What treatment should be given to a pediatric patient less than 1 year old with a viral Upper Respiratory Tract Infection (URTI)?

Treatment of Viral URTI in Infants Less Than 1 Year Old

For infants under 1 year with viral upper respiratory tract infections, provide supportive care only—no antibiotics, no cough/cold medications, and focus on maintaining hydration, adequate oxygenation, and fever control with acetaminophen or ibuprofen (if ≥6 months). 1

Core Management Principles

What NOT to Give

• No antibiotics should be prescribed for viral URTIs, as these conditions are primarily viral and antibiotics provide no benefit while increasing risks of adverse events and antibiotic resistance 2, 1
• No over-the-counter cough and cold medications in infants under 1 year—these have not been proven effective and carry safety concerns in this age group 3
• No aspirin due to risk of Reye syndrome 1

Supportive Care Measures

Fever and Discomfort Management:

• Acetaminophen for pain and fever relief (appropriate for all ages) 1
• Ibuprofen may be used if infant is ≥6 months of age 1
• These should be given for moderate to severe symptoms or control of high fever 1

Nasal Congestion:

• Saline nose drops are safe and can help with nasal congestion 3
• Gentle bulb suctioning to clear nasal secretions 3
• Humidified air may provide symptomatic relief 1

Hydration:

• Ensure adequate fluid intake through continued breastfeeding or formula feeding 3
• Monitor for signs of dehydration (decreased wet diapers, dry mucous membranes, lethargy) 4

Red Flags Requiring Immediate Evaluation

Seek urgent medical attention if the infant develops: 4

• Respiratory rate >60 breaths/min in infants
• Difficulty breathing, grunting, or cyanosis
• Apnea episodes (pauses in breathing)
• Poor feeding or signs of dehydration
• Persistent high fever (>3-5 days) 1

Special Consideration: RSV Bronchiolitis

If the infant progresses from upper to lower respiratory tract symptoms (increased cough, wheezing, increased respiratory effort), consider RSV bronchiolitis 5, 4:

• This remains a clinical diagnosis—diagnostic testing is not routinely needed 4
• Treatment remains supportive with attention to oxygenation and hydration 5, 4
• Hospitalization may be required for infants <60 days or those with severe symptoms 5
• Bronchodilators and corticosteroids are generally not useful 4

Common Pitfalls to Avoid

• Prescribing antibiotics "just in case"—this is the most common error and contributes to antibiotic resistance without providing benefit to the infant 2, 1
• Using combination cough/cold products—these are not recommended and potentially harmful in infants 3
• Delaying evaluation when red flags appear—infants under 1 year, especially those under 60 days, can deteriorate rapidly and require closer monitoring 5
• Failing to educate parents—explaining that viral URTIs are self-limited (typically resolving in 7-10 days) and providing clear return precautions is essential 1, 3

When to Reassess

Re-evaluation is warranted if: 1

• Fever persists beyond 3-5 days
• Symptoms worsen after initial improvement (suggesting possible secondary bacterial infection)
• New symptoms develop suggesting bacterial complications (such as acute otitis media or bacterial sinusitis)
• Symptoms persist beyond 10-14 days without improvement

Note: The evidence provided regarding vesicoureteral reflux 2 and bacterial sinusitis in children 1-18 years 2 is not applicable to the management of viral URTI in infants under 1 year and was appropriately excluded from this recommendation.