Recurrent Croup

Recurrent Croup

Once again, a common theme of the Morsels is a need for vigilance. Unfortunately, sometimes those seemingly straight forward cases of vomiting in fact are due to an Inborn Error of Metabolism and it requires our vigilance to make the diagnosis.  Many of us, however, also abide by the rule that “if it looks like a duck, walks like a duck, and quacks like a duck, then it is a duck.”  So what should we make of the patient who presents with what looks and sounds like croup, but it is recurrent?

Croup Basics

  • We have dealt with the common issue of Croup previously.
  • Croup caused by viral infection effecting the larynx, trachea, and/or bronchi.
  • Characterized by barking cough and stridor.
  • Can be associated with respiratory distress.
  • Typically seen during the Fall and Winter months.


Croup vs Recurrent Croup

  • Viral Croup is does not usually occur more than once (or twice) in a year in a otherwise healthy child.
  • Croup like symptoms that occur more frequently (>2 a year) have been called “Recurrent Croup.”
  • Essentially, recurrent croup is not due to a viral etiology and should be considered a RED FLAG for another condition.
  • Recurrent croup can be the presentation of underlying intrinsic or extrinsic airway narrowing.


  • Croup

    • Usually 1-2 episodes per year
    • Ages: 6 mos – 3 years with peak at 2 years
    • Usually short in duration (1-2 days)
    • Standard therapy usually treats the symptoms


  • Recurrent Croup

    • > 2 episodes per year
    • Any age.  Be suspicious of croup in a child < 6 months or > 3 years of age.
    • Relapsing and remitting course. Can persist over weeks.
    • Some or no response to standard therapy for croup.


Recurrent Croup – Some Causes to Consider

  • Airway
    • Subglottic stenosis
      • Congenital
      • Traumatic – from prior intubation
    • Subglottic cysts
    • Subglottic hemangioma
      • Look for hemangiomas on the child’s face, particularly the beard distribution.
    • Recurrent respiratory papillomatosis
    • Vocal cord paralysis
    • Tracheoesophageal fistula
    • Tracheomalacia
  • Others
    • Foreign Bodies
    • Congenital cardiovascular abnormality
    • Gastroesophageal reflux
    • Asthma / Allergy
    • Mediastinal mass


Timing of Stridor

  • Not everything works as planned… but listening to the timing of the stridor can help point toward potential cause.
  • Inspiratory
    • Supraglottic problem
    • Laryngomalacia is an example.
  • Expiratory
    • Tracheal pathology
    • Ex, compression from aberrant vascular structure.
  • Biphasic
    • Glottic or Subglottic problem
    • Subglottic stenosis or vocal cord paralysis are examples.


The Moral of the Morsel

  • If you are taking care of a child who is presenting with what appears to be croup, but this marks the 3rd or greater occurrence of it, then you are dealing with Recurrent Croup.
  • Recurrent Croup should be considered a RED FLAG for something that isn’t as simple as a viral illness (perhaps one of those needles of serious disease in the haystack of coughing).
  • Anatomic abnormalities have been reported in a significant proportion of patients with recurrent croup.
  • Have a lower threshold for checking plain films for possible foreign bodies.
  • Most, if not all, of these patients will require bronchoscopy by ENT to rule out anatomic abnormalities.




Joshi V1, Malik V2, Mirza O2, Kumar BN2. Fifteen-minute consultation: structured approach to management of a child with recurrent croup. Arch Dis Child Educ Pract Ed. 2014 Jun;99(3):90-3. PMID: 24231112. [PubMed] [Read by QxMD]

Rankin I1, Wang SM, Waters A, Clement WA, Kubba H. The management of recurrent croup in children. J Laryngol Otol. 2013 May;127(5):494-500. PMID: 23544702. [PubMed] [Read by QxMD]

Jabbour N1, Parker NP, Finkelstein M, Lander TA, Sidman JD. Incidence of operative endoscopy findings in recurrent croup. Otolaryngol Head Neck Surg. 2011 Apr;144(4):596-601. PMID: 21493242. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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21 Responses

  1. Jennifer says:

    My child is 7 years old. 8 years old n January. She has recurrent croup since birth. Is now having a bought. Treated with prednisoline.

    • Amanda says:

      My daughter is 7 years old. She was diagnosed with asthma at age 3. She has had recurrent croup since the age of two and now her pediatrician wants to have her evaluated by an ENT to make sure there is nothing structurally wrong with her airways. Fall and winter are peak months for the episodes of croup. Usually in the spring and summer months she does very well. Her doctor seems to be perplexed with her condition.

      • Michelle Albertson says:

        My son is 4 and has had reoccurring croup for several years. He has been to the ENT for airway test which came back fine. He has it all different seasons. His doctors are perplexed as well and have mentioned that he may have the type of asthma that demonstrates as purely cough (he doesn’t wheeze)

        • Sean Fox says:

          I hope your son begins to feel better very soon. Cough-Variant asthma is another good example of how not every illness is just like it is depicted in the medical text books.

