How should I treat a child’s uncomplicated runny nose (viral upper‑respiratory infection) with age‑appropriate supportive care and medication?

Treatment of Runny Nose in Children

For uncomplicated viral upper respiratory infections causing runny nose in children, provide supportive care only—avoid over-the-counter cough and cold medications in children under 6 years of age due to lack of efficacy and serious safety concerns including reported fatalities. 1, 2

Age-Appropriate Medication Guidelines

Children Under 6 Years

• Do NOT use over-the-counter antihistamines or decongestants in children under 6 years of age 1
• Between 1969 and 2006, there were 54 fatalities associated with decongestants (pseudoephedrine, phenylephrine, ephedrine) in children ≤6 years, with 43 deaths occurring in infants under 1 year 1
• During the same period, 69 fatalities were associated with antihistamines (diphenhydramine, brompheniramine, chlorpheniramine) in the same age group 1
• Controlled trials have shown that antihistamine-decongestant combination products are not effective for upper respiratory infection symptoms in young children 1

Children 6 Years and Older

• Topical decongestants (such as oxymetazoline nasal spray) may be used for short-term relief of nasal congestion 1
• Limit use to no more than 3 days to avoid rebound congestion (rhinitis medicamentosa), which can develop as early as the third or fourth day of treatment 1
• For children 6 to under 12 years: 2 or 3 sprays in each nostril not more often than every 10-12 hours, not exceeding 2 doses in 24 hours 3

Recommended Supportive Care

Safe and Effective Interventions

• Saline nasal irrigation provides symptom relief and potentially faster recovery, with moderate evidence quality 2, 4
• Saline helps eliminate excess mucus, reduce congestion, and improve breathing 4
• Adequate hydration to thin secretions 2, 5
• Age-appropriate antipyretics (acetaminophen or ibuprofen) for fever and comfort 2, 5
• Gentle nasal suctioning may help improve breathing, especially in infants 5
• Proper hand hygiene to prevent transmission 2

What NOT to Do

Avoid Antibiotics

• Antibiotics should NOT be prescribed for viral upper respiratory infections as they provide no benefit, may cause harm, and contribute to antibiotic resistance 1, 2, 6
• In adults with post-viral acute rhinosinusitis, antibiotics showed no effect on cure or duration of disease and caused significantly more adverse events (RR 1.28,95% CI 1.06-1.54) 1
• Three randomized controlled trials in children with post-viral rhinosinusitis showed no difference in cure rates or symptom scores between antibiotic and placebo groups at day 14 1

Avoid Ineffective Treatments

• Do NOT use chest physiotherapy—it provides no benefit 6, 5
• Do NOT rely on the color of nasal discharge to distinguish viral from bacterial infections; purulent discharge is a normal evolution of viral infections due to neutrophil influx 2, 6

When to Suspect Bacterial Infection Requiring Antibiotics

Three Specific Patterns Warrant Antibiotic Consideration

1. Persistent symptoms: ≥10 days without improvement 2, 6, 5
2. Double worsening: Initial improvement followed by worsening symptoms 2, 6, 5
3. Severe onset: High fever ≥39°C with purulent nasal discharge for at least 3-4 consecutive days 2, 6, 5

First-Line Antibiotic When Indicated

• Amoxicillin with or without clavulanate is the first-line choice when bacterial sinusitis criteria are met 6, 7

Red Flags Requiring Immediate Evaluation

• Persistent high fever for more than 3 days 2, 6
• Signs of respiratory distress (respiratory rate >50 breaths/min in toddlers, difficulty breathing, grunting, cyanosis) 6
• Oxygen saturation <92% 6
• Not feeding well or signs of dehydration 6, 5
• Symptoms that worsen after initial improvement 2, 6

Common Pitfalls to Avoid

• Do not assume bacterial infection based solely on colored/purulent nasal discharge—this is a normal part of viral URI evolution 2, 6
• Do not obtain imaging studies to distinguish viral URI from bacterial sinusitis—diagnosis is clinical 2, 6
• Do not prescribe antibiotics for uncomplicated viral URI—this contributes to antibiotic resistance without providing benefit 1, 2, 6
• Do not use topical decongestants in children under 6 years due to serious safety concerns 1

Expected Course of Illness

• Viral URIs typically last 5-7 days with symptoms peaking around days 3-6 2, 5
• Nasal discharge naturally evolves from clear/watery to thick and purulent over several days, then returns to clear before resolving 2
• Fever, when present, typically occurs early and resolves within 24-48 hours 2
• 10% of children may still be coughing at day 25, which is normal 6