Swanson’s Family Medicine Review 2017
Ch. 106 – Common Cold

A 4-Year-Old Child with a Runny Nose, Sore Throat, and Nonproductive Cough

A 4-year-old child with a runny nose, congestion, sneezing, and nonproductive cough comes to your office with his mother.  These symptoms started 4 days ago with  a sore throat that has since resolved. His appetite is mildly decreased, but he is well otherwise. He has had no fever, chills, or any other symptoms.

On examination, the child’s temperature is 37.6° C. His ears are clear, and his throat is slightly hyperemic. He has grayish thick nasal discharge, and the nasal  mucosa appears swollen with erythematous nasal turbinates. His lung fields are clear, there is no significant cervical lymphadenopathy, and no other localizing signs are present.

The child’s history is unremarkable, and he has had no significant medical illnesses. His immunizations are up to date.

1. What is the most likely diagnosis in this child?
2. What is the pathogen most frequently associated with this condition?
3. What investigation should be done at this time?
4. Which of the following statements regarding the common cold is (are) true?
   • adults are affected less often than children are
   • the highest incidence of the common cold is among children of kindergarten age
   • infants with older siblings in school or daycare have an increased incidence of colds

1. Preschool children who did not attend childcare are subject to how many colds on an average yearly basis?
2. What is the most effective preventive measure against the common cold?

1. This child most likely has the common cold or URI. It is a viral infection that typically occurs 2 or 3 days after infection. The first symptom noted is usually a scratchy throat, which resolves by the second or third day, and nasal symptoms predominate. All the choices listed are conditions that may mimic a cold. Sneezing and itching are predominant symptoms in allergic rhinitis. Foreign bodies are usually associated with unilateral foul-smelling discharge. Pertussis, associated with paroxysmal or persistent cough, is unlikely because he is vaccinated. The presence of a runny nose and a cough significantly diminishes the probability of streptococcal pharyngitis.

2. The most frequent cause of the common cold is a rhinovirus. Rhinoviruses are responsible for up to 50% of all cases of the common cold, especially in early fall. Rhinoviruses and coronaviruses are agents primarily associated with colds. Other viruses, such as influenza virus, parainfluenza virus, RSV, adenovirus, enterovirus, and mumps and measles viruses, are responsible for colds associated with other clinical syndromes. More than 100 serospecific rhinovirus types have been established, and many viruses remain untyped.

The absence of significant fever, cervical lymphadenopathy, and exudates along with the presence of rhinorrhea and cough significantly decreases the probability of pneumoniae as a cause of this patient’s symptoms.

3. Routine laboratory studies are not helpful or required for diagnosis and management of the common cold. Because the pretest probability of a streptococcal pharyngitis is very low, it is inappropriate to order a rapid antigen test for Streptococcus.

1. In general, the common cold affects children significantly more frequently than adults. The highest incidence is among children of kindergarten age. Adults with young children at home have an increased number of colds, as do infants with older siblings. Often, parents notice the latter (the “second sibling syndrome”) and sometimes need reassurance that their children do not have some other constitutional weakness. Children in out-of-home daycare have 50% more colds than those cared for only at home. This difference decreases as the length of time spent in daycare increases; however, the incidence of illness is higher in the daycare group in the first 3 years of life.

2. Treatment of the common cold focuses on relief of irritating symptoms of rhinorrhea, nasal congestion, and cough. Cold is a viral illness, and antibiotics are not recommended for treatment or prevention of secondary bacterial infection such as otitis media. Use of centrally acting sympathomimetics, such as dextromethorphan and codeine, is not recommended for treatment of cough caused by viral illness in children. They may be of some benefit in adults but may lead to serious adverse effects and dosing errors in children. Antihistamines, inhaled corticosteroids, oral prednisolone, and echinacea have not been shown to decrease the duration nor severity of illness. Antihistamine-decongestant combinations are no more effective than placebos for cough in children. Parental education on the use and side effects of these medications is the key to treatment. If parents insist on using medications, the physician should negotiate discontinuation of medication if symptoms do not improve in 2 days.

Rhinoviruses are temperature sensitive. A controlled study testing warm (30° C) humidified air against hot (45° C) humidified air to provide nasal hyperthermia for 20 to 30 minutes demonstrated a significant reduction in the severity and duration of common cold symptoms at higher temperatures. Thus, it may be that this “old-fashioned” remedy has some basis in fact. Nasal saline drops have also been found to provide relief from congestion. These have the least amount of side effects and are useful in providing some comfort. The use of zinc lozenges for treatment of the common cold in children has been demonstrated to be ineffective.

3. Preschool-aged children, 1 to 5 years old, who do not attend daycare are subject to six to eight colds annually. Infants younger than 1 year average six or seven colds a year. Children in daycare or preschool have a higher incidence because they have greater exposure to the illness. Parents experience approximately four colds and teenagers approximately four or five colds a year.

