What medication is recommended for a 5-year-old with an Upper Respiratory Tract Infection (URTI)?

Treatment of Upper Respiratory Tract Infection in a 5-Year-Old

Most URTIs in 5-year-olds are viral and do not require antibiotics—focus on supportive care with hydration, antipyretics, and nasal suctioning while avoiding over-the-counter cough and cold medications. 1

Supportive Care (First-Line for Viral URTI)

The vast majority of URTIs are viral and self-limiting, requiring only symptomatic management 2, 3:

• Ensure adequate hydration to help thin secretions 1
• Use acetaminophen or ibuprofen for fever control and comfort 1
• Perform gentle nasal suctioning if nasal congestion impairs breathing 1
• Avoid over-the-counter cough and cold medications in children under 6 years—these lack proven efficacy and carry risk of serious toxicity, including death (54 fatalities with decongestants and 69 with antihistamines reported between 1969-2006) 1

When Antibiotics Are Indicated

Antibiotics should only be prescribed when bacterial infection is confirmed or highly suspected 4, 1:

Acute Bacterial Rhinosinusitis (ABRS)

• Diagnostic criteria: Purulent nasal discharge persisting >10 days, or worsening symptoms after initial improvement ("double sickening"), or severe symptoms (fever ≥102°F with purulent discharge for ≥3 consecutive days) 4
• First-line treatment: Amoxicillin 45 mg/kg/day divided twice daily OR 40 mg/kg/day divided three times daily for mild-moderate cases 5
• High-dose amoxicillin (90 mg/kg/day) if recent antibiotic use within 4-6 weeks or severe symptoms 4, 5
• Alternative: Amoxicillin-clavulanate (90 mg/6.4 mg per kg/day) in areas with high penicillin-resistant S. pneumoniae prevalence 4, 5
• Duration: 5-8 days 5

Important caveat: Two pediatric trials showed conflicting results—one demonstrated benefit of amoxicillin-clavulanate over placebo (50% cure vs 14%), while another showed no significant difference (83.9% vs 71%, p=0.22). However, adverse events (particularly diarrhea) occurred in 44% of antibiotic-treated children versus 14% on placebo 4. This underscores the need for stringent diagnostic criteria before prescribing.

Streptococcal Pharyngitis

• Requires confirmation: Positive rapid antigen detection test or throat culture 6
• Treatment: Amoxicillin 50-75 mg/kg/day in 2 doses for 10 days 5, 1
• Do not prescribe antibiotics based on clinical criteria alone—viral pharyngitis is far more common 6

Acute Otitis Media

• First-line: Amoxicillin 40 mg/kg/day divided twice daily for 5 days 5
• High-dose (90 mg/kg/day) if recent antibiotic exposure or high local resistance 5

Clinical Monitoring

• Reassess at 48-72 hours if symptoms are not improving or worsening 5, 1
• Red flags requiring immediate evaluation: Respiratory rate >50 breaths/min, difficulty breathing, grunting, cyanosis, apnea episodes, poor feeding, or dehydration 7, 1
• If cough persists >4 weeks, consider alternative diagnoses including pertussis (especially with paroxysmal coughing and post-tussive vomiting) 7

Common Pitfalls to Avoid

• Do not prescribe antibiotics for typical viral URI symptoms (rhinorrhea, cough, low-grade fever) without evidence of bacterial superinfection 4, 1
• Avoid azithromycin as first-line—it provides inadequate coverage for common URTI pathogens (S. pneumoniae, H. influenzae) and is associated with QT prolongation risk 4
• Do not use chest physiotherapy—it provides no benefit 1
• Avoid topical decongestants in young children due to narrow therapeutic margin and cardiovascular/CNS side effects 1