Update: The Chronic Cough in Children online course is now available. Learn more here.
As a Pediatric ENT, I have seen countless toddlers, preschoolers and even school-aged kids with recurrent “croup.” These are usually medically healthy kids (born full term, no premature lungs, never been intubated or had a breathing tube in the throat, no complex heart conditions, etc.), yet these kids may have many "episodes" that can be scary.
After years of asking what kids eat and drink, and their bedtime snacking routine (if they have one), I figured out what they didn’t teach in medical school: not all croup is viral tracheobronchitis or related to a kid being sick! In fact, so many healthy young children have these attacks from acid reflux and they don’t have a virus. Instead the backwash of undigested stomach contents cause their larynx (voice box) to have a “Charley Horse” or “laryngospasm” and they breathe in hard and have a hard time getting air in. When I ask details about the episode, often parents are adamant their kid was not sick that day—no cold, runny nose or fever before the middle of the night event! Of course, parents will rush their croupy kid to a hospital emergency room. Hundreds of thousands of children are seen in the ED every year, as often as 8 - 10 times per year! Thankfully these kids are usually better quickly, after getting racemic epinephrine if needed, nebulized albuterol and I guarantee they will also get steroids, which are known to “decrease swelling.” Some of my patients have been prescribed a bottle of oral steroids that their parents/caregiver keeps in the fridge!
Having developed my career epiphany over 15 years by asking what children eat and drink, and their bedtime routines, I noticed something many children with recurrent croup have in common: a love of excessive sugary drinks and/or dairy, and often times they also have a bedtime snack or milk routine.
I have performed many airway endoscopies on children for recurrent croup. Most of them have normal airway anatomy and I can’t find any “narrowing” in their subglottis, an area below the vocal cord where the cartilage is a complete “ring” and unforgiving. The medical teaching is that there is narrowing of the airway due to swelling of the mucous membrane in the subglottis, which then decreases the cross-sectional area of the airway. Then, during a violent cough, air is being rushed through that narrowed circular area resulting in a seal like “bark.” I have always believed that most likely these attacks are actually a “laryngospasm” or “Charley Horse” of children’s larynx or voice box. The voice box will protect us from having food, beverages, stomach contents and anything that is not air, from going in. Anytime the mucosa or mucous membrane lining of the voice box senses any sensation of something about to enter, a cough will occur to make sure that our windpipe and lungs are kept free of anything other than air. This is how our bodies protect us.
After interviewing countless families about what their “croupy” child eats and drinks day-to-day, here is what almost all of these children have in common:
1. A love of Chocolate Milk!
This is the ultimate in the “Milk and Cookie Disease" as there is at least 25 grams of sugar per 8oz serving of chocolate milk, low fat or not. Most of these patients will drink it at least once per day, often 2 - 3 times with school lunches, then at home, and especially in the evenings and before bed! The milk and dairy become more acidic as they sit in the stomach and curdle, and the high sugar content breaks down into acid. This will make anyone “upchuck” a little into the throat, which I believe triggers the laryngospasm. (PS, strawberry milk is also bad.)
2. A love of JUICE!
Every day I share with families what they have never been told, it seems, that the American Academy of Pediatric national guidelines recommend no more than 4 - 6 oz of juice in a single day for kids ages 2 - 6. Parents have taught me that most American children consume WAY MORE than 4oz of juice per day! Apple juice, white grape or grape juice are a FAVORITE! These are incredibly high in sugar, therefore becomes highly acidic in the stomach. Juice throughout the day, at night and after dinner/before bed pretty much guarantees your child will have acid reflux and risk of croup.
SUGAR CONTENT IN BEVERAGES YOUR CHILD DRINKS
Apple juice: One 8oz glass of Motts 100% Apple Juice has 27.8 grams of sugar! Yes, the label stating that its 100% juice, or any other brand label that states, ”no sugar added,” generally gives parents false security that somehow it’s safe and good for kids. Absolutely not!
Pouch/sweetened beverages, like Capri Sun: There are 16 grams of sugar in each pouch! Now the company makes “Roaring Water,” or pouches may be labeled “25% less sugar!” I can’t believe most parents actually have a false sense of security and safety, and believe the labels and allow kids to drink so much juice. Most kids drink more than one pouch per day, and often parents will pack one for lunch and then who knows how many they have after school.
Fruit and/or vegetable pouches: A new ‘fad” and epidemic. Yes, while it’s convenient, it is also highly acidic. Read the ingredient list and you will find ascorbic acid, or some form of acid.
Gatorade: There are 34 grams of sugar in a 20oz bottle.
Soda: A 12oz can of Coke has 39 grams of sugar, a 20oz bottle has 65 grams of sugar, root beer has 39 grams of sugar and Sprite may be less, but it is still very sugary. All other sodas also high in sugar.
Drinkable yogurt/yogurt tubes: Some preschoolers eat 3 - 4 of these daily! It's not as nutritious as you think. Highly acidic and simply a carrier for sugar.
Strawberry milk or YOO HOO: These have 30 grams of sugar!
You get the point: the same kids who love sugary and/or dairy drinks do not drink much water, they tend to not eat much fresh fruits and vegetables, and they also love tubes of GoGurts, which have 10 grams of sugar per tube.
Sugar adds up quickly! A 10-year-old patient’s mother reported that, in a single day, her child drinks:
4 - 5 glasses of juice | 28 grams x 5 = 140 grams of sugar
2 - 3 glasses of chocolate or strawberry milk | 25 grams x 3 = 75 grams of sugar
3 - 5 Capri Suns | 16 grams x 4 = 64 grams of sugar
So far that’s 279 grams of sugar just on liquids alone and not including the rest of the diet, which likely includes candy, yogurt, fruit snacks and (let’s hope not) LUNCHABLES (46+ grams of sugar),
Please share this with all the families/parents that you know so that we can stop this horrific epidemic in America. My goal is that our children drink water again, and lots of it. We have to stop enabling and supporting industry crafted addiction by buying sugary food and drinks for our children. If we don’t teach kids to drink water now, they will probably have no reason to drink it ever for the rest of their lives. Children will unlikely grow up and just suddenly wean themselves off of sugar and processed foods and beverages. It is up to us to help them live A Healthier Wei! You can start today by taking the “Drink More Water” challenge here.
Learn more about croup and acid reflux, and all the symptoms it can cause in children in Acid Reflux in Children. You are probably saying right now, “Doctors have told us our child has acid reflux.” What they didn’t tell you is that the stomach acid in human stomachs for over 5000 years were there naturally, and that’s not why we have acid reflux. Our children and we as adults have acid reflux because our diet and the beverages we drink create a “Niagara Falls” of acid and the result is acid reflux. No pill will work against juice, soda, excessive dairy or yogurt, and especially if put it in the stomach close to bedtime.
As for children with recurrent croup, I have been very fortunate that most parents are willing to listen to me and make changes in their dietary habits because medications do not prevent nor stop croup. Most children stop having these episodes of “spasmodic croup” or recurrent croup, or whatever kind of croup, once parents eliminate the majority of sugar, juices and late afternoon/evening/bedtime snacks. A decrease in reflux results in the decreased over-triggering of the larynx to protect itself, and the hyper-reactiveness to constant and excessive coughing.