What is the recommended treatment for a kid's upper respiratory infection (URI)?

Management of Upper Respiratory Infections in Children

Most upper respiratory tract infections in children are viral and require only supportive care, not antibiotics. 1

Diagnosis: Distinguishing Viral from Bacterial Infections

The American Academy of Pediatrics emphasizes the importance of applying stringent diagnostic criteria to distinguish viral from bacterial infections to prevent antibiotic overuse 1. When evaluating a child with URI symptoms, consider:

• Viral URI (most common): Characterized by runny nose, cough, mild fever, sore throat, and general malaise
• Bacterial infections require specific diagnostic criteria:
  • Acute bacterial sinusitis: Requires symptoms that are either:
    • Persistent without improvement (nasal discharge or daytime cough >10 days)
    • Worsening after initial improvement (new fever, worsening cough/nasal discharge)
    • Severe (fever ≥39°C with purulent nasal discharge for ≥3 days) 2, 1
  • Acute otitis media: Requires middle ear effusion AND signs of inflammation:
    • Moderate/severe bulging of tympanic membrane, OR
    • Otorrhea not due to otitis externa, OR
    • Mild bulging with ear pain or erythema 2
  • Streptococcal pharyngitis: Requires confirmation by rapid testing or culture when at least 2 of the following are present:
    • Fever
    • Tonsillar exudate/swelling
    • Swollen/tender anterior cervical nodes
    • Absence of cough 2

Treatment Approach

1. Supportive Care for Viral URIs (First-line treatment)

• Maintain adequate hydration 1
• Saline nasal drops/spray to relieve congestion 1
• Honey for cough in children over 1 year of age 1
• Acetaminophen or ibuprofen for fever and pain relief 1
• Avoid antibiotics for viral URIs as they provide no benefit and only expose children to potential harm 2, 1, 3

2. Antibiotic Therapy (Only for confirmed bacterial infections)

If bacterial infection criteria are met, appropriate antibiotics may be indicated:

• Acute bacterial sinusitis:

  • First-line: Amoxicillin or amoxicillin-clavulanate 2

• Acute otitis media:

  • For children <2 years: Amoxicillin is first choice 2
  • For children ≥2 years with non-severe symptoms: Observation for 48-72 hours may be appropriate 2

• Group A streptococcal pharyngitis:

  • First-line: Penicillin or amoxicillin 2

3. Monitoring and Follow-up

• Review children if not improving after 48 hours on treatment 2, 1

• Educate families on:

  • Managing fever
  • Preventing dehydration
  • Identifying signs of deterioration 1

• Return precautions: Return if:

  • Symptoms worsen
  • Symptoms persist beyond 10 days
  • Difficulty breathing develops
  • Child unable to drink
  • Persistent high fever
  • Lethargy 1

Common Pitfalls to Avoid

1. Prescribing antibiotics for viral URIs: As many as 10 million antibiotic prescriptions per year are directed toward respiratory conditions for which they are unlikely to provide benefit 1. Antibiotics do not shorten the course of viral URIs and do not prevent the development of pneumonia 3.

2. Inadequate diagnostic criteria: Using loose criteria for diagnosing bacterial infections leads to antibiotic overuse. Apply stringent diagnostic criteria to identify true bacterial infections 2, 1.

3. Overlooking antibiotic adverse effects: Antibiotics are responsible for the largest number of unplanned medical visits for medication-related adverse events among children. Adverse events include diarrhea, rash, and potentially more severe reactions 2.

4. Chest physiotherapy: This is not beneficial and should not be performed in children with pneumonia 2.

By following these evidence-based guidelines, providers can ensure appropriate management of URIs in children, minimize unnecessary antibiotic use, and provide effective symptom relief while the infection resolves naturally.