This story is part of a series on parenting—from surveilling our teens to helping our kids navigate fake news and misinformation.
Twice last year I thought my children were about to die. The first episode took place one night in February. My 2-year-old daughter had been a little fussy before bed, but she wasn’t sick. In the early hours of the morning, though, she jerked awake with an awful sound—a wretched, desperate, wheezing inhalation that seemed to leave her nearly breathless. She couldn’t talk or answer questions; she only stared at us in panic. Within minutes we’d pulled on heavy coats and boots over our pajamas and rushed outside into the freezing rain. There’s an emergency department a few blocks from our house in New York City. I carried her there, gasping in my arms.
Nine months later, the same thing happened, more or less, on the night of Halloween. Our baby son—then just shy of 6 months old—woke up coughing in an eerie and unnatural way, as if he were blurting out a high-pitched syllable. I tried to be more calm this time, and fumbled with my phone for WebMD, to better understand whether our baby was in danger and if so to what degree. But it was very late. I was tired and confused. Again, we rushed to the hospital.
Both nights the diagnosis was the same: Our kids had croup—that blight on children under 5 (and almost no one else). The word itself can be a shibboleth for parents. If you’d mentioned croup to me not long ago, before my kids were born, I’d have thought it was an antiquated term, one of those conditions that has either been renamed by modern medicine or vaccinated into history—an exhibit in the same museum as pleurisy or dropsy or catarrh. But now that I’m a grown-up, and looking after a pair of tiny tracheas, I know croup to be a very modern, terrifying syndrome: A seizing of a child’s respiratory tract, often coming on at night, and manifesting as a queer distress. Your kid with croup may start coughing like a wounded seal; she may wheeze or make a grating sound while breathing in; and the skin around her ribs and chest could well retract with every breath. In short, it will appear as though your baby’s throat is closing up. It will seem to you that she’s on the verge of suffocation.
In fact, she’s not. Croup is mostly harmless. No one has made a careful tally of its mortal cost (in part because the victims are so few), but we have some expert guesswork. One official writeup in the journals pegs the rate of death from croup at 0.0001 percent, which is to say: 1 case in a million. Perhaps more realistic (but still not that dire) is an estimate from the University of Calgary professor and noted croup scholar David W. Johnson: He and his colleagues have presumed, through what he told me was a process of “smoking a cigar and waving it” and “an extrapolation from an extrapolation,” that 1 in 30,000 child-patients dies from the condition. (That’s about one-half the rate of death among infants and toddlers who get the flu.)
The rest, broadly speaking, are just fine.
These numbers make me wonder at the choices that I made on those scary nights last year. Did we really need to rush our children to the hospital? Both times the doctors told us it was “good” that we’d come in; both times our kids were given treatment, the steroid dexamethasone. (My daughter also got an epinephrine spray.) Then both times a heavy dose of billing followed: Several thousand dollars for each visit. The cost was a major insult to our budget and our bank account; and I gather the dangers we staved off were rather shrimpy.
Croup hasn’t always taken such a meager toll, of course. In the old days, when the illness was still described with the (as in “this child has the croup”), its course was understood to be quite grave. Francis Home, a Scottish doctor, was the first to make a careful study of this disease that “had entirely escaped all regular examination;” his inquiry, from 1765, warned readers that the croup “is silent in its progress, and gives no visible alarm, till death is near at hand.” Victorian physicians concurred with Home on the perils of the croup’s “stealth invasion,” and traced its march from what seemed to be a common cold to a deadly culmination: “The lips and nails become blue, every respiratory muscle seems to exert its utmost power to obtain the required air, … the veins of the face and neck become prominent, and a profuse perspiration bursts from every pore.” British records from the 1860s blame the croup for killing 1 toddler out of each 6,000.
But croup can come in many forms, some far deadlier than others. (The word croup describes a set of symptoms, not their cause.) For centuries, children’s barky coughs arose from infections with measles or diptheria; from time to time those kids would die. In the present day, with the benefit of modern vaccinations, these types of croup are very rare. Now, the condition is very often caused by parainfluenza virus, a source of mild respiratory ailments.
The treatments are better now, too. In the 19th century, a croupy child would have been dosed with emetics and forced to vomit up to half a dozen times per day. (This was meant to clear the mucus from his throat.) Other kids were given mercury and opium, or risky tracheotomies. Most common were prescriptions for moist air, delivered from a “croup-kettle.” This last approach was common through at least the 1980s and still shows up on websites telling parents how to handle croup. In truth, it may not help at all. Now the standard therapy is a single dose of corticosteroids, to tamp down inflammation of the larynx, which constricts the airway. Kids are given epinephrine when the croup is more severe.
Still it’s not at all an academic question, or a stingy one, to ask whether croupy kids ought to go to the ER. The total cost of this condition—I mean its dollar-value in the aggregate, for hospitals and parents and insurance companies—turns out to be immense. In the US, more than 18,000 kids (most below the age of 2) are admitted to the hospital for croup every year, at a cost of $121 million. That’s just a fraction of the medical-croupial complex, though. Inpatient admission for croup is very rare; it represents no more than 3 or 4 percent of cases seen by clinicians. Most kids, like mine, make it only so far as the emergency department. National data sets suggest such cases number at least 350,000 per year. (These arise most often in mid-autumn of odd-numbered years, when parainfluenza circulates most readily.) If the medical bills I paid were representative, then the annual cost of all these visits, to parents and insurers, would amount to roughly $875 million.