4. The most effective preventive measure against the common cold is meticulous handwashing and avoidance of contact with the face or nose. There is increasing evidence that aerosol spread of the cold viruses is less important than indirect spread. Experiments suggest that cold-causing viruses can be spread by self-inoculation from deposits of virus on such surfaces as plastics to the surface of the finger and then transferred to mucous membranes of the nose and eye. This is particularly true if the inoculum is still moist.Extra sleep has not been shown to be at all effective. Megadoses of vitamin C have been shown to have some effect in selected populations. Both in adults and in children, regular vitamin C supplementation resulted in a statistically highly significant reduction in the duration of respiratory episodes that occurred during the prophylactic supplementation period. For children, the pooled estimate was 13.2%; for adults, it was 7.7%. Other effective prophylactic therapies include Chizukit, nasal saline with irrigation, probiotics, and zinc sulfate.

   It is unrealistic to suggest avoidance of all contact with children and adults who have colds. Cold viruses are everywhere and will continue to be everywhere.

   Pleconaril is a rhinovirus capsid function inhibitor that exhibits antiviral activity; however, the U.S. Food and Drug Administration rejected its use in 2002 because of its side effects.

A 6-Month-Old with Nasal Congestion and Difficulty Feeding

A 6-month-old infant is brought to your office by her mother, who states that the child has been having nasal congestion for 5 days. The mother states that the child had a clear runny nose at first but now the drainage is thick and yellow, and she seems to be having difficulty with taking the bottle because “she just starts to snort and then spits it out.” She also reports that the baby has had only low-grade fevers with temperature below 38° C. The mother tells you that the baby seems cranky but is consolable and has had difficulty sleeping because of the breathing. She is concerned because her 5-year-old child’s birthday party is in 2 days and she does not want to get everyone infected. She asks you for an antibiotic. On examination, the infant is afebrile. There is no tachypnea. The conjunctivae are slightly  hyperemic but without purulent exudates. The nose is congested with erythematous mucosa and thick yellow drainage bilaterally. The ears are clear. The throat is pink, but postnasal drip is noted. The chest is without retractions and is clear to auscultation.

1. What is the diagnosis?
2. Which of the following agents is the least likely cause of the condition?
3. Which of the following statements about the treatment of this condition in infants is true?
4. Which of the following is the most common bacterial complication of this condition?
5. Which of the following statements is true and is the best answer to the mother’s concern?
6. Which of the following statements about complementary and alternative therapies for the common cold is true?

1. The infant has a common cold, in this case causing mostly a rhinosinusitis. In infants, it is difficult to distinguish bacterial from viral rhinosinusitis. Bacterial rhinosinusitis is a possible complication of viral rhinosinusitis and should be expected if the patient has symptoms lasting more than 10 days with purulent rhinorrhea, severe illness with temperature higher than 39° C, and facial pain. The patient does not have bacterial conjunctivitis because there is no drainage from the eyes. Bronchiolitis is most often caused by RSV, which is the most common viral pathogen causing lower respiratory tract illness in infants. Tachypnea and respiratory distress including wheezing are common presentations. Other manifestations of RSV in infants can be lethargy, irritability, apneic episodes, and poor feeding. Allergic rhinitis does not present with fever and usually is associated with pale, edematous, or violaceous turbinates.

2. Bordetella pertussis, Mycoplasma pneumoniae, and group A streptococci infections in catarrhal stage may be manifested as URI. All the other choices include the viruses that most frequently cause the common cold.

3. Decongestant and antihistamine use in infants has the potential for unusual central nervous system or cardiovascular side effects, such as extreme lethargy or irritability, which far outweigh the small potential benefits. For most URIs, the best treatment is no pharmacologic treatment; however, in those with fever, antipyretics may be used. Aspirin should be avoided because of the risk of Reye syndrome. Expectorants have not been proved to be effective for cough. Cough suppressants are also contraindicated for infants and in fact can cause paradoxical bronchoconstriction in some. Nasal saline drops followed by gentle bulb syringe suction can help loosen secretions and relieve obstruction temporarily and can be particularly helpful just before feeding.

1. Otitis media, the most common bacterial complication of the common cold, occurs in approximately one third of children younger than 4 years old with colds. Sinusitis, pneumonia, and pharyngitis are less common complications. Meningitis is not a typical complication of viral URIs but rarely can be caused by adenovirus in infants or patients who are immunocompromised.

2. There is not enough evidence of important benefits of antibiotics for the treatment of URIs. Indeed, studies have shown significant increases in adverse effects with their use. The infant is probably still infectious. Viral shedding during a URI usually lasts 7 to 14 days and occasionally longer. Even so, most transmission is thought to be by self-inoculation by contaminated hands and some by droplet spread through sneezing; it is unlikely that the infant will spread the infection to all the guests unless parents and sibling neglect to wash their hands and inoculate most household surfaces just before the guests arrive (because viruses can live up to a few hours on plastic surfaces). The color and thickness of nasal secretions do not help to differentiate between bacterial, viral, or allergic cause. 

