’t satisfy.
Vaccines are the one of the best inventions to prolong our lives. They really can help. I know the flu vaccine (or any vaccine) isn’t 100% effective, but it does help. Everyone over 6 months of age should get a flu shot.
I’ve heard from many pediatricians taking care of kids hospitalized with influenza, and none of the dying kids were vaccinated.
Kids who were vaccinated this season might get flu symptoms, but generally not as severe.
It does take 2 weeks for the vaccine to be effective, so get it ASAP. Kids under 9 years old who haven’t been vaccinated for flu previously will need 2 doses a month apart. Call around to see where you can get it.
Wash hands often. This goes without saying. Whatever you touch stays on your hands. When you bring your hands to your face, the germs get into your body. Teach kids to wash hands well too!
Teach kids to cover their cough (and sneeze) with their elbow. This collects most of the germs in the elbow. Hands touch other things, so if you cover with your hands, you need to wash them before touching anything.
The only time I don’t recommend the elbow trick is if you’re holding a baby. Their head is in your elbow, so you should use your hands to cover and wash often!
You can get masks at the pharmacy to cover your nose and mouth to protect yourself from catching something and to prevent spreading an illness you have. We have masks available for anyone who comes to our office. We ask those who are sick to wear them, but those who are well can also put them on to prevent catching something!
In my office you’ll see that most of our nurses and clinicians have opted to wear masks when seeing sick kids even though we all have had our flu vaccine!
Avoid the T-zone
Avoid touching your face. It’s a horrible habit that most of us have. Be conscious of how often you wipe your mouth, eyes, or nose. Those are the portals to our body. Avoid touching them unless you can wash your hands before and after. Show kids how the eyes, nose and mouth make a “T” and teach them to not touch their T-zone.
Stay home when sick.
I’ve heard many angry complaints from parents about exposures. One mother was sick because she was exposed at work and then her illness spread to her family. She was especially upset because the exposure was from a child of a co-worker who brought the child to work because the child was sick and couldn’t go to school.
Keep sick kids home. If you’re sick: stay home.
If you’re sick with a flu-like illnesss, don’t
run to the store.
send your child to school with ibuprofen.
go to work.
go to your child’s game.
Stay home unless you need to seek medical attention.
Tamiflu and other anti-virals
My office is getting inundated with phone calls requesting us to call out Tamiflu. In some instances it’s appropriate for us to prescribe it for prophylaxis, but often we want to see your child first. If your child has flu-like symptoms, I do not want to prescribe a treatment without first evaluating your child. I don’t want to miss a more serious case that needs to be hospitalized. I don’t want to treat bronchiolitis or another condition as flu and miss the proper treatment. More on treatment with Tamiflu below.
Some of the calls we are getting are from mothers with influenza who have newborns and their OB’s have recommended prophylaxis for the baby. If the baby is under 3 months of age, Tamiflu is not approved for prophylaxis. (See the chart and corresponding footnotes from the CDC below.) If you are sick, try these tips to prevent spreading illness to your kids.
Many calls are from parents worried about a classroom (or other) exposure in a child who is not high risk. Unfortunately we cannot and should not use Tamiflu for routine exposures. Tamiflu itself is not without risk and if overused it will not be available for people who might really need it.
Big event coming soon!
A big birthday party, a big test, a planned vacation, etc do not make your child high risk. We really shouldn’t use Tamiflu inappropriately just because flu will make life inconvenient. Remember that all treatments have potential side effects and if we use them indiscriminately they will not be available when really needed.
Tamiflu prophylaxis is recommended for high risk people who have known exposure.
Right now it’s hard to find Tamiflu in many parts of the country, so you might not be able to get it after you’re exposed (or even if you’re sick with flu).
What’s better than Tamiflu?
Flu season can last through April, so taking it for 10 days now won’t help in 2 weeks when you’re exposed again. The flu vaccine protects more effectively and for a longer duration!
If sick: Treat
Most flu symptoms can be treated at home.
Fever and pain reducers
Use age and weight appropriate pain and fever reducers, such as acetaminophen and ibuprofen to keep kids comfortable. It is not necessary to bring the temperature to normal – the goal is to keep them comfortable. Don’t fear the fever – it is the immune system hard at work!
Offer plenty of fluids
Infants should continue their breastmilk or formula as tolerated. Older kids can drink water and it’s okay for them to eat. There is no need to avoid foods if a child wants to eat – I don’t know where the “feed a fever starve a cold” or other common myths started. Of course, appetite is usually down during illness, so don’t push foods. Push fluids.
