From Vincent Iannelli, M.D.,
Your Guide to Pediatrics.
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About.com Health's Disease and Condition content is reviewed by Kate Grossman, MD

Croup is a common childhood viral illness that is easily recognized because of the distinctive characteristics that children have when they become infected. Like most viral illnesses, there is no cure for croup, but there are many symptomatic treatments that can help your child to feel better faster.

Croup, also called laryngotracheobronchitis, most commonly affects children between the ages of six months and three years, usually during the late fall, winter and early spring. Symptoms, which often include a runny nose and a brassy cough, develop about 2-6 days after being exposed to someone with croup.

One of the distinctive characteristics of croup is the abrupt or sudden onset of symptoms. Children will usually be well when they went to bed, and will then wake up in the middle of the night with a croupy cough and trouble breathing. The cough that children with croup have is also distinctive. Unlike other viral respiratory illnesses, which can cause a dry, wet, or deep cough, croup causes a cough that sounds like a barking seal.

Another common sound or symptom of croup is inspiratory stridor, which is a loud, high-pitched, harsh noise that children with croup often have when they are breathing in. Stridor is often confused with wheezing, but unlike wheezing, which is usually caused by inflammation in the lungs, stridor is caused by inflammation in the larger airways.

The pattern of symptoms in children with croup is also characteristic. In addition to beginning in the middle of the night, symptoms, which are often better during the day, worsen at night, although they are usually less intense each night. Symptoms also become worse if your child becomes anxious or agitated.

The symptoms of croup are caused by inflammation, swelling and the buildup of mucus in the larynx, trachea (windpipe) and bronchial tubes. Since younger infants and children have smaller airways, it makes sense that they are the ones most affected by croup. In contrast, older children will often just develop cold symptoms when they are infected by the same virus.

Children with croup will usually also have a hoarse voice, decreased appetite and a fever, which is usually low grade, but may rise up to 104 degrees F.

Croup Assessment

Because of the characteristic signs and symptoms of croup, this diagnosis is usually fairly easy to make. You can often tell a child has croup while they are still in the waiting room or before you enter the exam room, therefore, testing is usually not necessary.

Specifically, an xray is usually not required, and is usually only done to rule out other disorders, such as ingestion of a foreign body. When an xray is done, it will usually show a characteristic 'steeple sign,' which shows a narrowing of the trachea.

When assessing a child with croup, it is important to determine if he is having trouble breathing. Fortunately, most children have mild croup and have no trouble breathing, or they may only have stridor when they are crying or agitated. Children with moderate or severe croup will have rapid breathing and retractions, which is a sign of increased work of breathing. They may also have stridor when they are resting.

The croup score is an easy and standardized way to figure out if a child has mild, moderate or severe croup, which can help to dictate what treatments are necessary. The croup score is based on a child's color, level of alertness, degree of stridor, air movement, and degree of retractions, with 0 points given if these findings are normal or not present, and up to 3 points given for more severe symptoms.

Inspiratory Stridor

• None (0 points)
• When agitated (1 points)
• On/off at rest (2 points)
• Continuous at rest (3 points)

Retractions

• None (0 points)
• Mild (1 points)
• Moderate (2 points)
• Severe (3 points)

Air Movement/Entry

• Normal (0 points)
• Decreased (1 points)
• Moderately decreased (2 points)
• Severely decreased (3 points)

Cyanosis (Color)

• None (0 points)
• Dusky (1 point)
• Cyanotic on room air (2 points)
• Cyanotic with supplemental oxygen (3 points)

Level of Alertness (Mentation)

• Alert (0 points)
• Restless or anxious (1 points)
• Lethargic/Obtunded (2 points)

In general, children with a croup score of less than 4 have mild croup, 5-6 have mild/moderate croup, 7-8 have moderate croup, and greater than 9 have severe croup.

If you are unsure how severe your child's symptoms are, call your Pediatrician.