Croup

The term croup does not refer to a single illness, but rather a group of conditions involving inflammation of the upper airway that leads to a cough that sounds like a bark, particularly when a child is crying.

Most croup is caused by viruses, but similar symptoms may occasionally be caused by bacteria or an allergic reaction. The viruses most commonly involved are parainfluenza virus (accounting for most cases), adenovirus, respiratory syncytial virus, influenza, and measles.

Most children with viral croup are between the ages of 3 months and 5 years old. Croup is most likely to occur during the fall, winter, and early spring, and symptoms are most severe in kids younger than 3 years of age.

Most cases of croup due to viruses are mild and can be treated at home, though rarely it can be severe and even life-threatening. Some kids are more prone to developing croup, especially those who were born prematurely or with narrowed upper airways, and babies with a history of breathing problems like asthma.

The term spasmodic croup refers to a condition similar to viral croup, except that there are few accompanying symptoms of an infection. The cough frequently begins at night with a sudden onset and is often recurrent. The child usually has no fever with spasmodic croup. The symptoms are treated the same for either form of croup.

Signs and Symptoms

Croup is characterized by a loud cough that may sound like the barking of a seal and may be accompanied by fast or difficult breathing and sometimes a grunting noise or wheezing while breathing.

At first, a child may have cold symptoms like a stuffy or runny nose for a few days and may also have fever. As the upper airway (the lining of the windpipe and the voice box) becomes progressively inflamed and swollen, the child may become hoarse, with a harsh, barking cough.

If the upper airway becomes swollen to the point where it is partially blocked off, it becomes even more difficult for a child to breathe. This happens with severe croup. With severe croup, there may be a high-pitched or squeaking noise when breathing in (this is called stridor). A child will tend to breathe very fast, and the stomach or the skin between the ribs may seem to pull in during breathing since he or she is working hard to get air in to the lungs. The child may also appear pale or bluish around the mouth from not getting enough oxygen. These are signs that a child needs immediate medical attention.

Symptoms of croup often worsen at night and when the child is upset or crying. In addition to the effects on the upper airway, the infections that cause croup can result in inflammation further down the airway, including the bronchi (breathing tubes) and the lungs.

Contagiousness

Croup tends to occur in outbreaks in the fall, winter, and early spring when the viruses that usually cause it peak. Many kids who come in contact with the viruses that cause croup will not get croup, but will instead have symptoms of a head cold. The viruses that cause croup can be passed when someone coughs or sneezes.

Diagnosis

Doctors can usually diagnose croup by looking for the telltale barking cough and stridor, the squeaking sound on inhaling. They will also check for fever, cold symptoms (like a runny nose), or a recent viral illness, and ask questions to find out if the child has a prior history of croup or upper airway problems.

If croup is severe and slow to respond to treatment, a neck X-ray may also be taken to rule out any other reasons for the breathing difficulty, such as a foreign object lodged in the throat or epiglottitis (an inflammation of the epiglottis, the flap of tissue that covers the windpipe). Typical findings on an X-ray if a child has croup includes the top of the airway narrowing to a point, which doctors call a steeple sign.

Treatment

Most, though not all, cases of viral croup are mild. Breathing in moist air seems to relieve many of the symptoms. Doctors will also sometimes treat with steroids, which helps with the airway swelling.

One way to humidify the air is with a cool-mist humidifier. Having your child breathe in the moist air through the mouth will sometimes break a croup attack. Or try running a hot shower to create a steam-filled bathroom where you can sit with your child for 10 minutes. While sitting in the bathroom (but outside of the shower), try cuddling and reading a bedtime story to help calm your child.

Sometimes, during cooler months, taking your child outside for a few minutes can help break the attack because the cool air can shrink the swollen tissues lining the airway. Parents can also try driving the child in the car with the windows down to bring in cool air.

If your child has croup, consider sleeping overnight in the same room to provide close observation. If your child is breathing quickly, working hard to breathe, has any stridor, seems less alert than usual, or seems to be worsening in any way, seek medical attention immediately.

Medical professionals will need to evaluate your child if the croup appears serious or if there's any suspicion of airway blockage or bacterial infection. Medications such as epinephrine or corticosteroids may be given to reduce swelling in the upper airways. Oxygen may also be given, and sometimes a child with croup will need to remain in the hospital overnight for observation and further treatment. As with most illnesses, rest and plenty of fluids are recommended.