Saline and suction
Saline and suction can go a long way to help relieve nasal congestion. Noisy breathing isn’t necessarily bad, but if the breathing is labored that’s another story. Check out the Sounds of Coughing to learn how to identify various breathing problems.
Pediatricians don’t recommend cough medicines due to high risk of side effects. Kids over a year of age can use honey. Some kids can get relief from menthol products. I’ve previously written all about cough medicines if you want to read more.
Not every person with influenza needs to be seen by a medical provider. I know we’re all scared, but in most cases there isn’t much doctors and other healthcare professionals can do to help.
Medical offices, urgent care clinics and ERs are overwhelmed with mildly sick people, which makes it harder for those who are really sick to be seen.
If your child is low risk (anyone who doesn’t meet the high risk criteria above) and is drinking well, overall comfortable with support measures, and doesn’t have any breathing distress, you can manage at home. Certainly if the situation changes, bring him in, but coming in before any signs of distress will not “ward off” the development of those symptoms.
When you should bring your child to be evaluated
If you think your child might have another illness, such as Strep throat, ear infection or wheezing, bring him in for evaluation and treatment.
When any signs of distress are noticed in your child: bring him in.
If your child is high risk (as described above) and has sick symptoms, he should be seen to determine if Tamiflu is appropriate. I do not recommend getting Tamiflu called in if a child is symptomatic. A child should have an exam to be sure there aren’t complications before just starting Tamiflu. I’ve seen several kids whose parents thought they had flu, but their exam and labs showed otherwise. They could be properly treated for Strep throat, ear infections, or pneumonias instead of taking Tamiflu inappropriately after an evaluation.
How can you tell if it’s the flu or another upper respiratory tract infection?
I have seen many kids who are brought in with a runny nose just to see if it’s early flu. No. No it’s not. Flu hits like a tsunami: fever/chills, cough, body aches, and fatigue. But the child was playing in the waiting room full of kids who do have flu, so you might recognize flu symptoms soon.
If your low-risk child had the flu vaccine, they may still get influenza disease. But if it’s mild, they can be treated at home. If symptoms worsen, they should be seen. Yes, there is a benefit to starting Tamiflu early, but we shouldn’t use it for low risk people who aren’t significantly sick. Even if you come in early, Tamiflu probably won’t be recommended if your child doesn’t meet criteria. Tamiflu has some significant side effects and is in short supply. We shouldn’t overuse it.
We currently have the ability to do a rapid flu test in the office, but there is a national shortage of the test supplies, so we might choose to not test your child if they don’t meet high risk criteria. I know at least one local hospital is out of rapid test kits and we probably won’t be able to get more this season if we run out.
Don’t come to the office or go to an urgent care or emergency room just to be tested.
Please don’t be upset if we do not test your child, especially if your child is not high risk and we wouldn’t recommend Tamiflu if they are positive.
If your child has classic flu symptoms, the guidelines don’t rely on test results for treatment, so if your child meets criteria for treatment, we can prescribe without a positive test.
Knowing test results doesn’t really help guide treatment when we have such high numbers of flu in the community. It does help early in the season to recognize when flu is coming to town, but we know it’s here. Pretty much everywhere in the US, it’s here.
Most people want it gone now. (Or more likely, last week.)
Unfortunately despite our medical advancements over the years, we still have no cure for colds and coughs. Viruses do not get killed by antibiotics, and most colds and coughs are caused by viruses.
I don’t hold back on advice when I see kids with disturbing colds and coughs. I sympathize with the child and parents. I’ve been there: both as a person with a bad cold and as a parent watching my kids struggle with colds. But I still can’t make them better faster.
Blow the mucus out. If a child’s too young to blow his nose well, parents can suck the snot right out.
Honey for children over 12 months of age
Prop the head up during sleep
But then we still have the original question: How long will a cough or cold last?
One of my favorite graphs depicting the timeline of a typical upper respiratory infection is from research done in the 1960’s, but since we don’t have any better treatment now than we did back then, I find it to hold true to what I experience when I get a cold and what I see in the office.
Notice how the symptoms are most severe during the first 1-5 days, but still persist for at least 14 days. And at 14 days 20% of people still have a cough, 10% still have a runny nose. And the lines aren’t going down fast at that point, they both seem to linger.
Bear in mind that children tend to get about 8 colds per year, often in the fall/winter months, so a second virus might start developing symptoms right as the first cold is finally going away.
