Q&A: Nasty cough
My one year old has a nasty cough. It sounds like a bark and gets worse during the night. What causes this? Is it serious, and how can I help him?
DR JACO STRAUSS ANSWERS:
This is a condition we generally see in young children in the autumn as well as in the early winter months. You will know it as croup – or, as your doctor will call it, laryngotracheitis (or the more severe form, laryngotracheobronchitis). It is an acute inflammatory disease that results in the swelling of the voice box (larynx), windpipe (trachea) and bronchial tubes (bronchi).
It is mostly caused by the parainfluenza virus but can also be caused by respiratory syncytial virus, human metapneumovirus, influenza virus, rubella virus/measles and mycoplasma pneumonia. It spreads by airborne respiratory droplets, touching a contaminated surface, by skin-to-skin contact or saliva.
It usually starts with upper respiratory tract symptoms, such as a runny nose (rhinorrhoea), hoarseness of the voice (pharyngitis), a mild cough and a lowgrade temperature for about one to three days before the signs of upper airway obstruction may become apparent. Your child will then develop the characteristic “barking” cough, hoarseness and inspiratory stridor. The low-grade fever may be persistent, although temperatures may reach 39 to 40° Celsius. Some children stay afebrile, which means they don’t have fever. Symptoms are characteristically worse at night and often return, less severely for several days. It will resolve within a week. Patients with even mild disease may have stridor when agitated. Most young patients with croup will only progress as far as stridor and will have slight difficulty breathing before they start to recover. Older children are usually not seriously ill. The obstruction, however, can worsen, and you will then get stridor at rest, accompanied in severe cases by retractions, air hunger and cyanosis, or blue discolouration of the tongue and lips, or being very pale. If this is what you’re seeing, immediate attention is needed. Croup is diagnosed by a doctor, who might request a lateral neck X-ray to be sure. What we look out for is a narrowing of the airway such that the air column looks like a church steeple or pitched roof – when we see this, we know croup is a strong possibility. The X-ray can also exclude the presence of a laryngeal or esophageal foreign body, food or something the child swallowed that got stuck.
No blood will be taken, as it will be of no help and might worsen the symptoms of the child.
The mainstay of treatment for the child with croup is airway management. Viral croup will be treated based on the symptoms. In mild cases, signified by the barking cough and no stridor at rest, we will only administer supportive treatment such as paracetamol for the fever and oral hydration. Remember, antibiotics will not help. We can give Acyclovir for the child with herpes stomatitis and who had measles. We will also treat your child with a single dose of prednisone or dexamethasone. The latter will decrease the swelling in the larynx’s mucus membranes through their anti-inflammatory action. Glucocorticoids should not be administered to children with chickenpox and tuberculosis and will worsen the clinical course.
Patients with stridor at rest will require more active interventions such as oxygen. They will also be nebulised with adrenaline, and that will lead to a rapid onset of action within 10 to 30 minutes. If the symptoms resolve within three hours of glucocorticoids and nebulised adrenaline, your child will be discharged. If recurrent nebulised adrenaline treatments are required, or if respiratory distress persists, your child will need hospitalisation for supportive care, close observation and nebulisation treatment.
In patients with impending respiratory failure, an airway must be established. This will be done in the form of an artificial airway. A tube going into the windpipe will save your child. In severe cases, a tracheotomy may be necessary. In most cases, the child will improve within a week.
My take home message for you will be, if you are worried, please take your child to the nearest casualties to be checked, as croup can be a very mild disease – or even life threatening. ●