Duration

The symptoms of croup generally peak 2 to 3 days after the symptoms of infection start. Croup resulting from viral infection usually lasts less 3 to 7 days.

Complications

The vast majority of kids recover from croup with no complications. Rarely, some will develop complications like pneumonia.

Children who were born prematurely or who have a history of breathing problems or lung disease (such as asthma) are more likely to develop severe symptoms of croup and may require hospitalization. Croup rarely causes any long-term complications.

Prevention

Frequent hand washing and avoiding contact with people who have respiratory infections are the best ways to reduce the chance of spreading the viruses that cause croup.

When to Call the Doctor

Immediately call your doctor or seek medical attention if your child has any of the following symptoms:

• difficulty breathing, including rapid breathing, belly sinking in while breathing
• the skin between the ribs pulling in with each breath
• stridor
• pale or bluish color around the mouth
• drooling or difficulty swallowing
• greater inactivity than usual when ill or less alert than usual
• high fever
• very sick appearance
• seems to be getting worse

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Bronchiolitis

Bronchiolitis is a common illness of the respiratory tract caused by an infection that affects the tiny airways, called the bronchioles, that lead to the lungs. As these airways become inflamed, they swell and fill with mucus, making breathing difficult.

Bronchiolitis:

• most often affects infants and young children because their small airways can become blocked more easily than those of older kids or adults
• typically occurs during the first 2 years of life, with peak occurrence at about 3 to 6 months of age
• is more common in males, children who have not been breastfed, and those who live in crowded conditions

Day-care attendance and exposure to cigarette smoke also can increase the likelihood that an infant will develop bronchiolitis.

Although it's often a mild illness, some infants are at risk for a more severe disease that requires hospitalization. Conditions that increase the risk of severe bronchiolitis include prematurity, prior chronic heart or lung disease, and a weakened immune system due to illness or medications.

Kids who have had bronchiolitis may be more likely to develop asthma later in life, but it's unclear whether the illness causes or triggers asthma, or whether children who eventually develop asthma were simply more prone to developing bronchiolitis as infants. Studies are being done to clarify the relationship between bronchiolitis and the later development of asthma.

Bronchiolitis is usually caused by a viral infection, most commonly respiratory syncytial virus (RSV). RSV infections are responsible for more than half of all cases of bronchiolitis and are most widespread in the winter and early spring. Other viruses associated with bronchiolitis include rhinovirus, influenza (flu), and human metapneumovirus.

Signs and Symptoms

The first symptoms of bronchiolitis are usually the same as those of a common cold:

• stuffiness
• runny nose
• mild cough
• mild fever

These symptoms last a day or two and are followed by worsening of the cough and the appearance of wheezes (high-pitched whistling noises when exhaling).

Sometimes more severe respiratory difficulties gradually develop, marked by:

• rapid, shallow breathing
• a rapid heartbeat
• drawing in of the neck and chest with each breath, known as retractions
• flaring of the nostrils
• irritability, with difficulty sleeping and signs of fatigue or lethargy

The child may also have a poor appetite and may vomit after coughing. Less commonly, babies, especially those born prematurely, may have episodes where they briefly stop breathing (this is called apnea) before developing other symptoms.

In severe cases, symptoms may worsen quickly. A child with severe bronchiolitis may tire from the work of breathing and have poor air movement in and out of the lungs due to the clogging of the small airways. The skin can turn blue (called cyanosis), which is especially noticeable in the lips and fingernails. The child also can become dehydrated from working harder to breathe, vomiting, and taking in less during feedings.

Contagiousness

The infections that cause bronchiolitis are contagious. The germs can spread in tiny drops of fluid from an infected person's nose and mouth, which may become airborne via sneezes, coughs, or laughs, and also can end up on things the person has touched, such as used tissues or toys.

Infants in child-care centers have a higher risk of contracting an infection that may lead to bronchiolitis because they're in close contact with lots of other young children.

Prevention

The best way to prevent the spread of viruses that can cause bronchiolitis is frequent hand washing. It may help to keep infants away from others who have colds or coughs. Babies who are exposed to cigarette smoke are more likely to develop more severe bronchiolitis compared with those from smoke-free homes. Therefore, it's important to avoid exposing children to cigarette smoke.

Although a vaccine for bronchiolitis has not yet been developed, a medication can be given to lessen the severity of the disease. It contains antibodies to RSV and is injected monthly during peak RSV season. The medication is recommended only for infants at high risk of severe disease, such as those born very prematurely or those with chronic lung disease.

