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Upper Respiratory Infection

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Objectives
Describe the symptoms associated with an upper respiratory infection
Discuss the signs and symptoms of diagnoses that are often complications of upper
respiratory infections
Understand the limited role of diagnostic testing for patients with upper respiratory
infections
List the treatment options for patients with upper respiratory infections

Introduction
An upper respiratory infection (URI), also known as the common cold, is one of the most
common illnesses, leading to more health care provider visits and absences from school and
work than any other illness every year.  Hundreds of different types of viruses cause
inflammation of the membranes in the lining of the nose and throat.   Greater than 50% of
URI are caused by viruses from the rhinovirus family.

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Initial Actions and Primary Survey

As with all initial assessments in the emergency department, attention should be paid to the
patient’s vital signs including temperature, heart rate, respiratory rate, blood pressure, and
oxygen saturation (if obtained).  Neonates are obligate nose breathers and may be at greater
risk for respiratory distress.  The emergency department practitioner should also carefully
auscultate the lungs for adequate aeration and assess the quality of breathing.  Certain
viruses, such as respiratory syncytial virus, put a neonate at greater risk of apnea.  The
cardiovascular examination should include assessing for adequate distal perfusion and an
appropriate-for-age heart rate.  Finally, dehydration can be a complication of any viral illness
and therefore, an assessment of hydration (capillary refill, skin turgor, mucous membranes,
heart rate, responsiveness) should be a part of the initial evaluation.

Presentation
Viruses that cause URI are easily transmitted through sneezing, coughing, or nose blowing. 
Signs and symptoms of URI are rhinorrhea, nasal obstruction, and congestion.  Systemic
symptoms and signs such as headache, myalgias, and fever are may be absent or present
with mild symptoms.

Many viruses that cause rhinitis are also associated with other symptoms and signs such as
cough, wheezing, and fever.  The normal immune response to a virus will produce an
increase in mucus production (rhinorrhea), swelling of the nasal mucosa (congestion),
sneezing (due to irritation of the nose), and cough (due to increased mucus dripping down
the throat).

Table 1:  Selected Pathogens and Associated Symptoms

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Pathogen Signs and Symptoms

Human Rhinoviruses Wheezing & bronchiolitis

Coronaviruses Runny nose, cough

Respiratory Syncytial Viruses Bronchiolitis <2 years old

Human Metapneumovirus Pneumonia and bronchiolitis

Influenza Viruses Influenza, pneumonia, croup

Parainfluenza Viruses Croup, bronchiolitis

Adenoviruses Palpebral conjunctivitis, eye discharge,

pharyngeal erythema

Enteroviruses Herpangina; Aseptic meningitis

Children are most likely to have URI during the fall and winter, starting in late August or early
September until March or April.  The increased incidence of URI’s during the cold season
may be attributed to the fact that more children are indoors and in close contact to each
other.  Additionally, the humidity drops during this season, making the nasal passages drier
and more vulnerable to infection.

Young children have an average of 6-8 URI per year, but 10-15% of children have at least 12
infections per year.  The incidence decreases with age, with 2-3 illnesses per year by
adulthood.

Complications
The most common complication of URI is acute otitis media (AOM).  Symptoms of AOM
may include new-onset fever and earache after the first few days of the onset of URI
symptoms.  AOM has been reported in 5-30% of children with URI.  Younger age and children
in daycare are risk factors associated with a higher incidence.

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Sinusitis is also a complication of URI’s.  Differentiating the common cold from bacterial
sinusitis can be difficult.  The diagnosis of bacterial sinusitis should be considered if
rhinorrhea or daytime cough persists without improvement for at least 10-14 days especially
if fever, facial pain, or facial swelling develops.

Diagnostic Testing
Routine laboratory studies are not helpful for the diagnosis and management of URI.  The
viral pathogens associated with URI can be detected by polymerase chain reaction (PCR),
culture, antigen detection, or serologic methods.  These studies are generally not indicated in
the majority of patients.

Streptococcal pharyngitis and Bordetella pertussis can be suspected in some patients,

especially if there is a history of exposure.  Bacterial cultures or antigen detection is
indicated with appropriate antibiotics for positive results.

An important task of the physician caring for a child with an URI is to exclude other
conditions that are potentially more serious and/or treatable.  The differential diagnosis of
an URI is listed below.

