Who Let The Seals Out?

This week’s guest columnist is Dr. Tyler Hebert, Family Practice resident at the University Hospital and Clinics here in Lafayette.

The child wakes up in the middle of the night with a weird-sounding cough, struggling to breathe, a panicked look on her face. When she breathes in, she makes a honking sound. The parents jump in the car and race for the Emergency Department.  Upon arriving, the child is miraculously better.  She sits there cooing and gurgling, breathing just fine, looking between parents and doctor and nurse.  What’s all the fuss about, her expression says. “I swear she was in real trouble!” intones the mom. Rest assured mom, we believe you.  This is croup.

Croup is a condition brought on by regular winter cold viruses.  While most kids just have a cough and runny nose, a few get irritation in their airway below their vocal cords. The airway starts to swell closed, causing the characteristic “seal bark” cough. If you’ve never heard a seal bark at the aquarium, see it on Youtube. Instead of a dog’s “arf-arf” sound, seals make a much deeper “Orf-Orf” sound, as will your croup-afflicted child. When kids have bad attacks, they also have a sound when they breathe in called “stridor.”  Stridor is an inspiratory honking from even more narrowed airways.  When a child wakes up with this “Honk-Orf-Orf-Orf, Honk-Orf-Orf-Orf”, they’re working to get air through that narrowed passage.  They sound terrible and look panicked.

Daycare is a great thing.  At daycare, children get to socialize with other kids, receive important education, and parents can tend to their jobs and other responsibilities. Daycare plays a major role in many parents’ and children’s lives.  Daycares are also great places for kids to pass around cold viruses.

For the first 18 months of her life, our oldest daughter never got sick.  When she started daycare, she got her first runny nose. Then every other week she contracted yet another cold virus that her classmates passed around.  My youngest daughter got croup from these colds. Fortunately, we were able to settle her down at home and not need an ER visit. Remember how our girl above got better so fast?  There’s reasons for that we’ll go into below.

As we mentioned above, daycare can be a wonderful thing.  Kids get to play with other kids; and parents can go to work, earn money, and tend to other responsibilities.  Note how even during the worst of the pandemic this past spring, many daycares stayed open. They’re that important for families’ function.

Daycares are also great places for kids to get sick. Infants and toddlers are virus-breeding and virus-spreading factories. A child catches a cold virus, brews it in his body, and then begins sharing it with his environment: coughing, sneezing, and running mucus out his little nose. Put that kid in a room with several other active, exploring toddlers, and soon they’re inhaling virus-laden aerosol.  They also get virus-contaminated mucus smeared on them by their pestilent playmate, their hands go in their mouths, and bingo: several more virus-manufacturers-and-spreaders are recruited.

Like we said above, a few of those infected kids develop croup. Croup is a side-effect of cold viruses, wherein the afflicted child gets narrowing in her airway right below the vocal cords. Then she wakes up with that seal-bark cough and inspiratory honking called stridor. Often these kids struggle to breathe.

Fortunately, most kids get better within minutes of their attack. One reason for the noise is that they’re sucking in dry, night-time air, which is “sticky” in a narrowed airway.  Also, when they’re lying flat while sleeping, fluid in their body contributes to the swelling. When the child sits up, waking in her panic, the swelling drains away. Then when the parents drive to the Emergency Department, the moist outdoor air lubricates the kid’s airway, and upon arrival she looks fine.

Thus the basics of croup treatment.  When parents call the doctor for croup attacks, they’re advised to hold kids upright and take them outdoors, or into the bathroom with all the hot faucets on to steam it up.  If that doesn’t work, then get seen.  We often prescribe steroids to decrease the airway inflammation, and occasionally use a special breathing treatment called racemic epinephrine for bad cases.  Your usual home breathing treatment, albuterol, doesn’t help with croup, except for the mist coming out of the pipe. Easy enough to turn your little seals back into kids.

‘Tis The Season Of The Barking Cough

It was a case of Physician Heal Thyself, or in this pediatrician’s case, Heal Thine Own. One midnight in Baltimore, I was on duty in the Pediatric ED when my wife called: our son awoke struggling to breathe, such that he couldn’t even talk.  Miles away, I could only help over the phone.  I gave the standard pediatrician’s advice for croup : take him outside, keep him upright.  His breathing subsided, everyone calmed down, and I called in a prescription to the 24 hour pharmacy.  Croup can be scary, yet easily managed.  This week’s guest columnist, Dr. Leslie Sizemore, a family practice resident at the University Hospital and Clinics here in Lafayette, explains:

In the fall physicians prepare for the typical fall and winter illnesses. Everyone thinks of influenza virus (“the flu”) but we also worry about RSV, mycoplasma (“walking pneumonia”), common cold, and the ever recognizable croup.

What is croup?  Croup starts like any cold- dry cough, runny nose, hoarseness, and sometimes fever.  The characteristic “barking cough” comes about 12-48 hours later. The barking lasts about 3 days but the rest of the cold may take around 7 days to resolve. Sometimes croup comes on suddenly at night, with a previously well child awakening with the barking cough and shortness of breath.

Croup is caused by inflammation at the top of your windpipe, called the trachea, just below your vocal cords.  When these pipes get inflamed, they swell and the breathing space gets narrower.  The smaller space compresses the air during cough, making that strange cough like a barking seal.  If the swelling worsens, the child gets stridor, which is a high pitched whistling sound when breathing in.  When the airway is narrow enough to make stridor, kids really starting struggling to breathe.

We see croup mostly in the fall, October being the peak month.  This coincides with a peak in parainfluenza virus, the most common cause of croup.  Croup is mostly seen in kids age 6 months to 3 years, and is unusual beyond age 6.  Viruses that cause croup are spread by close contact, just like any cold.

Most cases of croup are mild with occasional barking cough, hoarseness, and maybe a little stridor when crying.  It is the more severe cases we worry about, when the swelling of the windpipe gets worse.  Then the child has that whistling stridor sound even at rest. These children need to get seen immediately.  If the airway gets too narrow the child may no longer be able to breath.  The good news is that less than 5% of kids with croup get put in the hospital, so these bad cases are rare.

How do we treat this nasty illness?  Since it is caused by a virus, we all know that antibiotics won’t help, since they don’t kill viruses.  We treat the symptoms while the child’s immune system gets rid of the virus.  We treat the airway inflammation with anti-inflammatory medicine- steroids.  This can be done in two ways: the child can be given a one-time shot, or be given three days of a liquid steroid by mouth. We all know which one the kid would prefer!

If the child is having stridor, we give them a breathing treatment with a medicine called epinephrine.  The breathing treatment, or nebulizer, is that pipe commonly used by asthmatics that turns medicine into a mist that is inhaled.  But instead of the albuterol that kids with asthma need, we put in epinephrine.

The epinephrine relaxes the muscles that line the windpipe.  We give this medicine only in the Emergency Department, not at home.  This is because the child needs to be watched for several hours after the treatment.  Sometimes kids who get the epinephrine treatment have “rebound,” where the stridor comes back within an hour, sometimes coming back worse.

For the other croup symptoms, you treat them like any other cold.  Give Tylenol or ibuprofen for fever and throat soreness.  Run a vaporizer by the bed for moist air to lubricate those inflamed airways.  Prop up the child’s head to help minimize gagging on secretions.  Give plenty of fluids, and in a few days your child should get better and go on about his business, no longer imitating a barking seal.