What are the appropriate treatment options for a child with an uncomplicated upper respiratory infection?

Treatment of Pediatric Upper Respiratory Infections

Uncomplicated viral upper respiratory infections in children should be managed with supportive care only—antibiotics provide no benefit and should not be prescribed. 1, 2

Supportive Care Measures

The cornerstone of management for pediatric URIs involves:

• Adequate hydration to maintain fluid balance and help thin secretions 2, 3
• Fever management with age-appropriate antipyretics (acetaminophen or ibuprofen) as needed for comfort 2, 3
• Saline nasal irrigation may provide symptom relief and potentially faster recovery 2
• Rest and maintaining comfortable humidity levels in the home environment 2
• Proper hand hygiene to prevent transmission to others 2

Important Medication Restrictions

• Avoid over-the-counter cough and cold medications in children under 6 years of age due to lack of efficacy and potential adverse effects 3
• Decongestants and antihistamines should be avoided in children under 3 years due to potential adverse effects 2
• Antibiotics are contraindicated for uncomplicated viral URIs as they provide no clinical benefit, expose children to unnecessary adverse events (diarrhea in 5%, rash, potential for serious allergic reactions), and contribute to antimicrobial resistance 1, 2, 4

When Antibiotics ARE Indicated

Antibiotics should only be prescribed when specific bacterial complications are diagnosed based on stringent clinical criteria 1, 3:

Acute Bacterial Rhinosinusitis

Suspect bacterial sinusitis requiring antibiotics when ANY of these patterns occur 2, 3:

• Persistent symptoms lasting ≥10 days without improvement (nasal discharge, daytime cough)
• Worsening symptoms after initial improvement ("double worsening")
• Severe onset with high fever (≥39°C/102.2°F) AND purulent nasal discharge AND facial pain for at least 3-4 consecutive days

First-line antibiotic: Amoxicillin 45 mg/kg/day divided twice daily, or high-dose amoxicillin 90 mg/kg/day for areas with high pneumococcal resistance 1, 3, 5

Alternative: Amoxicillin-clavulanate 90 mg/6.4 mg per kg per day if recent antibiotic exposure or treatment failure 1, 3

Acute Otitis Media

Diagnose AOM only when middle ear effusion is present AND signs of inflammation exist (moderate/severe tympanic membrane bulging, or mild bulging with ear pain or erythema) 3

First-line antibiotic: Amoxicillin 90 mg/kg/day divided twice daily 3, 5

Group A Streptococcal Pharyngitis

Test for streptococcus ONLY if at least 2 of these are present: fever, tonsillar exudate/swelling, swollen/tender anterior cervical nodes, or absence of cough 3

First-line antibiotic: Amoxicillin or penicillin, only after positive rapid test or culture 3, 5

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based on purulent nasal discharge color alone—this is a normal part of viral URI progression and does not indicate bacterial infection 2
• Do not obtain imaging studies (CT, X-ray) to distinguish viral URI from bacterial sinusitis in children 2
• Do not treat "just in case"—the harms of unnecessary antibiotics (adverse events in up to 44% of children, including diarrhea, rash, and contribution to resistance) outweigh any theoretical benefit 1
• Recognize that children in daycare may have protracted viral symptoms lasting up to 15 days, which still does not warrant antibiotics 2

When to Seek Follow-up

Instruct parents to return or call if 2:

• Persistent high fever for more than 3 days
• Worsening symptoms after initial improvement
• Symptoms persisting beyond 10 days without improvement
• Signs of respiratory distress (increased work of breathing, retractions)
• Severe symptoms with concurrent high fever and purulent discharge for the first 3-4 days

The Evidence Base

The American Academy of Pediatrics emphasizes that excessive antibiotic prescribing for URIs has decreased substantially (17% reduction in respiratory tract prescriptions from 1992-2000), but inappropriate prescribing remains common 1. Recent data show that even in 2020,8.8% of children with uncomplicated URIs still received unnecessary antibiotics 4. The most robust evidence demonstrates that antibiotics for viral URIs expose children to a 5% increased risk of diarrhea and rash, with no clinical benefit 1. When bacterial infections are properly diagnosed using stringent criteria, antibiotics do show benefit—for example, in acute bacterial sinusitis, cure rates improve from 14% with placebo to 50% with amoxicillin-clavulanate 1.