Laboured breathing while your child sleeps: what it can be and when to seek care

Laboured breathing while your child sleeps can be anything from a blocked nose to croup, RSV or asthma. What decides whether you should seek care is not the noise but the effort: is the child breathing fast, is the skin being drawn in between the ribs or at the base of the throat, are they pale or blue around the mouth? Then you call 112. Snoring without effort during a cold is harmless. Call 1177 (the national healthcare helpline) if you are unsure, they answer around the clock.

Few things are as frightening as standing by the bed at two in the morning listening to a child who sounds wrong. Most of it is harmless. This is how you tell the harmless from what needs care, and what you do in the meantime. The text is general, and it does not replace a call to 1177.

Ten past two one night in November, in a flat in Nacka. The two year old who went to bed with a slight cold suddenly sounds like a seal: a barking cough, a whistling sound when she breathes in, and she is crying in a way that makes dad go cold. It is croup, one of the most common reasons parents call 1177 in the middle of the night, and it usually gets better with cool air and a calm lap. But it is also the moment when you need to know exactly what you are looking for.

The difference between noise and effort

Usually harmless	Seek care
Snoring during a cold, breathing calmly	Breathing fast, over 50 breaths a minute in infants, over 40 in toddlers
Blocked nose, breathing through an open mouth	Retractions: the skin is sucked in between the ribs, below the ribcage or at the base of the throat
A slight rattle from mucus in the throat	The nostrils flare with every breath
Coughs, then sleeps calmly again	Pale, greyish or blue around the mouth
Wakes, grizzles, goes back to sleep	Listless, hard to wake, unable to drink or cry

How to count breaths

Rest your hand lightly on the child's chest or watch the tummy in good light, and count every rise for a full minute. Not fifteen seconds times four, because small children breathe unevenly. Ideally do it when the child is sleeping calmly, so you have something to compare with the next time they are ill. At the same time, look at the skin between the ribs and at the base of the throat: if it is sucked in with every breath, the child is working to get air, and then the number matters less.

Age	Roughly normal at rest	Seek care at
Under 1 year	30 to 50 breaths a minute	Over 50, or retractions
1 to 5 years	20 to 40	Over 40, or retractions
School age	15 to 25	Clearly faster than usual and laboured

The most common causes

• Blocked nose. Infants prefer to breathe through the nose. Saline drops, a nasal aspirator, a raised head end. More in Baby with a cold.
• Croup (falsk krupp). A barking cough and whistling on the in-breath, often suddenly at night in children between six months and three years. Cool air, sit the child upright, a calm voice. Call 1177 if it does not ease, 112 if there is clear difficulty breathing. Separate guide: Croup.
• RSV and bronchiolitis. In infants: fast, shallow breathing, retractions, difficulty feeding. Seek care the same day, 112 if the child is badly affected.
• Asthma. Wheezing on the out-breath, coughing at night, often with a cold or after exertion. Your vårdcentral (local health centre) for assessment, 112 if the child cannot get air.
• Enlarged tonsils or adenoids. Snoring every night, pauses in breathing, mouth breathing, tiredness during the day. Vårdcentral or BVC (the child health clinic every family is enrolled in), it can be treated.

Croup: the night step by step

1. Pick the child up and sit upright with them on your lap. Lying down makes the swelling worse.
2. Be calm, even if you are not. The child's panic makes the breathing worse, and the child reads you.
3. Cool air for ten to fifteen minutes: open the window, go out onto the balcony with a blanket around the child, or stand in front of an open fridge.
4. If it does not ease, or the child is whistling even at rest: call 1177. They may send you to A&E, where the child is given cortisone to bring down the swelling.
5. If the child turns blue, becomes listless, drools and cannot swallow, or sits leaning forward and struggling: 112.
6. The next day the child is often bright. Expect it to come back the following night anyway, and have the blanket ready.

What to do while you wait

1. Pick the child up, sit upright with them on your lap. A calm voice.
2. Cool air: open the window or go out onto the balcony with a blanket around the child.
3. Count breaths for one minute.
4. Look at the skin between the ribs in good light.
5. Call 1177 and describe what you see. They decide whether you should go in.
6. If the child turns blue, becomes listless or the breathing gets heavier and heavier: 112, immediately.

