What is the diagnosis and recommended treatment for a 5-year-old male patient presenting with rhinorrhea, nasal congestion, and fever?

Diagnosis and Management of Viral Upper Respiratory Infection in a 5-Year-Old

This 5-year-old has a viral upper respiratory infection (common cold) that requires supportive care only—no antibiotics, no over-the-counter cold medications, and reassurance about the self-limited nature of the illness.

Diagnosis

This clinical presentation is consistent with viral rhinosinusitis/common cold, characterized by:

• Rhinorrhea (runny nose), nasal congestion, and fever are the classic triad of viral upper respiratory infection in children 1, 2
• The vast majority (98-99.5%) of acute rhinosinusitis cases in children are viral 3
• Viral infections typically present with these symptoms and are self-limited, resolving within 7-10 days 1, 4

Key Diagnostic Considerations

Do NOT diagnose bacterial sinusitis unless specific criteria are met 5, 3:

• Symptoms persist >10 days without improvement, OR
• Symptoms worsen after 5-7 days of initial improvement ("double sickening"), OR
• Severe symptoms at onset (high fever >39°C, purulent nasal discharge, facial pain/swelling)

Since this child has only had symptoms for a few days with fever, this is clearly viral 1, 2.

Treatment Approach

What TO DO:

Supportive care is the cornerstone of management 4, 6:

• Fluids and rest 4
• Nasal saline irrigation to help with congestion 6
• Acetaminophen or ibuprofen for fever and discomfort 6
• Honey (1 teaspoon as needed) for cough if present—only for children ≥1 year old 6

What NOT TO DO:

Avoid over-the-counter cold and cough medications 7:

• The FDA and multiple advisory committees recommend against OTC cough/cold medications in children <6 years due to lack of efficacy and potential toxicity 7
• These medications have caused 54 fatalities with decongestants and 69 with antihistamines in children ≤6 years between 1969-2006 7
• Controlled trials show antihistamine-decongestant combinations are not effective for upper respiratory infections in young children 7

Do NOT prescribe antibiotics 1, 3:

• Antibiotics are ineffective for viral infections 1
• Bacterial superinfection occurs in <2% of cases 1
• Only 0.5-2% of acute rhinosinusitis is bacterial, and 60% of presumed bacterial cases resolve without antibiotics 3

Expected Course and Follow-Up

Natural history of viral URI 1:

• Mean duration: 6.6-8.9 days 1
• Symptoms may last up to 15 days in 7-13% of cases 1
• Cough may persist up to 10 days or longer 1

When to Reassess

Red flags requiring re-evaluation 5, 3:

• Symptoms persist >10 days without improvement 5, 3
• Symptoms worsen after initial improvement 5
• Development of severe unilateral facial pain, high fever returning, vision changes, or mental status changes 5
• Severe headache with neck stiffness (suggests complication) 5

Prevention and Contagion

Hand hygiene is the most effective prevention method 1:

• Rhinovirus spreads most efficiently through direct hand contact 1
• Viral shedding peaks in first 2-3 days and substantially decreases by day 7-10 5
• Recommend isolation at home for 7 days from symptom onset to reduce transmission 1
• Basic respiratory hygiene (covering coughs, handwashing) should continue even as symptoms improve 5

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based on symptom duration alone or the presence of colored nasal discharge—green mucus relates to neutrophils, not necessarily bacteria 3
• Do not use OTC cold medications in children <6 years—they are ineffective and potentially harmful 7
• Do not assume persistent cough requires antibiotics—postinfectious cough lasting 3-8 weeks is expected and self-limited 5
• Reassure parents about the self-limited nature of viral infections to manage expectations and avoid unnecessary treatments 6