Few medical conditions in young children are as scary as Croup, maybe febrile convulsions are just as bad.But the sound of a seal barking in your son or daughter’s bedroom in the middle of the night can be extremely frightening.When those parents jump out of bed to check on their child, they may find it sitting upright in bed, pale or scared looking, holding their head and chin up, and you might see how their ribs are sucked in with every breath.It’s scary.
This condition will most likely be Croup.Croup is an inflammation and swelling of the anatomical structures around your child’s voicebox, and because in young children these structures are still quite narrow, with swelling form a virus infection it can get quite tight down there quite quickly, and the symptoms of Croup develop.
Here’s what a voicebox looks like :

What you see there is the voicebox, the white strings are the vocal cords, and the hole leads into your lungs, through the cartilage part directly below the cords, called the trachea, or windpipe.
What usually happens is that your child has just developed a bit of a cold, maybe a runny nose or a bit of a cough, and might have had a fever during the day, but has been otherwise well and eating and drinking just fine, before at some point, most often at night, the noisy breathing and barking cough develop.Croup is most often caused by the viruses that also cause the common childhood upper respiratory infections, so it happens more often in winter, or when the seasons change.
Most often this condition will last 3-5 days(and nights), and if your child is not distressed and just has a barking cough, a visit to your GP might be all that’s needed, and the body will eventually resolve the swelling when it gets over the infection.
If there is not only the sealy cough but also noisy breathing, and your child has to generate lots of negative pressure in their chest to suck air through the swollen cords(you can see that, they will indraw their chest and the visible part of the windpipe, sometimes up to half of their chest diameter), then you should either call an ambulance or take them straight to Hospital, for they might need medication to bring the swelling around the voicebox down rapidly with a nebulized drug called Adrenaline(Epinephrine).Usually your GP or the Hospital doctor will also prescribe some Cortisone for 2 or 3 days, to help reduce the swelling and symptoms of Croup.Very rarely does a child with Croup need to have their air passage protected, if that is necessary, an Anaesthetist will usually make the child go to sleep in an operating theatre and then pass a breathing tube through the swollen cords, the child is then kept asleep until the swelling subsides.
Most often Croup will be mild or moderate, and some Cortisone syrup for a couple days is all that’s needed, maybe with some Paracetamol or Ibubrufen for pain and fever.The few more severe cases might require some Adrenaline, and observation in Hospital for a few hours.But usually within 3-5 days it’s all resolved.There is not usually a need for blood tests, Xrays or antibiotics for clearcut Croup, even if there is a fever present.

Here is a video of a child with severe stridor(the noisy breathing bit)and marked chest retractions, the cause here is not croup but a vocal cord dysfunction, but the symptoms are the same(warning, the child is not too well by the looks of it, and some people may find this disturbing) :

Now, there are 2 conditions I have to mention because they may present similar to Croup but are caused by bacterial infections of the windpipe, or the cartilage that sits like a lid over the voicebox, the so-called epiglottis.These won’t respond to the usual Croup treatment, and almost always need blood tests, iv antibiotics, possibly an XRay of the neck, and/or protection of the airway with a breathing tube.
Inflammation of the epiglottis mediated by a bacterium called Haemophilus influenzae causes a disease called epiglottitis.That’s a life-threatening swelling of the lid that sits over the voicebox and protects the lungs from food and saliva. If it swells up, it can obstruct the air passage very quickly.This condition is now extremely rare in countries where children are routinely vaccinated against HIB, I’ve never seen one myself.Those kids are very quite, very pale, they don’t cough, they sit upright with their head forward, and they might drool from the mouth because they can’t swallow.This is an emergency, that needs a breathing tube and antibiotics through a drip, and in that order.

Here’s what that looks like (pic by Charles Gomersall, link to original is here):

You can see the breathing tube going through the vocal cords, and the big red swollen epiglottis above it.

The other condition that can present similar to Croup is called bacterial tracheitis and is an infection, with inflammation, of the windpipe, that lies beneath the vocal cords.Those kids can have stridor, they most often appear toxic and have a high fever.
In very young children, say under 6 months, an immature voicebox or windpipe can imitate Croup symptoms(no coughing though)and stridor, but this is not caused by infection, but by collapse of the air passage due to immaturity, mostly at night or when asleep.

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