What medications are given to children with Upper Respiratory Tract Infections (URTI)?

Treatment of Upper Respiratory Tract Infections in Children

For most children with uncomplicated URTIs, no antibiotics should be given—only supportive care is appropriate, as these infections are predominantly viral. 1

When Antibiotics Are NOT Indicated

• Over-the-counter cough and cold medications must be avoided in children under 6 years of age due to lack of efficacy and significant safety concerns, including 54 fatalities associated with decongestants and 69 with antihistamines reported between 1969 and 2006. 1

• Antibiotics provide no benefit for common cold/viral URTI and nonspecific upper respiratory symptoms—they only expose children to potential harm. 1

• Topical decongestants should be used with extreme caution in children under 1 year due to narrow therapeutic margins and risk of cardiovascular and CNS side effects. 1

Supportive Care Measures (First-Line for Viral URTI)

• Maintain adequate hydration through continued breastfeeding or formula feeding. 1

• Use antipyretics (acetaminophen or ibuprofen) at appropriate doses for comfort. 1

• Monitor for signs of respiratory distress including respiratory rate, oxygen saturation, chest recession, and use of accessory muscles. 1

• Minimize handling to reduce metabolic and oxygen requirements. 1

When Antibiotics ARE Indicated

Antibiotics should only be prescribed when specific bacterial infections are diagnosed, such as: 1

Acute Bacterial Sinusitis Criteria:

• Symptoms persisting >10 days without improvement 1
• Severe symptoms (high fever ≥39°C with purulent nasal discharge for at least 3 consecutive days) 1
• Worsening symptoms after initial improvement (double-worsening) 1

Acute Otitis Media Criteria:

• Children under 2 years with bilateral AOM 2
• Children 6-23 months with bilateral AOM 2
• Children older than 2 years with bilateral AOM and otorrhea 2
• High-risk patients or those unable to ensure adequate follow-up 3

First-Line Antibiotic Treatment

Amoxicillin is the first-line antibiotic for bacterial URTIs in children. 4, 5, 3

Dosing Regimens:

• For mild to moderate infections: 45 mg/kg/day divided into two doses or 40 mg/kg/day divided into three doses 4

• For severe infections or suspected drug-resistant pathogens: 90 mg/kg/day 4

• For children under 3 years with suspected bacterial pneumonia: 80-100 mg/kg/day in three daily doses 4, 1

• Maximum dose for neonates and infants ≤3 months: 30 mg/kg/day divided every 12 hours 5

Treatment Duration:

• 5 days for uncomplicated acute otitis media 4
• 5-8 days for acute bacterial rhinosinusitis 4
• 10 days for children under 2 years with AOM 4
• Continue treatment for minimum 48-72 hours beyond symptom resolution 5

When to Use Amoxicillin-Clavulanate Instead

Consider amoxicillin-clavulanate (high-dose: 90 mg/6.4 mg per kg per day) for: 4

• Severe symptoms at presentation 4
• Recent antibiotic exposure (within 4-6 weeks) 4
• Known high local prevalence of amoxicillin-resistant Haemophilus influenzae 4
• Insufficient vaccination against H. influenzae type b 4
• Areas with high prevalence of penicillin-resistant S. pneumoniae 4
• Treatment failure after 48-72 hours of amoxicillin 4, 3

Important caveat: Amoxicillin-clavulanate has higher rates of adverse events, particularly diarrhea, compared to amoxicillin alone. 4

Alternative Antibiotics (Second-Line)

• Ceftriaxone for amoxicillin treatment failure within 48-72 hours 3
• Cefpodoxime proxetil or cefuroxime-axetil for specific indications 4, 3
• Macrolides only for patients with documented beta-lactam allergies (note: high pneumococcal resistance rates make them poor first-line choices) 4, 6

Critical Monitoring and Red Flags

• Evaluate treatment response after 48-72 hours—lack of improvement indicates treatment failure. 4

• Urgent evaluation required for: 1

  • Severe respiratory distress or increased work of breathing
  • Inability to maintain hydration
  • Oxygen desaturation
  • High fever with worsening clinical condition
  • No improvement or deterioration after 48-72 hours

Common Pitfalls to Avoid

• Do not prescribe antibiotics for viral URTIs—this contributes to antibiotic resistance and exposes children to unnecessary adverse effects including diarrhea, rash, and potentially severe reactions like Stevens-Johnson syndrome or anaphylaxis. 4, 1

• Avoid chest physiotherapy—it provides no benefit in children with respiratory infections. 1

• Do not use macrolides or oral third-generation cephalosporins as first-line agents due to high pneumococcal resistance rates. 4

• Remember that early-life antibiotic exposures may disrupt the microbiome, potentially contributing to long-term health effects including inflammatory bowel disease, obesity, eczema, and asthma. 4