There’s an important distinction between back to back illnesses versus a sinus infection requiring antibiotics. This is why doctors and nurses ask (and re-ask) about symptoms. The history and timeline of symptoms are very important in a proper diagnosis.
It isn’t the color of the mucus (really!) We don’t want people to unnecessarily take antibiotics. That leads to bacterial resistance, side effects of medicine, and increased cost to families.
So if you’re struggling with cough and cold symptoms in your house, follow these instructions.
To help determine when your child needs to be seen:
Urgently or emergently:
If your child is breathing more than 60 times in a minute, ribs are going in and out with breaths, or the belly is sucking in and out with each breath, your child needs to be seen in the office, at urgent care or an ER (preferably one that specializes in children), depending on time of day and your location. Another complication that kids must be seen for is dehydration. Dehydration may be present when the child is unable to take in enough fluids to make urine at least 4 times a day for infants, twice a day for older children.
Routine office visits:
If your child has ear pain, trouble sleeping, or general fussiness but is otherwise breathing comfortably and well hydrated, he should be seen during regular office hours. If the cold is worsening after 10-14 days, bring your child in during regular office hours.
This is the time of year it seems everyone’s coughing. I’ve heard from more than one worried parent that their child coughs to the point of vomiting. In the medical world, we call this post-tussive emesis.
Post = after, tussive = cough, emesis = vomit
Kids tend to have a very active gag reflex, so they sometimes gag themselves and vomit with cough. This can be good, since it gets the mucus out of the back of the throat. You can try to teach older kids to hack and spit it out, cough and spit it out, gargle with salt water, and rinse mucus out of the nose.
Of course it’s not fun to vomit after coughing because everything in the stomach comes up and makes a huge mess. Sometimes the vomit comes out of the nose, which can burn from the stomach acid. And vomiting can be very scary to kids.
Are there serious concerns when kids vomit from coughing?
In medical school I learned that when kids cough to the point of vomiting we should consider whooping cough, pneumonia and asthma.
In reality I find that many kids with regular cough and colds can gag from cough, but I always consider the more serious options.
What should I do if my child vomits from a cough?
First, keep your cool.
If a parent starts to get flustered, it makes the child more worried, which never helps.
Make sure your child’s breathing is okay.
Obviously he is coughing, but between coughs if the breathing rate is too fast or labored, he should be evaluated ASAP.
Rinse out your child’s mouth (and nose if needed- saline drops or rinses work well for this). Vomit is just nasty tasting and can burn in the nose.
Treat the cough.
If your child has asthma, give a breathing treatment or their rescue inhaler.
If your child is over a year of age, you can use honey to help a cough. A teaspoon usually does the trick.
If your infant is under a year of age or your child has not had the whooping cough vaccines (Dtap in infants and young kids and Tdap in tweens), he should be evaluated. Some babies with whooping cough stop breathing so many are hospitalized to monitor for complications.
After a single episode of vomiting if your child’s breathing is comfortable, just continue to manage at home.
If your child develops difficulty breathing or dehydration, he should be seen as soon as possible, ideally at a location that routinely cares for children.
If your child continues to vomit after coughing but is comfortable between episodes and is well hydrated, he should be seen during normal business hours at his regular doctor’s office.
I’ve seen a few kids this season who have influenza despite the fact that they had the vaccine. When the family hears that the flu test is positive (or that symptoms are consistent with influenza and testing isn’t done), they often say they won’t do the flu shot again because it didn’t work.
Don’t rely on Tamiflu to treat flu symptoms once you’ve gotten sick.
Tamiflu really isn’t that great of a treatment. It hasn’t been shown to decrease hospitalization or complication rates. It shortens the course by about a day. It has side effects and can be expensive. During flu outbreaks it can be hard to find.
I get a lot of requests for an over the counter cough suppressant suggestion or a prescription cough medicine for kids so they can sleep. Despite my attempts at educating the family about why I don’t recommend any cough medicines, many parents are upset leaving without a medicine.
I have collected numerous articles that show why I treat cough the way I do. Links are included throughout this blog. Click away to learn more!
First, a little background
Most cough medicines were studied in adults and the dosing for kids was calculated from the adult dosage.
Kids are not small adults. Their bodies handle illness and metabolize drugs differently.
But few studies have been done to show if medicines work at all, and if they do, what the best dose is for kids of various ages and sizes.
