Sudden Barky Cough? Think Croup

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. 

Cool air

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…)

Steam

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?

Fever/pain relievers

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.

Steroids

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.

Breathing treatments

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.

Antibiotics

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!

The sounds of coughing…

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.

cough wheeze stridorIn 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.

Croup

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

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

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.

For more information on this (even a video of a scope into the airway), check out Children’s Hospital of Philidelphia’s Laryngomalacia page.

Pneumonia

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

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

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.

Asthma

Asthma Attack in a child starts with information on asthma, then at 1:50 video of what retractions look like.

Asthma attack shows the typical short breathing in phase with long exhale seen with an asthma attack. Also you can see the airway pulling in at the neck (retractions).

Bronchiolitis, often simply called RSV, but caused by many viruses

Bronchiolitis Cough, 3.5 months old shows a baby with a wet sounding cough, typical of bronchiolitis.

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.

Whooping Cough

Pertussis – Whooping Cough: A Family’s Story is an informational video on pertussis with the classic whooping cough in a child and pictures of a newborn with pertussis.

Silence the Sounds of Pertussis – Whooping Cough is a commercial for vaccinating, but it starts with the typical whooping cough sound.

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.

Final words…

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.

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