What is the likely diagnosis and treatment for a 2-year-old patient presenting with red itchy eyes, cough, and congestion?

Likely Diagnosis and Treatment for a 2-Year-Old with Red Itchy Eyes, Cough, and Congestion

This child most likely has a viral upper respiratory infection with associated viral or allergic conjunctivitis, and treatment should focus on supportive care with avoidance of over-the-counter cough and cold medications, which are contraindicated in this age group. 1

Clinical Assessment

Distinguishing Features to Evaluate

The presentation requires differentiating between viral conjunctivitis (associated with the URI) versus allergic conjunctivitis:

• Viral conjunctivitis typically presents with watery discharge, follicular reaction on the inferior tarsal conjunctiva, and often accompanies upper respiratory infections with preauricular lymphadenopathy 2, 3
• Allergic conjunctivitis is characterized by bilateral itching as the most prominent feature, watery discharge, and may have concurrent allergic rhinitis symptoms like sneezing and nasal pruritus 2, 3
• Check for clear versus purulent discharge—purulent discharge with matted eyelids suggests bacterial conjunctivitis, which is less likely given the concurrent URI symptoms 3

The combination of cough, congestion, and red itchy eyes in a 2-year-old strongly suggests either a viral URI with concurrent viral conjunctivitis, or a viral URI with allergic conjunctivitis if the child has atopic history 2, 4

Treatment Approach

For the Conjunctivitis

If viral conjunctivitis (watery discharge, URI symptoms, possible preauricular nodes):

• Supportive care only—artificial tears for symptomatic relief 3
• Cold compresses 2
• Avoid antibiotics entirely, as they provide no benefit and may cause toxicity 3
• Educate parents about high contagiousness for 10-14 days from symptom onset 3
• Hand hygiene is critical to prevent spread 2

If allergic conjunctivitis (prominent itching, bilateral, possible atopic history):

• Topical antihistamines with mast cell-stabilizing activity such as ketotifen (available over-the-counter) 2, 3, 5
• Cold compresses and refrigerated artificial tears 2
• Avoid eye rubbing 2
• Environmental modifications: identify and avoid allergens if possible 2

For the Upper Respiratory Symptoms

Critical: Do NOT prescribe the following in a 2-year-old:

• Over-the-counter cough and cold medications (contraindicated under age 4-6 years due to lack of efficacy and documented fatalities) 6, 1
• Decongestants (topical or oral) 6, 1
• Antihistamines for the URI symptoms 6, 1
• Antibiotics (unless bacterial complications develop) 1, 4

Recommended supportive care:

• Maintain adequate hydration through continued breastfeeding or formula feeding 1
• Gentle nasal suctioning to clear secretions 1
• Supported sitting position during feeding and rest 1
• Weight-based acetaminophen for fever and discomfort 1
• Nasal saline irrigation can help with congestion 7

Expected Course and Follow-Up

• Most viral URIs resolve within 1-3 weeks, with 90% of children cough-free by day 21 1
• Viral conjunctivitis is self-limited, typically resolving within 5-14 days 3

Red Flags Requiring Urgent Evaluation

For the eyes:

• Visual loss or decreased vision 3
• Moderate to severe pain 3
• Severe purulent discharge 3
• Corneal involvement 3

For respiratory symptoms:

• Respiratory rate >70 breaths/minute (infants) or >50 breaths/minute (toddlers) 1
• Difficulty breathing, grunting, or cyanosis 1
• Oxygen saturation <92% 1
• Poor feeding or signs of dehydration 1
• Persistent high fever ≥100.4°F for 3+ consecutive days 1

Common Pitfalls to Avoid

• Never prescribe OTC cough and cold medications in children under 4-6 years—between 1969-2006, there were 54 decongestant-related and 69 antihistamine-related fatalities in children ≤6 years 6
• Do not prescribe antibiotics for viral URI—the vast majority of coughs and colds in this age group are viral 1, 4
• Do not use topical corticosteroids for conjunctivitis without ophthalmology consultation, as they can prolong viral infections and worsen herpes simplex infections 3
• Avoid indiscriminate antibiotic use for conjunctivitis, which contributes to resistance 3