In 2008 the FDA stated that toddlers and babies should not use cold and cough medicines.
Drug makers voluntarily changed the labeling of over the counter (OTC) cough and cold products, recommending them only for children aged 4 and older. The American Academy of Pediatrics says there is no reason that parents should use them in children under age 6 because of the risks without benefit.
Despite this, studies show that 60% of parents of children under 2 years have given a cough and cold medicine. Why? In my opinion, they are desperate to help their child and don’t think it is enough risk to not at least try.
I know it’s frustrating when your child is up all night coughing. It’s frustrating when my kids and I are up all night coughing.
do you know what we do in my house?
Humidify the air of the bedroom (during the dry months)
Extra water to drink all day
Honey before bedtime in an herbal tea (No honey before 1 year of age!)
Encourage cough during the day to help clear the airways
Sleep with water next to the bed to sip on all night long
Back rubs, hugs, kisses, & reminders that it will get better
Nap during the day as needed to catch up on lost sleep
Watch for signs of wheezing or distress
That’s about it for the cough.
If something hurts, we use a pain reliever like ibuprofen or acetaminophen. We use those only if something hurts, not just because and not for fever without discomfort.
Why don’t I give my family cough medicines?
Because they don’t work.
The OTC options:
A Cochrane Review in 2007 was done to look at over the counter cough medicine effectiveness in both children and adults. These reviews look at many studies and analyze the data. Unfortunately there are very few studies, and many were of poor quality because they relied on patient report. In studies that included children, they found:
Antitussives were no more effective than placebo for kids. (one study) In adults codeine was no more effective than placebo. Two studies showed a benefit to dextromethorphan, but another study did not, so mixed results.
Expectorants had NO studies done in children. In adults guaifenesin compared to placebo did not show a statistically different response.
Mucolytics more effective than placebo from day 4-10 in kids. (one study) In adults cough frequency was decreased on days 4 and 8 of the cough. (Note: I am not sure what OTC mucolytic was studied. I am only aware of pulmozyme and mucomyst, both used by prescription in children with cystic fibrosis.)
Antihistamine-decongestant combinations offered no benefit over placebo. (2 studies) One of two studies showed benefit in adults. The other did not.
Antihistamine shows no benefit over placebo. (one study) In adults antihistamines did not help either.
Another Cochrane Review in 2012 once again failed to show any real benefits of cough medicines, especially given the risks of side effects.
What about some specific studies on OTC medicines?
Does guaifenesin help? It is thought to thin mucus to help clear the airways. It does not stop the cough. Studies vary in effectiveness and are typically done in adults, but it may be helpful in children over 4 years of age. Do not use combination cough medicines though, for all the reasons above.
What side effects and other problems are there from over the counter cough medicines?
As stated above, the dosages for children were extrapolated from studies in adults. Children metabolize differently, so the appropriate dosage is not known for children. Taking too much cold medicine can produce dangerous side effects, including shallow breathing and death.
Many cough medicines have more than one active ingredient. This can increase the risk of overdosing. It also contributes to excess medicines given for problems that are not present. For instance if there is a pain reliever plus cough suppressant, your child gets both medicines even if he only has pain or a cough. Always choose medicines with one active ingredient.
Accidentally giving a child a too much medicine can be easy to do. Parents might use two different brands of medicine at the same time, not realizing they contain the same ingredients. Or they can measure incorrectly with a spoon or due to a darkened room. Or one parent forgets to say when the medicine was given and the other parent gives another dose too soon.
And then there’s non-accidental overdose. There is significant abuse potential: One in 20 teens has used over the counter cough medicines to get high. Another great reason to keep them out of the house!
Side effects of cough medicines include:
Nausea and vomiting
Double or blurred vision
Impaired physical coordination
Rapid heart beat
Numbness of fingers and toes
Death, especially in children under 2 years of age and those with too high of a dose
When we have newborns we don’t want them exposed to germs. We avoid large crowds, especially during the sick season. We won’t let anyone who hasn’t washed their hands hold our precious baby. We might even wash our hands until they crack and bleed.
But what happens when Mom or Dad gets sick? What about older siblings? How can we prevent Baby from getting sick if there are germs in the house?
In most circumstances it is not possible for the primary caretaker to be completely isolated from a baby, but there are things you can do to help prevent Baby from getting sick.
Wash hands frequently, especially after touching your face, blowing your nose, eating, using common items (phone, money, etc) and toileting.
