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