What is the recommended management for a 3-month-old infant with a 2-week history of cough and runny nose, but no fever, normal vital signs, and clear chest with referred sounds from upper respiratory congestion?

Management of a 3-Month-Old with Prolonged Upper Respiratory Symptoms

This 3-month-old infant with a 2-week history of cough and rhinorrhea, clear chest examination, normal vital signs, and no fever can be safely managed with supportive care at home, as the clinical presentation is consistent with a self-limited viral upper respiratory infection without evidence of pneumonia or respiratory distress. 1

Key Clinical Assessment Points

The absence of respiratory distress is the critical determining factor for outpatient management. This infant lacks the concerning features that would mandate hospitalization, including:

• No hypoxemia (SpO2 remains >90%) 2
• No respiratory distress (no retractions, nasal flaring, or grunting) 2
• No tachypnea 2
• Normal feeding and elimination patterns 3
• No toxic appearance or lethargy 2

While infants <3-6 months with suspected bacterial pneumonia warrant hospitalization 2, 3, this infant's clear chest examination and referred upper airway sounds indicate upper respiratory congestion rather than lower respiratory tract infection. 1

Recommended Management Approach

Supportive Care Measures

• Nasal suctioning before feeds and sleep to relieve congestion and maintain adequate oral intake 1
• Ensure adequate hydration through continued breastfeeding or formula feeding 3
• Upright positioning during and after feeds to minimize aspiration risk from nasal secretions 1
• Humidified air to help loosen secretions 1

What NOT to Do

• Do not prescribe antibiotics, as viral upper respiratory infections are self-limited and antibiotics provide no benefit 1
• Do not use bronchodilators or systemic corticosteroids in infants this age, as they are not recommended for bronchiolitis or viral respiratory infections 1
• Do not obtain chest radiography unless clinical deterioration occurs, as routine imaging is not indicated for uncomplicated upper respiratory infections 1

Close Follow-Up Parameters

Instruct parents to return immediately or call if any of the following develop:

• Increased work of breathing (retractions, nasal flaring, grunting) 2
• Decreased oral intake or signs of dehydration (fewer wet diapers) 3
• Development of fever 4
• Apneic episodes or color changes 2, 3
• Lethargy or decreased responsiveness 2, 3
• Persistent tachypnea (respiratory rate >50/min in this age group) 2

Schedule follow-up within 2-3 days to reassess clinical status and ensure symptom resolution is progressing 3

Special Consideration: Pertussis

Given the 2-week duration of cough in a 3-month-old, consider pertussis in the differential diagnosis. 2 While classic "whooping" may be absent in young infants, pertussis can present with:

• Paroxysmal coughing episodes 2
• Post-tussive vomiting 2
• Apneic spells (particularly concerning in infants <6 months) 2

If pertussis is suspected based on paroxysmal cough pattern or known exposure, obtain nasopharyngeal swab for PCR testing and initiate azithromycin (10 mg/kg/day for 5 days) to reduce transmission, even though it may not alter clinical course at 2 weeks into illness. 2 Household contacts should receive prophylaxis regardless of vaccination status. 2

Common Pitfalls to Avoid

Do not dismiss prolonged symptoms as "just a cold" without ensuring adequate follow-up, as young infants can deteriorate rapidly if secondary bacterial infection develops. 3, 4

Do not assume clear lungs on auscultation completely excludes lower respiratory tract involvement - if clinical deterioration occurs, reassess thoroughly as infants can have pneumonia with initially subtle findings. 2

Do not overlook feeding difficulties as an early sign of respiratory compromise in this age group, as increased work of breathing may manifest first as poor feeding rather than obvious respiratory distress. 3