Wash Baby’s hands after diaper changes too. Make this a habit even when you’re not sick… you never know when you’re shedding those first germs!
Wipe down surfaces
Viruses that cause the common cold, flu, and vomiting and diarrhea can live on surfaces longer than many expect.
Clean the surfaces of commonly touched things such as doorknobs; handles to drawers, cabinets, and the refrigerator; phones; and money frequently when there is illness in the area.
Avoid touching your face
Avoid touching your eyes, nose and mouth – these are the “doors” germs use to get in and out of your body.
Pay attention to how often you do this. Most people touch their face many times a day. This contributes to getting sick.
Kiss the top of the head
Resist kissing Baby on the face, hands, and feet.
I know they’re cute and you love to give kisses, but putting germs around their eyes, nose, and mouth allows the germs to get in. They put their hands and feet in their mouth, so those need to stay clean too.
Cover your cough
I often recommend that people cover coughs and sneezes with their elbow to avoid getting germs on their hands and reduce the risk of spreading those germs.
When you’re responsible for a baby, the baby’s head is often in your elbow, so I don’t recommend this trick for caretakers of babies. Cover the cough or sneeze with your hands and then wash them with soap and water or use a hand sanitizer if soap and water aren’t available.
If you’re vaccinated against influenza, whooping cough, and other vaccine preventable diseases, you’re less likely to bring those germs home. Encourage everyone around your baby to be vaccinated.
If you get your recommended Tdap and seasonal flu vaccine while pregnant, Baby benefits from passive immunity.
Parents often bring in kids with a cough but can’t describe what it sounds like. I sometimes get to hear it if they cough, but Murphy’s Law also says that a child who coughs often throughout the night and frequently during the day will have a 15 minute period of no cough at the exact time the doctor is in the exam room.
In all seriousness — coughs, regardless of the source — are usually worse at night, which means your doctor won’t usually get to hear the worst of it.
They can also change over time. For instance, croup often starts as a sudden barky cough that over days turns into a wet cough.
I often wish there was one place I could refer parents to so they could see what various coughs sound like, so I decided to put a list together. The internet is ripe with videos, but I have spent many hours watching videos that weren’t very helpful in order to find these. I’m sure I missed some of the best ones, so if you have one that you really like, please post in the comments below.
Regardless of how the cough sounds, if you’re worried about your child’s breathing or the sound of the cough, bring your child in to be seen.
Disclaimer: I have no ties to any of the videos below and am not responsible for any of the opinions or errors within them. Some are professionally done and others are videos parents uploaded. Some have advertisements which I do not endorse.
The initial seconds of this baby with croup stridor video show the typical croupy cough. At about 0:55 it shows the stridor that many kids with croup have. Stridor is a whistling sound as the baby breathes in (often confused with wheezing, which happens when you breathe out). It is common in croup and is caused by the swelling near the voice box. (Older kids and adults who get the same viruses that cause croup in younger kids often get laryngitis from the swelling near the voice box in a larger neck.)
This ER physician of TheEDExitVideo spends the first couple of minutes discussing what causes croup. At 2:27 sounds of stridor in an otherwise happy looking baby are shown. At 3:44 is a picture showing intercostal retractions (also seen with wheezing or other types of respiratory distress).
TheKidsDr also has a great informational video on croup.
Dry cough can be from an irritation in the throat, asthma, acid reflux, or any common cold. It can also come from a habit cough (often seen after an illness and goes away with sleep only to return when awake).
If you’re sitting here reading this and not sick, make yourself cough. That’s what a dry cough sounds like.
Laryngomalacia wasn’t on my original list because it isn’t from a virus or bacteria causing illness, but it is a cause of noisy breathing in infants. It is caused by floppy tissues near the voice box (i.e. larynx). Linden’s Laryngomalacia – 3 Months shows this breathing. It is often worst when baby is excited or fussy.
The cough with pneumonia can sound like a wet cough or dry cough, so no specific videos are for this cause of cough.
The clues to pneumonia include a fever with cough, difficulty breathing between coughs, shallow breathing, shortness of breath with brief exertion, pain in the chest, rapid breathing, or vomiting after cough.
Pneumonia can be caused from viruses and bacteria and can range in severity. Walking pneumonia generally means that the person is not sick enough to require hospitalization.
Some pneumonias lead to severe difficulty breathing and require oxygen support.
Wet cough can be from pneumonia or bronchitis, but also from postnasal drip with a common cold or allergies.
