What’s Up Doc? COVID test is negative; barking cough and fever may mean toddler has croup – MetroWest Daily News

Dr. Jeff Hersh| Daily News Correspondent

Q:My almost2-year-oldsondevelopeda barking-like cough and fever. I was afraid it was COVID,so brought him to his pediatrician.She said it was croup and his COVID test was negative. What iscroup?

A:When we breathe the air enters through our nose or mouth, goes through the throat into the larynx (the voice box), then through the trachea (the windpipe), and on to the large airways (bronchi), thensmaller airways (bronchioles) and finally to the lungs where oxygen passes through the alveoli (the tiny air sacs) walls to be taken up by the blood and carbon dioxide leaves the blood to be exhaled.

Croup is a respiratory (breathing) illness due to narrowing of the upper airway,i.e., the larynx, trachea and/or the bronchi,frominflammation or other swelling.Older patients typically have larger airways so can tolerate some amount of swelling, and hence do not usuallydevelopcroup. Therefore, it is younger patients, particularly between the ages of 6 months and 7 years, that typically develop croup symptoms.

There are two major types of croup, infectious croup and spasmodic croup.

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Infectious croup is usually due to a viral illness (although bacterial tracheitis, where pus forms in reaction to a bacterial infection of the trachea,is a rare infectious cause), most commonly parainfluenzavirusalthough many other viruses have been implicated as well.The symptoms of infectious croup typically begin with cold-like symptoms, sometimes with a fever, and then develop intothe classic symptoms of croup, including stridor (a harsh typically high-pitched vibrating/whistling noise during inhalation), a hoarse voice and/or a high-pitched cough (oftendescribed assoundinglike a barking seal)and/orotherbreathing problems.These symptoms are typically worse at night,andwhen the patient is agitated or anxious.Theyareusually mild, last three to five days and resolve on their own.However, if the symptoms become more severe (the child develops high-pitched noises during both inhalation and exhalation, they turn blue/gray around the nose/mouth/anywhere else, they struggle to breathe, they become listlessor they develop any other worrisome changes)they should be brought to medical careimmediately.

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Spasmodic croup(sometimes called recurrent croup as the child may get it multiple times)is due to non-infectiousupper airwayswelling due to edema (a fluid collection in the tissues which may be of an allergic or other etiology).Otherwise,itis similar toinfectious croup(although since it is not due to infection there is usually no fever).

Croup is very common, accounting forup to15% of visits to pediatric clinicsand 1% to 2%of visits to theemergency department.Overall, croup has a very good prognosis.Over85%-95%of children seen for croup can be discharged home after being treated. Of theless than5%-15%requiring hospitalization,only a tiny percentage (overall only 0.1%of all croup patients seen) are severe enough to require a breathing tube (intubation)for a machine to assist/breath for them. Of this very small number requiring intubation, less than one percent die (so less than 1 in 100,000 who were brought for medical evaluation).

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Kids with croup usually do not need any laboratory or imaging tests (although these may be ordered to rule out other possible causes of their symptoms).Instead, the severity of a childs croupisevaluatedbased ontheir symptoms, with some scoringsystemshaving been created to quantify the severity. One such system, the Westly croup severity score, assigns pointsper the clinicians assessmentas follows:

Treatment for mild croup usually includes supportive care such as over-the-counter medicationsfor fever, increased fluidsand keeping a close eye outto identify any worsening. Although cool mist/humidification has not been shown to significantly impact the disease, it also has not been shown tocause harm, and this home remedy is commonly used by many families.

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Moderate and severe croup will commonly be treated with steroid medications (a single dose of dexamethasone has been shown to be beneficial as it is thought to decrease inflammation), nebulized racemic epinephrine (which decreases spasm of the smooth muscles hence opening up theupperairways), oxygen as needed, and possiblyheliox(a mixture of helium and oxygen as opposed to normal air which is a mixture of nitrogen and oxygen, thought to help since helium is smaller than nitrogen and this mixture is thought to decrease the work needed to breath).

Patients,specifically includingthose treated with nebulized epinephrine,should be closely observed for at least 3 hours aftertheirtreatment even if theyhavegreatly improved, as sometimes therecanbea rebound of more severe symptoms when the treatments wear off.Patients whose symptoms are so severe that they cannot breatheon their own, although rare, may require intubation.

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If your child develops croup-like symptoms and you haveaconcernthatthey are not breathingwellyou should seek medical care immediately. If they are seen and discharged they will still need to be very closely monitored in case symptoms return and/or worsen.

Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com.

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What's Up Doc? COVID test is negative; barking cough and fever may mean toddler has croup - MetroWest Daily News