What is the diagnosis and treatment for a pediatric patient presenting with cough, abdominal pain, fever (warm to touch), and nasal congestion?

Diagnosis and Management of Pediatric Upper Respiratory Infection

Most Likely Diagnosis

This child most likely has a viral upper respiratory infection (common cold/viral rhinitis), which is self-limited and does not require antibiotics. 1, 2

The presentation of cough, nasal congestion, and fever ("warm to touch") in a pediatric patient is classic for viral URI. 1, 3 The abdominal pain is likely secondary to coughing or swallowed mucus, which is common in young children with respiratory infections. 4

Key Diagnostic Considerations

When to Suspect Bacterial Infection

You should NOT diagnose bacterial sinusitis unless the child meets one of these three specific criteria: 1

• Persistent symptoms: Nasal discharge or daytime cough for >10 days without improvement 1
• Worsening symptoms: New or worsening fever, cough, or nasal discharge after initial improvement ("double sickening") 1
• Severe symptoms: Fever ≥39°C (102.2°F) with purulent nasal discharge for ≥3 consecutive days 1

Critical pitfall: The color of nasal discharge does NOT distinguish viral from bacterial infection—mucopurulent secretions commonly occur with viral infections after a few days. 2, 5

Red Flags Requiring Urgent Evaluation

Seek immediate medical attention if the child develops: 2

• Respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children) 2
• Difficulty breathing, grunting, or cyanosis 2
• Oxygen saturation <92% 2
• Not feeding well or signs of dehydration 2
• Severe unilateral facial pain/swelling (orbital complications) 1
• Severe headache, photophobia, or altered mental status (CNS complications) 1

Treatment Approach

Supportive Care (First-Line Management)

Provide supportive care only—antibiotics are not indicated for viral URI. 1, 2

Appropriate supportive measures include: 2, 3, 6

• Acetaminophen or ibuprofen for fever and discomfort 2, 3
• Adequate hydration to thin secretions 2, 6
• Gentle nasal suctioning for infants 2
• Honey for cough (only if child is >1 year old) 6
• Nasal saline irrigation 6

Critical Safety Warning for Young Children

Do NOT use over-the-counter cough and cold medications in children under 2 years of age. 2 These medications:

• Have no proven efficacy in children <6 years 2
• Caused 54 decongestant-related deaths and 69 antihistamine-related deaths in children <6 years between 1969-2006 2
• Were voluntarily removed from the market for children <2 years in 2007 2

Do NOT use topical decongestants in children <1 year due to narrow therapeutic window and risk of cardiovascular/CNS toxicity. 2

When to Prescribe Antibiotics

Only prescribe antibiotics if the child meets criteria for acute bacterial sinusitis (see above). 1

First-line antibiotic choice: Amoxicillin or amoxicillin-clavulanate 1

For penicillin allergy: Cefdinir, cefuroxime, or cefpodoxime 1

Avoid: Trimethoprim-sulfamethoxazole and azithromycin due to high resistance rates in pneumococcus and H. influenzae 1

Follow-Up and Expected Course

Natural History of Viral URI

• Most viral URIs resolve within 7-10 days 7, 6
• Cough may persist up to 10 days or longer 7
• Approximately 7-13% of cases have symptoms lasting >15 days 7
• 90% of children with bronchiolitis are cough-free by day 21 2

When to Re-Evaluate

Schedule follow-up if: 2

• Symptoms are deteriorating or not improving after 48 hours 2
• Symptoms persist beyond 10 days without improvement (consider bacterial sinusitis) 1
• Cough persists beyond 4 weeks (transitions to chronic cough requiring systematic evaluation) 2

Imaging Considerations

Do NOT obtain imaging for uncomplicated viral URI. 1 Plain radiography, CT, and MRI should not be performed to differentiate viral from bacterial infection. 1

Only obtain contrast-enhanced CT or MRI if you suspect orbital or CNS complications (proptosis, impaired extraocular movements, severe headache, focal neurologic findings). 1