Acute Laringo-Tracheo-Bronchitis
We have been seeing many children in the last few days with croup again. Croup is a viral infection of the upper airways. Children under 4 years of age are mostly affected. It can also occur in older children though. I’ve seen children get it up to 13 years of age.
Older children are less often affected, due to the larger diameter of their airways. The same amount of swelling in small diameter airways of younger children causes more obstruction to air flow than in that of older individuals with bigger air passages.
Typical croup is caused by the PARAINFLUENZA virus of which there are 4 serotypes.
Besides croup, these viruses can cause bronchiolitis and or pneumonia in children.
Classical Croup symptoms are a BARKING COUGH with or without fever and varying degrees of DIFFICULTY in BREATHING IN. The typical sound is called a STRIDOR and sounds as if something is stuck in the throat when choking. Their voices may also sound hoarse.
Children usually go to bed well and then wake the parents with a dry, barking cough and this stridor when inhaling. The typical time would be between 11 pm and 2 am. Croup is often better during the day and worse by night.
When your child starts breathing difficult it is a medical emergency and its best to take your child to the hospital’s emergency unit right away.
Between the house and the hospital some children’s symptoms may improve, due to the difference in temperature indoors and outdoors.
Croup is also called Acute Laringo-Tracheo-Bronchitis because it starts of as typical croup and then progresses to tracheitis and bronchitis over the next few days and as mentioned, sometimes even lower to the smallest airways causing bronchiolitis and pneumonia in infants.
Initially there would be the croup symptoms as described, but then the cough will change over the next few days as it progresses lower down. The initial dry cough will get progressively more phlegmy and wet and infants may even become wheezy and short of breath.
There may be other causes to this croup like symptoms that needs to be excluded by the attending doctor.
* Epiglottis, which is a bacterial infection of the epiglottis that closes of the airways when swallowing food. It is caused by bacteria that children nowadays get vaccinated against. Since the vaccine was introduced we do not see this very serious condition anymore. Unvaccinated children may still be susceptible, though children are acutely ill with very high fevers and salivation.
* Retro pharyngeal abscess.
* Foreign body inhalation.
* Laryngomalacia in younger children, usually since birth, but outgrows it with time. It could be aggravated by reflux.
* Cysts, polyps or cancerous growths of the upper airways. These usually causes chronic persistent croup symptoms.
* Anatomical abnormalities of the upper airways with compression from abnormally positioned blood vessels. These structural abnormalities would give symptoms since birth.
When a child develops a STRIDOR (high pitched sound when breathing in) with a dry, barking cough you need to take your child to the doctor or ER no matter what time of the day or night it is.
The doctor will access the degree of airways obstruction. There are 4 stages.
The main treatment for croup is to maintain an open airway.
Medical treatment in the form of oral or injectable cortisone and cortisone inhalations are usually very successful. In severe cases inhalations of Adrenalin would also be given.
In extremely severe cases children might need to have an airway tube put in through the nose or mouth or even need an emergency surgical procedure called a tracheostomy to open the airways.
Most children that are admitted during the night to the hospital would improve enough to be discharged the next morning.
The treatment started in hospital would then be continued at home for the next 3-5 days.
If you are in any doubt about your child’s condition or diagnosis, always rather consult a doctor as soon as possible.
I consider croup to be a true medical emergency when a child develops a stridor and breathing difficulties.

Dr Willem Smit


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