  2. Laura says:

    My daughter is 11 years old and still gets recurrent croup requiring steroids, with many episodes each year. She is currently having an episode and had another about 3-4 months ago. It doesn’t appear to be seasonal as we live in Australia and summer is just ending with most days still in the high 30’s (degrees C). There is bushfire smoke in the air at the moment though, so I wonder if that has anything to do with it. This post has been very helpful and informative. It is clear recurrent croup at 11 is not normal and time we got it investigated properly. Will ask our doctor to refer to an ENT specialist.

    • Dru says:

      I also live in Australia and find my sons croup doesnt just happen in winter. Hes 4 now but has had several episodes. Everytime he gets taken to the ER and is given steriods.

  3. terri rybicki says:

    My son just turned 5 he has croup 3 times a year October ,February and march. Almost to the date since he has been 1. It’s appear to be when the weather switches from hot to cold and back to cold and hot drastically. Doctors can’t figure it out. Doesn’t appear to be asthma cause it only occurs in certain seasons. Same thing happens he has no symptoms and in the middle of the night starts barking and can’t breath. Do steroids and nebulizer for 3 days and than he’s good till the next season change.

  4. Keesha Asher says:

    My 5 year old son has had Croup 26 times and Strider 6 times in the past 30 months. We have treated him with prednisolone, sometimes decadron. He had a bronc scope in January, which did not reveal any anatomical issues. He was on Amoxicillin for a year to attempt to ward off any sinus infections. He was also on Prilosec for a year to treat any possible reflux. He is currently taking Delura (maintenance), Zyrtec, Abuterol when needed, Flonase, and Saline rinses. We have seen countless Pulmonologist, GI, Pediatrics, Holistic medicine doctors yet he still experiences Croup on a monthly basis. The only response I have received is “Hopefully he will grow out of it.” One over the counter medical that seems to help is Zarbee’s mucus reducer. Our next step is nutrient testing, retesting for allergies and attempting to start a gluten free diet.

    • Elizabeth C says:

      We are in the same boat. Specialist says son doesn’t have asthma, yet we have this ‘croup like cough’ about 1x month. Horrific coughing at night, usually triggered by a virus/ croaky voice. Treated with a one off prednisolone dose. Inhalers used but don’t always show improvement. Specialist thinks it’s just the aerosol asuch as anything giving relief. Had adenoids and tonsils out but nothing has changed.
      Specialist says he will grow out of it, fingers crossed. Interesting as he (doctor)does not believe that ‘cough variant asthma’ exists. Just a term that evolved.

  5. Kayla says:

    Interesting read! My son is now 7, almost 8, and gets croup 6+ times per year since he was 2. He has it now (second time this month!). He’s been to an ENT and his airway anatomy was ruled as normal. We use a nebulizer at home with albuterol solution. Doesn’t seem to help with strider, but improves his oxygen levels. So frustrating when he wakes up not being able to breathe in the middle of the night with no prior symptoms. Doctors say he will grow out of it. ??

    • Gina says:

      My daughter is 18 months and has had croup 5 times since birth. She has seen an ENT who did a scope and said she has reflux. She wants my daughter to have a bronchoscopy and laryngoscopy at the hospital which is an outpatient procedure but she has to have anesthesia so I am putting it off because my husband and I are to nervous to have her under like that. Has anyone had their child have any of these procedures? My daughter had croup again last night and it’s the first time she’s had it that she didn’t end up at the hospital im hoping it gets better but we will se what tonight brings.

      • Sean Fox says:

        Gina, I’m sorry your family has been dealing with this issues. As I note in the Morsel, “recurrent croup” really should make us think of other conditions that are not croup. Often this evaluation involves bronchoscopy and endoscopy. These procedures are done commonly. Make sure you discuss your questions and concerns with your doctors.

  6. veronica says:

    my son is almost 7 & has this recurring croup cough since he was born. he had two bronchoscopys leading to discovery of bronchialmalaysia, laryngeal Malaysia & a hernia as well as severe acid reflux. he has to be hospitalized & treated when he goes through his “episodes”. But somehow the pulmonologists the gastroenterologist and the ent all point to mucous asthma caused by acid travel up his esophogous creating the asthma. but that doesn’t explain the recurring croup. I get told He will grow out of it. he takes 8 medications a day one of them being erythromycin to help with stomachs empty (I was told) along with his acid reflux pills inhalers nose sprays and the isopropeum bromide med treatments. there must be something else causing all these children to be sick…

  7. Helena says:

    My 4 year old son has had croup 5 times since he was 18 months old, but three doses of croup meds have been given to him in the last 2 months. He has had a horrible dry cough every 30 secs-1 min the last 24 hours, and this cough has stayed with him the last five weeks. Have vicks on his chest / back / feet, given chinese herbal cough syrup Nim Jom a few times a night if it’s really bad, Advil on harsh nights, the cool mist humidifier is on max the last 5 weeks and very clean with colloidal silver added to the water, we do not have mold issues in the sills or his room, and he’s starting to look pale from crummy nights of waking up for two hours at a time and coughing incessantly. I am stuck of where to go next and could REALLY use some advice. ….See the doc and get a referral? I don’t now what else to do for him.

