Patient Presentation
A 2-year-old female comes to clinic after 3 days of clear rhinorrhea. She has been have some coughing and sneezing that her mother says is worse during sleep. She has had a “low grade fever” of 100 degrees Fahrenheit.
She has had no sore throat, ear pain, or rash. She has been drinking normally but has been taking less solid food. She is not playing as much, taking longer naps and wants to be held more. Mother denies seeing her put objects in her nose.
She is in daycare and has had a cold in the past but the coughing is bothering the mother.
The past medical history and family history are negative.
The pertinent physical exam shows an alert female who is afebrile and has a respiratory rate of 24.
HEENT reveals copious clear rhinorrhea anteriorly and in the posterior pharynx. Ears and throat are normal. Lungs are clear.
The diagnosis of an acute upper respiratory infection was made. The mother was counseled about the natural history, and told to give lots of fluids including trying chicken soup.
Discussion
Upper respiratory tract infections (i.e. URIs or common colds) and their potential remedies have been around for centuries.
Adults have about 2 – 4 colds per yearn and children probably more especially those in childcare.
There are at least 200 different viruses identified as causing URIs, most commonly, rhinovirus and coronaviruses but also adenoviruses, enteroviruses, parainfluenza viruses and respiratory syncytial viruses.
Clinically these viruses cause nasal congestion, nasal discharge, post nasal drip. throat clearing and sneezing. Symptoms are usually self-limited lasting 5-7 days.
Many different treatments have been offered over time. Maimonides the Egyptian, Jewish physician and philosopher recommended chicken soup in the 12th century.
Learning Point
Because the numerous studies involving different medications being compared in different populations, it can be difficult to sort out what the research studies show. This is especially true for children whom are often not included in the studies.
Below are recommendations from the Cochrane Collaboration (CC), American College of Chest Physicians (CC) and the American Academy of Pediatrics (AAP).
URI Prevention
- Echinacea – Does not prevent URIs (CC)
- Vitamin C – May prevent getting an URI in people exposed to heavy physical or cold stress (i.e. marathon runners and skiers) (CC)
URI Treatment
- Antibiotics – There is no benefit to using antibiotics. (CC, AACP)
- Antihistamines – No evidence of significant effects in children or adults using antihistamines alone. (CC, AACP)
- Decongestants – Single doses may be moderately effective in adults. Repeated doses are not significantly better than placebo. There is no data for children. (CC, they are not recommended by AACP)
- Antihistamine/Decongestants combinations – Not effective in “small” children, but may cause some general improvement in symptoms in “older children” and adults. (CC) Brompheniramine and sustained-released pseudo-ephedrine are recommended by the AACP but no specific age range is given.
- Cough suppressants – Cough suppressants (peripheral or central) are not recommended for adults or children. (AACP, AAP) Ipratropium bromide is the only inhaled cough suppressant recommended by the AACP but no specific age range is given.
- Chicken Soup – Inhibits neutrophil chemotaxis in vitro (see study below)
- Echinacea – In some preparations might be effective if taken early in adults. There is no data for children. (CC)
- Heated humidified air (i.e. steam) – Not enough evidence to show if it helps or hinders URI symptoms There is no data for children. (CC) Some people recommend cold humidity but no recommendations are given from these 3 groups.
- Vitamin C – Taken at onset of cold symptoms shows no consistent effect on duration or severity of symptoms. There is no data for children. (CC)
- Zinc – Data is conflicting (CC) and it is not recommended by the AACP
Questions for Further Discussion
1. Does green rhinorrhea mean there is a bacterial supra-infection on top of the URI?
2. What are the definitions of acute, sub-acute and chronic cough?
Related Cases
- Disease
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for these topics: Common Cold and Nose Disorders
and at Pediatric Common Questions, Quick Answers for this topic: Cold/Upper Respiratory Tract Infection
To view current news articles on this topic check Google News.
American Academy of Pediatrics. Committee on Drugs. Use of Codeine- and Dextromethorphan-Containing Cough Remedies in Children
Pediatrics. 1997;99;918-920.
American College of Chest Physicians. Evidence-Based Clinical Practice Guidelines. Diagnosis and Management of Cough Executive Summary. Chest. 2006;129:1S-23S.
Rennard BO. Ertl RF. Gossman GL. Robbins RA. Rennard SI. Chicken Soup Inhibits Neutrophil Chemotaxis in Vitro. Chest. 2000;118:1150-1157.
Singh M. Heated, Humidified Air for the Common Cold. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab001728.html (cited 8/31/06)
De Sutter AIM, Lemiengre M, Campbell H. Antihistamines for the Common Cold. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab001267.html (cited 8/31/06)
Taverner D, Latte J, Draper M. Nasal Decongestants for the Common Cold. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab001953.html (cited 8/31/06)
Linde K, Barrett B, Wˆlkart K, Bauer R, Melchart D. Echinacea for Preventing and Treatment the Common Cold. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab000530.html (cited 8/31/06)
Douglas RM, Hemila H, Chalker E, D’Souza RRD, Treacy B. Vitamin C for Preventing and Treatment the Common Cold. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab000980.html (cited 8/31/06)
Arroll B, Kenealy T. Antibiotics for the Common Cold and Acute Purulant Rhinitis. The Cochrane Database of Systematic Reviews 2006;3. Available from the Internet at http://www.cochrane.org/reviews/en/ab000247.html (cited 8/31/06)
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
September 25, 2006
Pediatric Education 