What are the common causes and management of fever, cough, and rhinorrhea (runny nose) in different age groups?

Common Causes of Fever, Cough, and Rhinorrhea by Age Group

Neonates (0-2 months)

Viral upper respiratory infections are the most common cause, with influenza identified as the leading reason for hospital admission in febrile neonates during epidemic periods. 1

• Presentation is often non-specific: pallor, floppiness (poor peripheral circulation, poor tone), lethargy, poor feeding, and episodes of apnea 1
• Fever may be the only presenting feature in this age group, making differentiation from serious bacterial infection challenging 1
• Pertussis must be considered in unimmunized infants presenting with protracted cough, cyanosis, persistent rhinorrhea, and marked lymphocytosis 2
• All febrile neonates require physician evaluation due to higher risk of complications and difficulty distinguishing viral from bacterial sepsis 3

Infants and Very Young Children (2 months to 2 years)

Viral upper respiratory infections remain the predominant cause, with fever potentially being the sole initial manifestation. 1, 4

• Common viral pathogens include: influenza, RSV, human rhinovirus (HRV), parainfluenza virus (PIV), and human coronavirus 4, 5
• Clinical presentation: irritability, toxic appearance, fever, cough, and rhinorrhea 1
• Gastrointestinal symptoms (diarrhea, vomiting) occur more frequently in this age group compared to older children 1
• Febrile convulsions, particularly repeated convulsions, are positively associated with influenza A 1
• Otitis media is a common complication in young children with viral URIs 1
• Admission rates for children under 2 years are 12 times higher than for children aged 5-17 years 1
• Children under 1 year should always be evaluated by a physician due to elevated complication risk 3

Distinguishing Viral URI from Acute Bacterial Sinusitis in Young Children

• Most viral URIs resolve within 6.6-8.9 days, though symptoms may persist beyond 15 days in 7-13% of cases, particularly in daycare attendees 1
• Fewer than 1 in 15 children develop true bacterial sinusitis during or after a common cold 1
• Bacterial sinusitis should be suspected when symptoms are:
  • Persistent: runny nose or daytime cough for ≥10 days without improvement 1
  • Severe: fever ≥39°C (102.2°F) for ≥3 consecutive days with thick, colored nasal mucus 1
  • Worsening: new-onset fever ≥38°C (100.4°F) or substantial increase in cough/rhinorrhea after initial improvement 1

Older Children (2-12 years)

Viral upper respiratory infections present with the classic triad of cough, fever, and rhinorrhea, with influenza being highly prevalent during winter months. 1, 4

• Common viral pathogens: influenza A and B, human rhinovirus, parainfluenza virus type III, human coronavirus-NL63 1, 5
• Typical presentation: sudden onset of high fever, chills, cough, headache, sore throat, fatigue, nasal stuffiness, and conjunctivitis 1
• The triad of cough, headache, and pharyngitis has 80% sensitivity and 78% specificity for influenza during epidemic periods 1
• Fever typically settles in 2-4 days, though dry cough and clear nasal discharge may persist for 1-2 weeks 1, 4
• Colored nasal discharge does not indicate bacterial infection during the first 10 days, as mucopurulent secretions commonly occur with viral URIs due to neutrophil influx 1

High-Risk Populations

Children with asthma and chronic medical conditions experience substantially higher morbidity and require inpatient care disproportionately during influenza seasons 1

• Underlying conditions increasing risk: asthma (42% of hospitalizations), congenital cardiac anomalies (28.5%), chronic lung disease of prematurity, immunodeficiencies, malignancies, renal disease, hemoglobinopathies, and diabetes 1
• Non-ambulant children also experience substantial morbidity requiring ventilatory support more frequently 1

Adolescents (13-18 years)

Presentation does not differ significantly from adults, with influenza and other respiratory viruses causing the classic constellation of symptoms. 1

• Common features: sudden onset of high fever, chills, cough, headache, sore throat, fatigue, nasal stuffiness, and conjunctivitis 1
• Symptom duration mirrors that of older children: fever resolves in 2-4 days, cough and rhinorrhea persist 1-2 weeks 1

Management Principles Across All Ages

Supportive care with antipyretics and hydration forms the cornerstone of management for uncomplicated viral URIs. 4, 3, 6

• Antipyretics: acetaminophen or ibuprofen for fever control 4, 3, 6
• Never use aspirin in children under 16 years due to Reye syndrome risk 4, 3
• Ensure adequate fluid intake to maintain hydration 4, 3
• Expected course: fever settles in 2-4 days, cough may persist 1-2 weeks 4
• Honey (for children ≥1 year) is the only proven effective treatment for acute cough in children 7, 6
• Over-the-counter cough and cold medications should not be used in children <4 years and have not been shown to improve symptoms in any age group 7, 6

Antiviral Therapy Considerations

• Oseltamivir should be considered for influenza-like illness if within 48 hours of symptom onset during known influenza circulation 3, 8
• Oseltamivir reduces time to improvement by 1.3 days in adults and 1.5 days in children aged 1-12 years 8
• Dosing for children 1-12 years: 2 mg/kg twice daily for 5 days 8
• Dosing for children 2 weeks to <1 year: 3 mg/kg twice daily for 5 days 8

Red Flags Requiring Urgent Evaluation

Any child presenting with signs of respiratory distress, altered consciousness, or severe dehydration requires immediate physician assessment. 4, 3

• Respiratory distress: markedly elevated respiratory rate, grunting, intercostal retractions, breathlessness 4, 3
• Cyanosis or hypoxia 4, 3
• Severe dehydration or inability to take oral fluids 4, 3
• Altered consciousness or drowsiness 4, 3
• Extreme pallor or signs of septicemia 4
• Fever persisting >4-5 days without improvement 4
• Severe earache suggesting otitis media 4

Common Pitfalls to Avoid

• Do not prescribe antibiotics for uncomplicated viral URIs as they provide no benefit and increase adverse effects and resistance 1, 4
• Do not order chest radiography in children with normal vital signs and clear lung examination as yield is very low 4
• Do not use antihistamines or decongestants as primary treatment in children with acute sinusitis, as data are insufficient to support their use 1
• Do not assume colored nasal discharge indicates bacterial infection before 10 days of symptoms 1
• In unimmunized children, maintain lower threshold for considering pertussis with persistent paroxysmal cough 3, 2