What are the typical symptoms and recommended management for the common cold?

Common Cold: Symptoms and Management

Typical Symptoms

The common cold presents with rhinorrhea, nasal congestion, sneezing, sore throat, cough, low-grade fever, headache, and general malaise—symptoms that are self-limited and typically resolve within 7-10 days, though up to 25% of patients may experience symptoms for up to 14 days. 1, 2

Symptom Timeline and Progression

• Sore throat peaks early and typically resolves by day 3-4 of illness 1
• Fever and myalgia resolve within 5 days 1
• Nasal congestion and cough persist longer, commonly continuing into the second and third week 1, 3
• Colored nasal secretions are a normal part of the viral cold course and do not indicate bacterial infection 1, 2
• In children specifically, fever is common during the first 3 days, and colds last 10-14 days compared to less than a week in adults 3

Additional Clinical Features

• Throat clearing, postnasal drip, and general weakness may occur 4
• In children, colored nasal secretions may be the only indication of nasal involvement 3
• The paranasal sinuses and middle ear cavities are commonly involved during viral colds even without bacterial superinfection 3

Recommended Management

First-Line Symptomatic Treatment

Use combination antihistamine-decongestant-analgesic products as they provide superior relief compared to single agents, with approximately 1 in 4 patients experiencing significant improvement (odds ratio of treatment failure 0.47; NNTB 5.6). 1, 2

• NSAIDs (ibuprofen 400-800 mg every 6-8 hours) are effective for headache, ear pain, muscle/joint pain, malaise, and also improve sneezing 1
• Acetaminophen/paracetamol (1000mg every 4-6 hours, maximum 4000mg/24 hours) is preferred first-line for pain and fever due to superior safety profile with no GI bleeding risk, no renal effects, and no cardiovascular toxicity 2
• Oral decongestants (pseudoephedrine or phenylephrine) provide modest benefit for nasal congestion 1
• Topical nasal decongestants are effective but limit use to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 1, 2
• Ipratropium bromide nasal spray effectively reduces rhinorrhea but does not improve nasal congestion 1

Cough Management

• Dextromethorphan (60 mg for maximum effect) suppresses acute cough, though standard OTC doses are likely subtherapeutic 1
• Honey and lemon is recommended as a simple, inexpensive home remedy with patient-reported benefit (for children ≥1 year old) 1, 5
• Menthol inhalation provides acute but short-lived cough suppression 1
• Avoid opiate antitussives due to significant adverse effects without clear superiority 1

Evidence-Based Adjunctive Therapies

• Zinc lozenges (≥75 mg/day as acetate or gluconate) significantly reduce cold duration BUT only if started within 24 hours of symptom onset—no benefit if symptoms already established beyond 24 hours 1, 2, 5
• Nasal saline irrigation provides modest symptom relief, particularly beneficial in children, by diluting secretions and facilitating elimination 1, 5

Pediatric-Specific Considerations

• Acetaminophen/paracetamol for fever and pain 1
• Avoid decongestants and antihistamines in children under 3-4 years due to possible adverse effects with no proven benefits 2, 5
• Over-the-counter cold medications should not be used in children younger than four years 5, 6
• Acetylcysteine, honey (≥1 year old), nasal saline irrigation, intranasal ipratropium, and topical ointment containing camphor, menthol, and eucalyptus oils are safe and effective in children 5

What Does NOT Work (Critical Pitfalls)

• Antibiotics are never indicated for uncomplicated common cold—they do not shorten symptom duration, do not prevent complications (sinusitis, otitis media, asthma exacerbation), and contribute to antimicrobial resistance 7, 1, 2
• Intranasal corticosteroids are ineffective for acute cold symptoms 1, 2
• Non-sedating antihistamines (newer generation) are ineffective 1
• Vitamin C and echinacea have no proven benefit for treatment 2

When to Reassess or Suspect Complications

Red Flags Requiring Further Evaluation

• Hemoptysis (any amount warrants chest radiograph) 1
• Fever >38°C (100.4°F) persisting beyond 3 days or appearing after initial improvement 7, 1
• Severe unilateral facial pain suggesting bacterial sinusitis 1
• "Double sickening" pattern (initial improvement followed by worsening) 1, 2
• Acute breathlessness requiring assessment for asthma or anaphylaxis 1

Persistent Symptoms Beyond 10 Days

• Approximately 25% of patients continue with cough and nasal discharge up to 14 days—this is normal and does not indicate bacterial infection 1, 3
• Do not diagnose bacterial sinusitis in the first 10 days—87% of patients show sinus abnormalities on CT during viral colds that resolve without antibiotics 1
• Only suspect bacterial infection if at least 3 of 5 criteria are present: discolored purulent nasal discharge, severe local pain, fever >38°C, "double sickening" pattern, elevated inflammatory markers 1
• Only 0.5-2% of viral URIs develop bacterial complications 1

Patient Education Essentials

• The common cold is viral and self-limited, generally resolving in 7-10 days 7, 1
• Antibiotics will not help and may cause harm 7, 2
• Hand hygiene (washing hands thoroughly with soap and water) is the single most effective prevention measure because transmission occurs primarily through direct hand contact with contaminated surfaces 8, 5
• Patients are most contagious during the first 3 days of illness, though viral shedding begins 1-2 days before symptoms and continues for 5-10 days 8
• Cover mouth and nose when coughing/sneezing, dispose of tissues immediately, and avoid touching face 8