Table 2:  Differential Diagnosis of Upper Respiratory Infections

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Etiology Unique Features

Sinusitis 14 days nasal discharge, cough, fevers,

facial pain

Pneumonia Purulent cough, fevers >101

Allergic Rhinitis Itching, sneezing

Rhinitis Medicamentosa History of nasal decongestant use

Pertussis Paroxysmal coughing fits, vomiting with

cough

Foreign Body Unilateral foul smelling

discharge/secretions

Epiglottitis Dysphagia, drooling, stridor, high fever,

especially in a previously unimmunized
child

Treatment
Antibiotics are ineffective and not indicated to treat URI.  Antibiotic overuse in children has
become a common problem and bacterial antibiotic resistance is increasing.

Inhaled corticosteroids and oral steroids are also ineffective when given to children without
asthma.  Cough in patients with URI can be due to postnasal drip.  Some providers will use a
first-generation antihistamine (anticholinergic properties) but should be used with caution
the very young child.  It should be noted that second-generation “nonsedating”
antihistamines have no effect on an URI.  Honey (5-10mL in children >1 year old) has a mild
effect on relieving nocturnal cough and is unlikely to be harmful.  Honey should be avoided in
children younger than 1 year of age because of the risk for botulism.  Codeine,
dextromethorphan, and expectorants such as guaifenesin are not effective antitussive
agents.

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Treatment is based on symptomatic relief and supportive care.  Options for relief of nasal
obstruction begin with saline nose drops.  Saline (used as drops or as a spray) can help to
thin nasal secretions and improve nasal breathing.  Adrenergic agents such as
xylometazoline, oxymetazoline, or phenylephrine are available as drops or sprays and may be
used in the older child (> 12 years).  These should be used with caution.  Prolonged use can
result in the development of rhinitis medicamentosa, a type of rebound effect that causes
the sensation of nasal obstruction when the drug is discontinued.  Generally, it is not
recommended for use longer than 3 consecutive days.

Zinc, given as oral lozenges to previously healthy patients, reduces the duration but not the
severity of symptoms of URI’s if begun within 24 hours of symptoms.  However, the effect of
zinc on symptoms has been inconsistent to date.

Vitamin C and Echinacea, an herbal treatment, are no more effective than placebo for the
treatment of URI’s.

Pearls and Pitfalls

The majority of URI’s are caused by the rhinovirus family
Younger children have more URI’s than older children and adults
Acute otitis media and sinusitis are known complications of URI
There is a limited role for diagnostic testing in the setting of an URI
Treatment options are limited, supportive, and focus on controlling symptoms

References
1. Ballengee, Cortney R., and Ronald B. Turner. “Supportive treatment for children with the
common cold.” Current opinion in pediatrics 26.1 (2014): 114-118.
2. Bell, Edward A., and David E. Tunkel. “Article Commentary: Over-the-counter cough and
cold medications in children: Are they helpful?.”Otolaryngology–Head and Neck
Surgery 142.5 (2010): 647-650.
3. Carr, Brandon C. “Efficacy, abuse, and toxicity of over-the-counter cough and cold
medicines in the pediatric population.” Current opinion in pediatrics18.2 (2006): 184-188.

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4. Cohen, Herman Avner, et al. “Effect of honey on nocturnal cough and sleep quality: a
double-blind, randomized, placebo-controlled study.” Pediatrics130.3 (2012): 465-471.
5. Das, Rashmi Ranjan, and Meenu Singh. “Oral zinc for the common cold.”JAMA 311.14
(2014): 1440-1441.
6. Fashner, Julia, Kevin Ericson, and Sarah Werner. “Treatment of the common cold in
children and adults.” American family physician 86.2 (2012): 153.
7. Karsch-Völk, Marlies, Bruce Barrett, and Klaus Linde. “Echinacea for preventing and
treating the common cold.” JAMA 313.6 (2015): 618-619.
8. Kliegman, Robert M., et al. Nelson textbook of pediatrics. Elsevier Health Sciences,
2016.
9. Pappas, Diane E., et al. “Symptom profile of common colds in school-aged children.” The
Pediatric infectious disease journal 27.1 (2008): 8-11.
10. Thompson, Matthew, et al. “Duration of symptoms of respiratory tract infections in
children: systematic review.” BMJ 347 (2013): f7027.
11. World Health Organization. “Cough and cold remedies for the treatment of acute
respiratory infections in young children.” (2001).  Available
at: http://www.who.int/maternal_child_adolescent/documents/fch_cah_01_02/en/
(http://www.who.int/maternal_child_adolescent/documents/fch_cah_01_02/en/)

Pediatric Upper Respiratory Infection

Author: John M. Cox, MD, Medical College of Wisconsin

Editor: S. Margaret Paik, MD, Associate Professor of Pediatrics, The University of Chicago, Comer
Children’s Hospital, Chicago, IL

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