1. Echinacea purpurea for prophylaxis of URIs does not significantly decrease the frequency, severity, or duration of URIs. There is great difficulty in interpreting the research on echinacea because of the heterogeneity of the product (i.e., there is no standardization of any particular component). Regardless, it is one of the top three herbs sold in the United States. Vitamin C prophylaxis may modestly reduce the duration and severity of the common cold in the general population and may reduce the incidence of the illness in people exposed to physical and environmental stresses. We found that zinc (lozenges or syrup) is beneficial in reducing the duration and severity of the common cold in healthy people when it is taken within 24 hours of onset of symptoms. People taking zinc are also less likely to have persistence of their cold symptoms beyond 7 days of treatment. Zinc supplementation for at least 5 months reduces incidence, school absenteeism, and prescription of antibiotics for children with the common cold.

An 8-year-old boy is brought to your office with “a cold.” He has had the cold for approximately 10 days, and his rhinorrhea, cough, and congestion continue. His mother tells you that she has just seen her fam ily physician for the same symptoms and an antibiotic was prescribed. She asks you to prescribe the same for her son. On examination, the boy has nasal congestion and a hyperemic throat. No other abnormalities are found. Discuss your approach to this patient’s request.

The prescription of antibiotics for an obvious viral infection (the common cold is probably the best example) is likely to be the most frequent “mistake” made by family physicians. It is obviously much easier to prescribe an antibiotic for the child than to explain to the parent why one is not needed. Considering that URIs are a frequent presenting complaint to a family physician’s office, this mistake may actually occur several times a day in an average practice. A reasonable approach to take to this patient’s request may be the following.

1. Explain the viral nature of the symptoms and your certainty in coming to that conclusion regarding the
2. Explain the side effects of antibiotics, including drug intolerance, drug allergy, and the possibility of creating an environment in the patient’s body that promotes the growth of resistant
3. Thoroughly discuss some alternatives to antibiotic therapy that the patient may pursue for symptom relief. For children older than 5 years, these include the use of steam, buckwheat honey, vapor rub, zinc sulfate, and geranium extract. Also suggest increased rest and adequate fluid hydration

1. Take the opportunity to discuss how meticulous handwashing and related hygienic measures can significantly decrease spread of the common cold among family members.
2. Repeat the following age-old edict to the parent: “The symptoms will abate in a week with antibiotics and in 7 days without” (having said that, remember that 30% of patients with common cold symptoms who had visited a physician still had a cough and a runny nose by the eighth day).
3. Do not compromise your principles and prescribe an antibiotic when you know it is, at best, not indicated and possibly harmful. If the parent insists on an antibiotic, consider this an opportunity to discuss your philosophy of care with the patient. Have the parent consider whether he or she is comfortable with the advice you are giving. If not, you should ask the parent if he or she really wishes to continue care in your practice. This can actually be done in a very pleasant manner. There is rarely a problem in reaching a mutually agreeable position. It comes down to a question of trust between the parent, the patient, and the physician.

Summary

1. As the most common presentation of a URI, the cold is the most common problem presenting to the family physician (Table 106-1).
2. Viral infections are the major cause of common
3. Rhinovirus is the most common pathogen (30% to 50%). Another 15% is represented by influenza virus; parainfluenza A, B, and C viruses; and
4. The differential diagnosis of a cold includes allergic rhinitis, vasomotor rhinitis, intranasal foreign body, and
5. No laboratory investigations are The combination of rhinorrhea, cough, congestion, sneezing, and a sore throat (or some reasonable combination) in the absence of significant fever, cervical nodes, or an exudate virtually rules out streptococcal pharyngitis.
6. Prevention of spread to family members is best accomplished by meticulous hygiene. Self-inoculation and direct transfer by hand-to-hand contact is more important than aerosol
7. There is some evidence that large doses of vitamin C may shorten the course of the common cold and slightly better evidence that zinc lozenges can shorten the course of pediatric colds by as much as 1
8. Treatment is symptomatic: steam, nasal saline, and bulb suction. Decongestants and antihistamines, which are commonly used, have no proven
9. Antibiotics have no role in the treatment of uncomplicated URI.

TABLE 106-1 Characteristics of Viral Colds in Adults and Young Children
Characteristic	Adults	Children
Frequency	2-4 per year	One per month, September-April
Fever	Rare	Common during first 3 days
Nasal manifestations	Congestion	Colored nasal discharge
Duration of illness	5-7 days	14 days

From Hendley JO: Epidemiology, pathogenesis, and treatment of the common cold. Semin Pediatr Infect Dis 9:50–55, 1998.

Suggested Reading

Armengol CE, Hendley JO, Winther B. Occurrence of acute otitis media during colds in children younger than four years old. Pediatr Infect Dis J. 2011;30:518–520.

Douglas RM, Hemilä H, Chalker E, et al. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2007;(3):CD000980.

Ebell MH. Antihistamines for the common cold. Am Fam Physician. 2004;70:486.

Fashner J, Ericson K, Werner S. Treatment of the common cold in children and adults. Am Fam Physician. 2012;86:153–159. Pratter MR. Cough and the common cold: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1

Suppl):72S–74S.

Simasek M. Treatment of the common cold. Am Fam Physician.

2007;75:515–520.