Emergency care is a source of massive overspending, overall: It’s said that two-thirds of all visits to the ER may be avoidable. But even taken in this broader context, croup appears to be a suck on clinicians’ time and resources. According to the University of Calgary’s David Johnson, one-quarter to one-third of all kids who come into an emergency department are suffering from some form of respiratory distress; and he guesses that croup specifically accounts for 3 to 5 percent of all ER visits by children.
Yet as we’ve seen, the number of kids who die from croup is minuscule; and just a tiny fraction are deemed to be in any danger whatsoever. Kirsten Bechtel of the Yale University School of Medicine told me that she’d worked as a pediatric emergency physician for 24 years. In all that time, she said, she saw maybe 10 instances of croup—out of “thousands” in all—in which the child appeared to be in real trouble, with slowed respiration and signs of cyanosis. One of Johnson’s studies in Alberta found that about 85 percent of kids who show up with croup at general emergency departments turn out to have a “mild” form of the condition. Less than 1 percent have symptoms labeled as “severe.”
Thinking back on my own experience, it’s pretty clear my son had mild croup; my daughter’s case may have been classed as “moderate.” In any case, Johnson says his research finds that croup doesn’t tend to worsen over time: If your kids start off with mild symptoms, they’ll likely stay that way and clear up on their own.
Still, it’s often treated quite aggressively by doctors. A study published last year put some numbers to the problem. The authors pointed out that three kids with croup are admitted to the hospital for every one whose case might be “severe.” More than 27 percent of all croup patients receive a spritz of epinephrine, though this is only indicated for about 15 percent. Another one-fifth of children receive a chest x-ray, which tends to be of little value. One in eight are put on antibiotics, despite the fact that croup is almost always viral.
Johnson agreed that these are problems, especially the overuse of x-rays and antibiotics. But he wasn’t really worried by the fact that, according to this study, three-quarters of all kids who show up at the ER with croup are given dexamethasone. The treatment helps even those with mild symptoms, Johnson said. According to his research, a single dose can halve the odds of their return to the ER; it also seems to save parents from some stress and sleep loss.
But it seems to me that many of those kids and parents might have gotten a similar benefit from a simple conversation. I thought back to my interactions with the triage nurse at the ER. She’d seemed a little bored. What if she’d sent us home right there and then, maybe with some tips to calm us down? I’m sure that if she’d run us through the stats on croup—if she’d told us that it’s almost never truly dangerous, that it resolves itself and rarely worsens over time—the conversation would have eased our sleep in the absence of any medicine. More to the point, we could have skipped the foofaraw with the ER doctors. (If I hadn’t been so addled by the wheezing, and so afraid my child’s time was running out, I might have gotten this advice by phone. Our pediatrician’s office has a nurse on call to do just this.) So I asked Johnson: Is it possible that a talking-to would be effective, too—and keep ER visits to a minimum?
Johnson agreed this might be useful, but he noted it would take a large, randomized trial to be sure of the effect. In the meantime, though, there’s every reason to continue treating kids at the ER with dexamethasone. It spares them some discomfort, and the side effects are negligible. A single dose, he added, “costs pennies, even in the US.”
I’d seen the tab; he was (sort of) right. The dexamethasone my daughter got was billed at $2.86. But that was just the medicine. The hospital also charged us for its doctors’ time and judgment—their “medical decision making of moderate complexity,” to be specific—and did so at a rate of $4,572 on the first visit and $6,151 for the second. Even though my wife and I are privileged to have insurance, even though our kids were seen in-network, and even though their ailments were both banal and non-life-threatening, we still ended up more than $3,000 in the hole. When I told Johnson this, the Canadian was dumbfounded. “Holy mackerel,” he said. “Holy mackerel!”
Yet it isn’t hard to understand why this boondoggle would persist, and will persist, no matter what we do. Croup is the perfect vector for anxiety and overzealous care. It comes on when you’re half-asleep. If you’ve heard of croup, you may think you know what’s going on, that it’s nothing serious, that it isn’t worth your feeling panic. You may even understand that a nervous atmosphere could only make your child’s symptoms worse. But in those groggy moments, your reasoning will shrink into the shadows of the terrifying symptoms, or get drowned out by their din: Your baby’s throat is closing up; she’s barking in the night.
One could certainly lay some blame for croup’s overtreatment on the bloat and bad incentives of our health care system. But I think there is another, deeper source of the dysfunction: The bloat and bad incentives of a parent’s dread. Babies are, if nothing else, nonstop engines for “decision making of moderate complexity”: Is my little guy really in distress, or was that just a baby’s fart? Or maybe he’s farting in a way that means he’s in distress? My parental brain is always searching for an equipoise of these intense emotions: a balance between sanity and neediness and caution. At times it feels like placing bets: Yeah, I think my kid is fine—I’m pretty sure she won’t fall off that jungle gym, or that it wouldn’t be that bad even if she did. But how sure is pretty sure? And what if she’s at some teeny-tiny risk of a genuine catastrophe? Am I prepared to stake her life, my darling n-of-1, against those odds?
It’s midnight and your baby’s gasping. How sure are you that she’s OK? There isn’t time to think. You go to the ER.
And then your baby’s fine.
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