When kids “cough stuff up” it is usually the postnasal drip being coughed up, not mucus from the lungs coming up. The same is true if they “cough up blood”. This blood is usually from a bloody nose draining into the throat, not from lung tissue. (Note: bloody mucus can be from more serious causes and if your child has no signs of blood in the nose or is otherwise ill, he should be properly assessed by a physician.)
Wheezing is typical in asthma (and bronchiolitis). Many parents mistake the upper airway congestion sound that many kids make with postnasal drip as wheezing.
Wheezing can sound like a whistle as a child breathes out. Ethan’s wheezing shows a baby with noisy breathing without distress. This Wheezing – Lung Sounds Collection video has the sounds one would hear with a stethoscope, but if you put your ear against your child’s back (without a shirt) you might be able to hear them.
If you don’t hear wheezing, but your child is struggling to breathe, it does not mean there is no wheezing! Treat like you would if you hear the wheeze.
Bronchiolitis is a video from the ER physician Dr Oller. He reviews causes of bronchiolitis, how it’s spread, and how it affects the body. At 1:40 he discusses the natural progression of the simple cold into bronchiolitis. At 3:04 there is a picture of how we collect a nasal swab to help with diagnose of any viral illness.
Sick with Bronchilitis shows an infant with suprasternal retractions (sucking in at the base of the neck) and the typical cough associated with bronchiolitis. The man erroneously says “croupy”, see below for croup.
RSV and Infant Treatment shows the best treatment for babies with RSV (or any bronchitis): suctioning. Some babies need this deep suctioning in the doctor’s office or hospital. Others can get by with nasal aspirating at home. I’m not a fan of the bulb syringe for this. Here’s a good review of various aspirators.
Pertussis (whooping cough) shows a young infant with a cough from pertussis. Young infants do not always whoop, they stop breathing.
8 Year Old With Pertussis (Whooping Cough) shows a typical cough for an older child. Her positioning in front of the toilet shows that these kids often vomit from the force of the cough. The 2nd video from this same girl shows how normal and healthy kids can appear between episodes.
Regardless of the sound of the cough or the ability to feel rattling in the chest, how kids are breathing is most important.
Coughs can often sound just awful but if the child is breathing comfortably and well appearing otherwise, it is probably not serious.
Conversely, some kids have a minimal cough but are suffering from difficulty breathing. If they are unable to talk and breathe or eat and breathe they should be seen. If the ribs suck in and out or the breathing is continuously more rapid than normal, they should be seen.
Don’t rely on the cough alone to decide how sick your child is. If they seem uncomfortable breathing it’s time for them to be evaluated.
I was at the gym today and an otherwise great instructor who seems to know a lot about health was sharing incorrect information about the flu with the class of about 40 people. She said that she had received several texts from other instructors asking her to cover their classes because they were vomiting. Then she went on to say that many at first thought it was food poisoning, but it’s spreading like illness, so it’s the flu, not food poisoning. She made a big deal that the flu is here. Is vomiting from the flu?
The flu causes predominantly fever, cough, sore throat, and body aches for many days. It can cause vomiting and diarrhea, but those aren’t usually the predominant symptoms. And the flu doesn’t cause just a few hours of extreme vomiting like we’re seeing these days.
Why do I care if people call this stomach bug “flu”?
The biggest reason I care is that it leads people to make other incorrect assumptions and to get the wrong treatments.
I hear all the time that people had the flu the year they got a flu shot, so they don’t want to get it anymore.
When probed about their illness, it’s usually not consistent with the flu. It was either a cold and cough or a stomach virus.
If they think a common cold or vomiting is from the flu, they’re mistaken.
They need to know that this isn’t the flu.
Common colds and vomiting are not prevented with the flu shot.
The flu shot has nothing to do with protecting against most cases of vomiting and diarrhea or most upper respiratory tract infections.
Of course there are people who got the flu shot (or FluMist when it was available) who did come down with the flu. They had a positive flu test and symptoms were consistent with the flu. But if they get influenza after the vaccine they tend to have milder symptoms. They tend to not end up in the hospital or dead if they’ve had the vaccine. Yes, even healthy young people can end up very sick from influenza. They can even die. (The FluMist didn’t protect well and was removed from the market due to this.)
We forget about all the times people did get the vaccine and they didn’t catch the flu even with likely exposure. Lack of disease is easy to fail to acknowledge.
We know the flu vaccine is imperfect. But if the majority of people get vaccinated, we can slow the rate of spread and protect us all against influenza most effectively.