What is the treatment approach for a 6-year-old female presenting with cough, fever, nausea, vomiting, and sore throat for 5 days?

Treatment of a 6-Year-Old with 5 Days of Cough, Fever, Nausea, Vomiting, and Sore Throat

This child requires immediate clinical reassessment because symptoms persisting beyond 48-72 hours without improvement indicate either a complicating bacterial infection or severe illness requiring urgent evaluation. 1

Immediate Assessment Priorities

Check for red flags requiring urgent hospital evaluation:

• Severe respiratory distress (markedly raised respiratory rate, grunting, intercostal recession, breathlessness with chest signs) 2
• Oxygen saturation <92% 2
• Severe dehydration or inability to maintain hydration 1
• Altered conscious level 2
• Signs of septicemia (extreme pallor, hypotension) 2

If any red flags are present, immediate hospital referral is mandatory. 2, 1

Treatment Algorithm for Stable Patients

Step 1: Determine if Bacterial Infection is Present

After 5 days of symptoms, consider acute bacterial rhinosinusitis if:

• Symptoms persist >10 days without improvement (not yet met in this case) 3
• Severe symptoms: fever >39°C with purulent nasal discharge or facial pain for ≥3 consecutive days 3
• "Double sickening" pattern: worsening after initial improvement 3

For streptococcal pharyngitis, look for:

• Temperature >38°C, tonsillar exudates, cervical adenopathy, absence of cough 4
• The presence of cough, nausea, and vomiting makes viral infection more likely 4

Step 2: Initiate Treatment Based on Clinical Picture

If bacterial infection is suspected (streptococcal pharyngitis or bacterial sinusitis):

• First-line: Amoxicillin 45-90 mg/kg/day divided into 2-3 doses for 10 days 5
• For this 6-year-old with moderate symptoms, use 45 mg/kg/day 5
• If severe symptoms or recent antibiotic exposure: Amoxicillin-clavulanate 90 mg/kg/day (amoxicillin component) divided into 3 doses 2, 5

If viral upper respiratory infection (most likely given symptom constellation):

• Supportive care only—antibiotics provide no benefit and cause harm 1, 3
• Acetaminophen or ibuprofen for fever and pain (avoid aspirin in children) 2, 1
• Maintain hydration with oral fluids 1
• Avoid over-the-counter cough and cold medications—these are contraindicated in children under 6 years due to lack of efficacy and significant safety concerns, including 54 reported fatalities with decongestants and 69 with antihistamines 1

Step 3: Manage Vomiting

For persistent vomiting preventing oral intake:

• Ondansetron 0.2 mg/kg oral (maximum 4 mg) may be used 6
• Monitor hydration status closely 6
• If unable to maintain hydration, hospital referral for IV fluids is required 1

Step 4: Reassessment Timeline

Mandatory reassessment after 48-72 hours of treatment (or sooner if worsening): 2, 3

• Primary criterion: fever resolution (should occur within 24 hours for bacterial pneumonia, 2-4 days for other bacterial infections) 3
• Cough may persist longer and should not be the sole indicator of treatment failure 3

If no improvement after 48 hours on amoxicillin:

• Consider atypical bacteria (Mycoplasma, Chlamydia) and switch to macrolide monotherapy 2
• Alternatively, consider amoxicillin-clavulanate if not already prescribed 2

If no improvement after 5 days of appropriate therapy:

• Hospitalization is warranted for further evaluation 2
• Consider chest radiograph to exclude pneumonia or pleural effusion 2

Critical Pitfalls to Avoid

• Never prescribe antibiotics empirically for viral URTI symptoms—this causes antibiotic resistance and exposes the child to unnecessary harm 1, 3
• Do not use first-generation cephalosporins (cephalexin) for respiratory infections—they have inadequate activity against S. pneumoniae 3
• Do not delay reassessment—children can deteriorate rapidly, and complications like pneumonia or empyema require early detection 2
• Avoid topical decongestants in young children due to narrow therapeutic window and risk of cardiovascular/CNS toxicity 1