Croup in Children: Barking Cough, Stridor, and When to Seek Care

Which children get croup?

Croup is most common in young children because their airways are naturally smaller.

• It occurs most often between about 6 months and 3 years of age, although children from roughly 3 months to 5 years can develop it.
• It is slightly more common in boys.
• It occurs most often during the fall and winter, although it can happen at any time of year.
• Some children experience croup more than once.

As children grow, their airways become larger, so the same amount of swelling is less likely to cause the characteristic barking cough and noisy breathing.

What are the signs and symptoms?

Croup often begins like an ordinary cold.

Your child may first develop:

• Runny nose
• Nasal congestion
• Fever
• Mild sore throat or fussiness

Then the characteristic symptoms appear, often later in the day or during the night:

• A barking, seal-like cough
• A hoarse or raspy voice or cry
• A harsh, high-pitched sound when breathing in, called stridor

Symptoms are often worse at night and may become louder when a child is crying, frightened, or upset.

Croup often improves during the daytime and becomes more noticeable again the following night.

Most children improve over several days, although the barking cough can occasionally linger longer.

What exactly is stridor?

Stridor is a harsh or squeaky sound caused by air moving through a narrowed upper airway.

The most important question is when you hear it.

Stridor only when crying or upset

Some children with mild croup develop stridor only when:

• Crying
• Coughing
• Running around
• Becoming frightened or agitated

When the child becomes calm, the noisy breathing disappears.

This is generally less concerning than stridor at rest, although your pediatrician may still recommend treatment.

Stridor while calm or at rest

Stridor that continues while your child is calm and resting is a sign of more significant airway narrowing.

This deserves prompt medical evaluation, particularly if it is accompanied by:

• Retractions or pulling in around the ribs or neck
• Fast or labored breathing
• Difficulty drinking
• Increasing tiredness

Caring for mild croup at home

A child with a barking cough who is breathing comfortably and does not have stridor at rest can often be cared for at home.

Keep your child calm

This is one of the most useful things you can do.

Crying and agitation increase airflow through the narrowed airway and can make both stridor and the barking cough sound significantly worse.

Hold your child, speak calmly, and allow them to remain in whatever comfortable position they prefer.

Keep your child upright

Many children are more comfortable sitting upright or being held against a parent's chest.

There is no need to force them to lie down.

Offer fluids

Encourage frequent fluids.

For babies, continue breast milk or formula.

If breathing or congestion makes feeding difficult, smaller and more frequent feeds may be easier.

Cool outdoor air may help temporarily

Some children seem to improve after breathing cool outdoor air for a short period.

A clinical study found that exposure to cold outdoor air helped reduce symptoms in some children with mild-to-moderate croup while steroid medicine was beginning to work.

If the weather is comfortably cool, stepping outside with your child for a few minutes may be reasonable.

Do not use cool air as a substitute for medical evaluation if your child has stridor at rest, significant retractions, color changes, or other signs of breathing difficulty.

What about steam?

Steam from a hot shower was traditionally recommended for croup, but studies have not shown that steam reliably improves croup symptoms.

Very hot steam also creates a risk of burns.

There is no need to sit your child next to boiling water or expose them to very hot steam.

Fever and discomfort

Acetaminophen or ibuprofen may be used when appropriate for your child's age and weight if they are uncomfortable.

Ibuprofen is generally used in children 6 months and older unless a clinician recommends otherwise.

What about cough medicines?

Over-the-counter cough and cold medicines do not treat the airway swelling that causes croup.

For young children, routine use of these medicines is generally avoided unless a clinician recommends a specific product.

The most important treatments for croup are reducing airway swelling and monitoring breathing—not suppressing the cough.

Medical treatment for croup

Dexamethasone

Doctors commonly treat croup with a steroid medicine called dexamethasone.

A single dose can:

• Reduce swelling in the airway
• Improve the barking cough and stridor
• Reduce the chance that symptoms worsen
• Lower the likelihood of needing additional medical care

Dexamethasone is effective even for relatively mild croup.

Usually only one dose is needed.

Nebulized epinephrine

Children with more significant airway narrowing may receive a breathing treatment with nebulized epinephrine in an urgent care center or emergency department.

Epinephrine can shrink airway swelling very quickly and often improves breathing within minutes.

Its effect is temporary, however.

Children who receive nebulized epinephrine are generally observed for several hours—often about 2 to 4 hours—to make sure significant symptoms do not return as the medicine wears off.

Antibiotics

Antibiotics do not treat typical croup because croup is usually caused by a virus.

When should I call the pediatrician or seek same-day care?

Contact your child's pediatrician or seek same-day evaluation if:

• Your child develops stridor when crying or active
• The barking cough is becoming more severe rather than improving
• Your child is drinking less than usual
• Fever lasts more than about 3 days
• Fever goes away and then returns
• Symptoms improve and then become significantly worse
• Your child has repeated episodes of croup
• You are unsure whether your child's breathing is normal

If breathing becomes difficult, do not wait for an office appointment.

When should I go to the emergency department?

Seek emergency medical care if your child has:

• Stridor while calm or resting
• Significant pulling in around the ribs, breastbone, or base of the neck with each breath
• Fast, labored breathing or obvious struggle to breathe
• Difficulty speaking, crying, drinking, or feeding because of breathing difficulty
• Blue, gray, or markedly pale lips, tongue, or skin
• Pauses in breathing
• Extreme sleepiness, limpness, confusion, or difficulty waking
• Severe agitation together with difficulty breathing
• Drooling or inability to swallow saliva

Drooling, severe difficulty swallowing, a very ill appearance, or sudden severe breathing difficulty can sometimes indicate a condition other than ordinary viral croup and needs urgent evaluation.

For a possible life-threatening emergency, call 911.

A note about repeated croup

Some children develop croup more than once.

An occasional repeat episode can happen, particularly during the preschool years.

However, further evaluation may be reasonable when a child:

• Has more than about two episodes of croup per year
• Develops repeated croup outside the usual preschool age range
• Has symptoms that last unusually long
• Responds poorly to standard croup treatment
• Has persistent noisy breathing between illnesses

In those situations, your pediatrician may recommend evaluation by an ear, nose, and throat specialist, pulmonologist, or another specialist to look for an underlying airway issue.

The bottom line

Croup can sound frightening—especially when a child suddenly wakes in the middle of the night with a barking cough.

Fortunately, most croup is mild and improves over several days.

For mild illness:

• Keep your child calm
• Let them remain upright and comfortable
• Offer fluids
• Cool outdoor air may temporarily help some children
• Avoid relying on cough medicines or hot steam

A single dose of dexamethasone is highly effective when medical treatment is needed.

The most important warning sign is stridor while your child is calm or resting, especially when accompanied by retractions, difficulty drinking, abnormal color, or increasing exhaustion.

When your child's breathing worries you, having them evaluated is always reasonable.