    • Gina says:

      Hi Helena,
      Have you brought him to see an ENT? I brought my daughter because the pediatrician referred me to one. They did a scope in the office and said she has reflux which might be the cause of the croup but they want her to have a bronchoscopy under anesthesia which my husband and I are not really comfortable with. She’s 20 months and has had croup 8 times, 5 of those which she had to be hospitalized. My advice to you would be to see an ENT maybe they can find out why your son gets it so much this way they can treat him accordingly. The ENT had given my daughter medicine to take daily for reflux and it seems to be helping. Also do you have a fireplace or wood stove? The doctor at the hospital last time I was there had told me never to put the fireplace on as it is not good for croup either and we had been putting it on a lot.

      • Helena says:

        I really appreciate your response, that’s what we’re going to do this morning. Take him and get him referred to the ear nose and throat doctor. It’s just ridiculous that his cough has gone on this long, last night was a couple three hour chunks of time where he was coughing nonstop for the whole three hours… It was really tough. We took him outside for cool air, gave him Benadryl and that helped him sleep the last couple of hours… But I’m also nervous on him getting anything invasive done. We do not have any wood stoves and fireplaces or anything that would provide smoke in the home, and his cool mist humidifier was on high and has been cleaned and added with colloidal silver as well… Just a frustrating scenario with him being so sick.

  8. Susy says:

    My daughter she just turn 2 years and have a cough for over 2 month, she was diagnosed with pneumonia and she still have the cough especially at night doctors said she might have asthma but I don’t think is that if anybody can help me I’m so frustrated

  9. Sylvia says:

    I finally feel like I’m not alone. My 5-year-old daughter just had 4th episode of croup in the last 8 months and 4 episodes of croup last year. She had her first croup just after starting a daycare at age of 4. She never had croup before starting a daycare. We had to take her to ER 3 times, twice last year and once this year. We took her to ENT and were told she would have to get bronchoscopy and endoscopy under full anesthesia, but like a lot of parents we are very concerned about such an aggressive procedure. Last week I went to another pediatrician and I mentioned that my daughter has acid reflux symptoms, especially before going to sleep. She would always complain about something in her throat and feeling like she is going to vomit when she is laying down at night. She also complained few times about her stomach feeling hot and she gets the hoarseness in her voice and clears her throat often. Additionally, she had cough 5 weeks straight. All these symptoms started after she went through severe stomach virus last year. The evening episodes gave her panic attacks and she was in my opinion misdiagnosed by her pediatrician as having Anxieties. We went through the counseling sessions which eliminated panic attacks, but she is still scared when she has the Acid reflux symptom at bed time. After hearing all this, the new doctor decided to put her on medication to treat the acid reflux for a month to possibly 3 months. She has been taking that medication for less than a week now, so it is very hard to say if this will resolve the problem or not. Additionally, we took her to the allergist and the skin test showed she is allergic to weeds and dust mites. We have washed and removed some of the carpets, bought new mattress, the pillow and hypoallergic mattress covers as well as the special vacuum that kills the dust mites and all the viruses and bacteria. She was on Zyrtec for over 2 month and 1 week after I stopped giving her Zyrtec she got croup again. She is back on Zyrtec. My hope is that with the allergy and acid reflux treatments she will discontinue having croup and we won’t have to put her through bronchoscopy and endoscopy. Let me just add these croup episodes are very different each time, sometimes they come as secondary effect after a cold or upper respiratory infection turning into stridor at night and some barky cough while other times it just starts with a stridor and then turns into cough and other cold symptoms. She has them different times of year. She has been treated with steroids each time.

    • Sylvia says:

      Yesterday I took my daughter to another ENT and she performed nasal endoscopy and confirmed inflammation of her voice box and throat area which supports the acid reflux. She prescribed Zantac in addition to Prevacid Solutab that my daughter has been taking for the last 3+ weeks. So now she is on Prevacid in the morning and Zantac at night. Additionally, the doctor recommended Nasacort at bedtime. I really hope this new treatment will completely eliminate the croup. I wish all of you moms that you find knowledgeable medical staff that can find the root cause of your child’s issues and will be able to implement treatment plan to help eliminate the croup.

  10. April Houston says:

    My son is 14 and has “chronic croup”. He had has first bought with it when he was 4 months old. He has always had boughts of it every 2-3 months year round. He was around 8 before he didn’t have to be admitted to the hospital for it…always 2 week stays under oxygen tent each time. His doctor swears that I am an expert and makes sure I have what he needs at home to treat him when it happens. He had it again last week and I’m worried it has turned into pneumonia…not common with him, the weather has been awful here lately. He has had so many test done when he was younger and the best answer we have received was that his is caused by acid reflux which is caused by stomach spasms….with no answer to what causes his stomach spasms. Also, the acid reflux caused his tracheomalacia. It doesn’t help that on top of that he has Autism/ADHD combined type, a vision impairment and now struggling with some hearing loss. I wish we could find a doctor that could help him.

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