What to tell 1177

The nurse asks questions in a set order, and it goes faster if you have the answers ready:

• The child's age and approximate weight
• How long it has been going on, and whether it started suddenly
• Breaths per minute, and whether you can see retractions
• The skin colour around the mouth and on the lips
• Fever, and how high
• Whether the child is drinking, weeing and responsive
• Any medicines the child has, for example asthma medication, and whether you have given anything
• Whether it has happened before, and what helped then

The bedroom: what helps prevent it

• A cool room, an extra blanket rather than warm air. Dry, warm air makes the mucous membranes worse.
• Smoke-free, always. Even smoke on clothes affects small airways.
• A raised head end for children over one: a book or a towel under the head end of the mattress, never a pillow under a baby's head.
• Saline drops and a nasal aspirator before bed when the child has a cold, so they can breathe through the nose.
• Children with known asthma: take the medication as planned, and keep it to hand at night.

The next day: förskola or home?

A child who has had croup in the night is often bright in the morning, and if they want to go to förskola (municipal preschool, from age one) and are fever-free it is often fine, tell the staff what happened. A child with a fever, fast breathing or who cannot keep up should stay at home. If you are unsure whether the child could be with a nanny instead, the reasoning is in A nanny when your child is sick.

How we do it with our families

Doaa has an evening shift with a family in Nacka on Wednesdays, from six until half past ten. One evening in November, at nine, she hears the three year old coughing with a bark in his bed. She does what we go through with every nanny at the first meeting: picks the child up onto her lap, goes out onto the balcony with a blanket, talks calmly and counts breaths with the clock on her phone. Thirty-two a minute, no retractions, skin colour normal. After a quarter of an hour the boy is breathing calmly again. She calls the parents straight away and tells them exactly what she saw, they come home an hour early and call 1177 for advice ahead of the night. Her note reads: "21.05 barking cough, balcony 15 min, 32 breaths per minute, no retractions, back to sleep 21.40." That is the kind of note a parent wants. At the first meeting we also go through where any medicines the child has are kept and how they are given, and the rule is the same for the nanny as for you: 1177 at the slightest doubt, 112 for difficulty breathing, the parents straight afterwards.

This text is general information and does not replace advice from BVC, your vårdcentral or 1177. If you are worried about your child, call 1177. In an emergency, call 112.

Read more: Croup · Baby with a cold · Fever in children · FAQ

Frequently asked questions

What is croup?

A viral infection that causes swelling in the larynx, with a barking cough and a whistling sound on the in-breath, usually at night. Most common between six months and three years. Cool air and sitting upright help, and it often comes back the next night. Call 1177 if the child is struggling to breathe, 112 if they turn blue or run out of strength.

Is it dangerous that my child snores?

Snoring now and then during a cold is harmless. If the child snores every night, breathes through an open mouth, has pauses in breathing or is very tired during the day, it may be due to enlarged tonsils or adenoids. Raise it with BVC or your vårdcentral, it can be assessed and treated, and it affects sleep more than you would think.

How many breaths a minute is normal?

Roughly: infants 30 to 50 a minute, one to five year olds 20 to 40, school-age children 15 to 25. Count for a full minute while the child sleeps calmly, not fifteen seconds times four, and compare with how it usually is. Fever raises the rate somewhat. What decides it is whether the breathing is also laboured.

When should we call 112?

When the child is breathing very fast and with effort, has retractions between the ribs or at the base of the throat, turns blue or grey-pale around the mouth, cannot manage to talk or cry, drools and cannot swallow, or is listless and hard to rouse. Do not wait for it to pass, and do not put off calling because you are unsure.

How do I know if it is RSV?

RSV starts as a cold and in infants can move down into the small airways: fast, shallow breathing, retractions, wheezing on the out-breath, not managing to feed and many short pauses in breathing. Older children usually just get a cold. If a baby under one has those symptoms, seek care the same day, and call 112 if the child is badly affected.