Incubation

The incubation period (the time between infection and the onset of symptoms) ranges from several days to a week, depending on the infection causing the bronchiolitis.

Duration

Cases of bronchiolitis typically last about 12 days, but kids with severe cases can cough for weeks. The illness generally peaks on about the second to third day after the child starts coughing and having difficulty breathing and then gradually resolves.

Professional Treatment

Fortunately, most cases of bronchiolitis are mild and require no specific professional treatment. Antibiotics aren't useful because bronchiolitis is caused by a viral infection, and antibiotics are only effective against bacterial infections. Medication may sometimes be given to help open a child's airways.

Infants who have trouble breathing, are dehydrated, or appear fatigued should always be evaluated by a doctor. Those who are moderately or severely ill may need to be hospitalized, watched closely, and given fluids and humidified oxygen. Rarely, in very severe cases, some babies are placed on respirators to help them breathe until they start to get better.

Home Treatment

The best treatment for most kids is time to recover and plenty of fluids. Making sure a child drinks enough fluids can be a tricky task, however, because infants with bronchiolitis may not feel like drinking. They should be offered fluids in small amounts at more frequent intervals than usual.

Indoor air, especially during winter, can dry out airways and make the mucus stickier. Some parents use a cool-mist vaporizer or humidifier in the child's room to help loosen mucus in the airway and relieve cough and congestion. If you use one, clean it daily with household bleach to prevent mold from building up. Avoid hot-water and steam humidifiers, which can be hazardous and can cause scalding.

To clear nasal congestion, try a bulb syringe and saline (saltwater) nose drops. This can be especially helpful just before feeding and sleeping. Sometimes, keeping the child in a slight upright position may help improve labored breathing. Give acetaminophen to reduce fever and make the child more comfortable.

When to Call the Doctor

Call your doctor if your child:

• is breathing quickly, especially if this is accompanied by retractions or wheezing
• might be dehydrated due to poor appetite or vomiting
• is sleepier than usual
• has a high fever
• has a worsening cough
• appears fatigued or lethargic

Seek immediate help if you feel your child is having difficulty breathing and the cough, retractions, or wheezing are getting worse, or if his or her lips or fingernails appear blue.

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Adenovirus

Adenoviruses — a group of viruses that infect the membranes (tissue linings) of the respiratory tract, the eyes, the intestines, and the urinary tract — account for about 10% of acute respiratory infections in children and are a frequent cause of diarrhea.

Adenoviral infections affect infants and young children much more frequently than adults. Child-care centers and schools sometimes experience multiple cases of respiratory infections and diarrhea that are caused by adenovirus.

Although these infections can occur at any time of the year, respiratory tract disease caused by adenovirus is more common in late winter, spring, and early summer. However, conjunctivitis and pharyngoconjunctival fever caused by adenovirus tend to affect older kids mostly in the summer.

The majority of the population will have experienced at least one adenoviral infection by age 10. Although adenoviral infection in kids can occur at any age, most take place in the first years of life. Since there are many different types of adenovirus, repeated adenoviral infections can occur.

Signs and Symptoms

Depending on which part of the body is affected, the signs and symptoms of adenoviral infections vary:

Febrile respiratory disease, which is an infection of the respiratory tract that includes a fever, is the most common result of adenoviral infection in children. The illness often appears flu-like and can include symptoms of pharyngitis (inflammation of the pharynx, or sore throat), rhinitis (inflammation of nasal membranes, or a congested, runny nose), cough, and swollen lymph nodes (glands). Sometimes the respiratory infection leads to acute otitis media, an infection of the middle ear. Adenovirus often affects the lower respiratory tract as well, causing bronchiolitis, croup, or viral pneumonia, which is less common but can cause serious illness in infants. Adenovirus can also produce a dry, harsh cough that can resemble whooping cough (pertussis).

Gastroenteritis is an inflammation of the stomach and the small and large intestines. Symptoms include watery diarrhea, vomiting, headache, fever, and abdominal cramps.

Urinary tract infections can cause frequent urination, burning, pain, and blood in the urine.

