What is the treatment for an 8-year-old child with green nasal discharge and fever?

Treatment of 8-Year-Old with Green Nasal Mucus and Fever

For an 8-year-old with green nasal discharge and fever, antibiotic therapy with amoxicillin (90 mg/kg/day divided into 2 doses, maximum 4 g/day) should be initiated if the child presents with severe-onset acute bacterial sinusitis (fever ≥39°C for at least 3 consecutive days with purulent nasal discharge) or worsening symptoms after initial improvement. 1

Diagnostic Criteria

The clinical presentation must meet one of three patterns to diagnose acute bacterial sinusitis 1:

• Severe-onset: Fever ≥39°C (102.2°F) for at least 3 consecutive days with thick, colored nasal discharge 1
• Worsening course: Initial improvement from a viral cold followed by new-onset fever ≥38°C or substantial increase in symptoms 1
• Persistent illness: Nasal discharge (any quality) or daytime cough lasting >10 days without improvement 1

Critical distinction: Green or colored mucus alone does NOT indicate bacterial sinusitis—fewer than 1 in 15 children with colored nasal discharge during a cold develop true bacterial sinusitis 1. The pattern and duration of symptoms are what matter.

Treatment Algorithm

For Severe-Onset or Worsening Course (Your Patient Likely Fits Here)

Immediate antibiotic therapy is indicated 1:

• First-line: Amoxicillin 90 mg/kg/day divided into 2 doses (maximum 4 g/day) 1, 2
• Alternative if recent antibiotic use or high-risk: Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component 3
• If penicillin allergy: Cefdinir, cefpodoxime, or cefuroxime 3

For Persistent Illness Only (>10 Days, Mild Symptoms)

Two management options exist 1:

1. Observation for 3 additional days with close follow-up, then treat if no improvement
2. Immediate antibiotic therapy if symptoms significantly impact quality of life (sleep disturbance, school absence) 1

Key Clinical Pitfalls to Avoid

• Do NOT diagnose sinusitis based on colored mucus alone—most viral colds produce colored mucus by days 3-5 that clears by day 10 1
• Do NOT order imaging studies (X-rays, CT scans) for uncomplicated acute bacterial sinusitis—they do not change management and show abnormalities in 68% of symptomatic children and 42% of healthy children 1
• Do NOT use antihistamines, decongestants, or mucolytics as primary treatment—insufficient evidence supports their use 1

Reassessment Criteria

Re-evaluate within 72 hours if 1:

• Symptoms worsen at any time
• No improvement after 72 hours of antibiotic therapy
• New symptoms develop (orbital swelling, severe headache, altered mental status)

If treatment fails, switch to amoxicillin-clavulanate (high-dose) or a third-generation cephalosporin like cefdinir 3.

When to Consider Hospitalization

Admit if the child develops 1:

• Orbital complications (periorbital edema, proptosis, vision changes)
• Intracranial complications (severe headache, altered consciousness)
• Inability to tolerate oral medications
• Signs of severe systemic illness

Supportive Care

While antibiotics address the bacterial infection 1:

• Antipyretics (acetaminophen or ibuprofen) for fever and discomfort 1
• Adequate hydration 1
• Saline nasal irrigation (not spray) may provide symptomatic relief, though evidence is mixed 1