Eye Infections:

• Conjunctivitis (or pinkeye) is a mild inflammation of the conjunctiva (membranes that cover the eye and inner surfaces of the eyelids). Symptoms include red eyes, discharge, tearing, and the feeling that there's something in the eye.
• Pharyngoconjunctival fever, often seen in small outbreaks among school-age children, occurs when adenovirus affects both the lining of the eye and the respiratory tract. Symptoms include very red eyes and a severe sore throat, sometimes accompanied by low-grade fever, rhinitis, and swollen lymph nodes.
• Keratoconjunctivitis is a more severe infection that involves both the conjunctiva and cornea (the transparent front part of the eye). This type of adenoviral infection is extremely contagious, and occurs most often in older children and young adults, who complain of red eyes, photophobia (discomfort of the eyes upon exposure to light), tearing, and pain.

Contagiousness

Adenovirus is highly contagious, as indicated by the occurrence of multiple cases in situations of close contact, such as child-care centers, schools, hospitals, and summer camps.

The types of adenovirus that cause respiratory and intestinal infections spread from person to person through respiratory secretions (coughs or sneezes) or fecal contamination. Fecal material can be ingested through contamination of water supplies, poor hand washing between the bathroom and the kitchen, eating food contaminated by houseflies, or poor hygiene after handling diapers.

A child might also pick up the virus by holding hands or sharing a toy with an infected person. Indirect transmission can occur through exposure to the contaminated surfaces of furniture and other objects.

The types of adenovirus causing conjunctivitis may be transmitted by water (in lakes and swimming pools), by sharing contaminated objects (such as towels or toys), or by touch.

Once a child is exposed to adenovirus, symptoms can develop from 2 days to 2 weeks later.

Treatment

Adenoviral illnesses often resemble certain bacterial infections, which can be treated with antibiotics. But antibiotics don't work against viruses. To diagnose the true cause of the symptoms so that proper treatment can be prescribed, your doctor may want to test a sample of respiratory or conjunctival secretions, a stool specimen, or blood or urine sample — depending on what condition is being considered.

The doctor will decide on a course of action based on your child's condition. Adenoviral infections usually don't require hospitalization. However, infants and young children may not be able to drink enough fluids to replace what they lose during vomiting or diarrhea and may therefore need to be hospitalized to correct or prevent dehydration. Also, young — especially premature — infants with pneumonia usually need to be hospitalized.

In most cases, a child's body will get rid of the virus over time. Because antibiotics are of no use in treating a viral infection, you should simply try to make your child more comfortable.

If your child has a respiratory infection or fever, getting plenty of rest and taking in extra fluids is essential. A cool-mist humidifier (vaporizer) may help loosen congestion and make your child more comfortable. Be sure to clean and dry the humidifier thoroughly each day to prevent bacterial or mold contamination. If your child is under 6 months old, you may need to clear his or her nose with a bulb syringe.

Don't give any over-the-counter (OTC) cold remedies or cough medicines without checking with your child's doctor. You can use acetaminophen to treat a fever; however, do not give aspirin because of the risk of Reye syndrome, a life-threatening illness.

If your child has diarrhea or is vomiting, increase fluid intake and check with the doctor about giving an oral rehydration solution to prevent dehydration.

To relieve the symptoms of conjunctivitis, use warm compresses and a topical eye ointment or drops if your doctor recommends them.

Duration

Most adenoviral infections last from a few days to a week. Severe respiratory infections may last longer and cause lingering symptoms, such as a cough. Pneumonia can last anywhere from 2 to 4 weeks.

In cases of pharyngoconjunctival fever, sore throat and fever may disappear within a week, but conjunctivitis can persist for another several days to a week. The more severe keratoconjunctivitis can even last for several weeks. Adenovirus can also cause diarrhea that lasts up to 2 weeks, which is longer than other viral diarrheas.

Prevention

There's no way to completely prevent adenoviral infections in kids. To reduce the risk of transmission, parents and other caregivers should encourage frequent hand washing, keep shared surfaces such as countertops and toys clean, and remove children with infections from group settings until symptoms subside.

When to Call the Doctor

Most of these adenoviral conditions and their symptoms are also associated with other causes. Call your doctor if:

• a fever continues more than a few days
• symptoms seem to get worse after a week
• your child has breathing problems
• your child is under 3 months old
• any swelling and redness around the eye becomes more severe or painful
• your child shows signs of dehydration, such as appearing tired or lacking energy, producing less urine or tears, or having a dry mouth or sunken eyes

Remember that you know your child best. If he or she appears to be severely ill, don't hesitate to call your doctor right away.

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