Patient education: The common cold in children (Beyond the Basics)

COMMON COLD OVERVIEW — The common cold is the most common illness in the United States. Infants and children are affected more often and experience more prolonged symptoms than adults. The common cold accounts for approximately 22 million missed days of school and 20 million absences from work, including time away from work caring for ill children.

This topic review discusses the causes, symptoms, and treatment of the common cold in children. The common cold in adults is discussed separately. (See "Patient education: The common cold in adults (Beyond the Basics)".)

COMMON COLD CAUSES — The common cold is a group of symptoms caused by a number of different viruses. There are more than 100 different varieties of rhinovirus, the type of virus responsible for the greatest number of colds. Other viruses that cause colds include enteroviruses (echovirus and coxsackieviruses) and coronaviruses, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19). Because there are so many viruses that cause the symptoms of the common cold, people may have multiple colds each year and dozens over a lifetime.

Children under six years average six to eight colds per year (up to one per month, September through April), with symptoms lasting an average of 14 days. This means that a child could be ill with intermittent cold symptoms for nearly half of the days in this time period without cause for concern. Young children in daycare appear to suffer from more colds than children cared for at home. However, when day-care children enter primary school, they catch fewer colds, presumably because they are already immune to a larger number.

Seasonal patterns — The common cold may occur at any time of year, although most colds occur during the fall and winter months, regardless of the geographic location. Colds are not caused by cold climates or being exposed to cold air.

Transmission — Colds are transmitted from person-to-person, either by direct contact or by contact with the virus in the environment. Colds are most contagious during the first two to four days.

Direct contact — People with colds typically carry the cold virus on their hands, where it is capable of infecting another person for at least two hours. If a child with a cold touches another child or adult, who then touches their eye, nose, or mouth, the virus can later infect that person.

Infection from particles on surfaces — Some cold viruses can live on surfaces (such as countertops, door handles, or toys) for up to one day.

Inhaling viral particles — Droplets containing viral particles can be exhaled into the air by breathing or coughing. Rhinoviruses are not usually transmitted as a result of contact with infected droplets, although influenza virus and coronavirus can be transmitted via small droplets. Cold viruses are not usually spread through saliva.

COMMON COLD SYMPTOMS

●Typical common cold – The signs and symptoms of a cold usually begin one to two days after exposure. In children, nasal congestion is the most prominent symptom. Children can also have clear, yellow, or green-colored nasal discharge; fever (temperature higher than 100.4°F or 38°C) is common during the first three days of the illness. The table describes how to take a child's temperature (table 1). (See "Patient education: Fever in children (Beyond the Basics)".)

Other symptoms may include sore throat, cough, irritability, difficulty sleeping, and decreased appetite. The lining of the nose may become red and swollen, and the lymph nodes (glands) in the neck may become slightly enlarged.

The symptoms of a cold are usually worst during the first 10 days. However, some children continue to have a runny nose, congestion, and a cough beyond 10 days. In addition, it is not unusual for a child to develop a second cold as the symptoms of the first cold are resolving; this can make it seem as if the child has a single cold that lasts for weeks or even months, especially during the fall and winter. This is not a cause for concern, unless the child has any of the more serious symptoms, discussed below. (See 'When to seek help' below.)

Symptoms of allergies (allergic rhinitis) are slightly different than those of a cold and may include bothersome itching of the nose and eyes. (See "Patient education: Allergic rhinitis (Beyond the Basics)" and "Patient education: Environmental allergies in children (The Basics)".)

●Common cold caused by SARS-CoV-2 – A common cold caused by SARS-CoV-2 (the virus that causes COVID-19) typically begins four to six days after exposure but may occur as long as 14 days after exposure. In most children, symptoms include fever and a nonproductive cough, although runny nose, abdominal pain, vomiting, or diarrhea may also occur. COVID-19 infection in children is usually mild or even asymptomatic. Severe infection, hospitalization, and death are less common in children than adults.

Unfortunately, a cold caused by SARS-CoV-2 in a child looks like a cold caused by any other cold virus and can only be diagnosed with a COVID-19 test. (See "Patient education: COVID-19 and children (The Basics)".)

COMMON COLD COMPLICATIONS — Most children who have colds do not develop complications. However, parents or caregivers should be aware of the signs and symptoms of potential complications.

Ear infection — Children with a cold may develop a bacterial or viral ear infection. If a child develops a fever (temperature higher than 100.4°F or 38°C) after the first three days of cold symptoms, an ear infection may be to blame. (See "Patient education: Ear infections (otitis media) in children (Beyond the Basics)".)

Asthma — Colds can cause wheezing in children who have not wheezed before or worsening of asthma in children who have a history of this condition.

Sinusitis — Children who have nasal congestion that does not improve over the course of 10 days may have a bacterial sinus infection.

Pneumonia — Children who develop a fever after the first three days of cold symptoms may have bacterial pneumonia, especially if the child also has a cough and is breathing rapidly.

Complications related to SARS-CoV-2 — Children with SARS-CoV-2 infection or recent exposure to someone with SARS-CoV-2 infection may develop rare but serious complications. These include:

●Multisystem inflammatory syndrome in children (MIS-C) – MIS-C is a life-threatening condition characterized by inflammation of the heart, lungs, kidneys, and other organs. It generally occurs in children age 6 to 12 years, but it can occur at any age. Affected children have fever and appear ill. They also may have abdominal pain, vomiting, diarrhea, rash, or bloodshot eyes.

Caregivers who are concerned that their child may have MIS-C should seek emergency care.

●Inflammation of the heart muscle (myocarditis) or the sac surrounding the heart (pericarditis) – Myocarditis and pericarditis are uncommon but life-threatening complications of viral respiratory infections, including COVID-19. In children with myocarditis or pericarditis, exercise can lead to an abnormal heart rhythm, which may cause sudden death in young athletes.

Children and adolescents can have myocarditis or pericarditis without any symptoms. When symptoms occur, they include chest pain, problems breathing, a racing heart, and fatigue.

●Return to sports – Student athletes with cardiac symptoms during a viral illness, those with severe illness (hospitalization, MIS-C, organ damage, etc), and those who have evidence of injury to the heart (eg, myocarditis, abnormal cardiac testing during the viral infection) should be evaluated by a cardiologist before returning to sports practice or competition [1].

COMMON COLD TREATMENT

Symptomatic treatment — The treatment of an infant or child with a cold is different than treatment recommended for adults. Antihistamines, decongestants, cough medicines, and expectorants, alone and in combinations, are all marketed for the symptoms of a cold. However, there have been few clinical trials of these products in infants and children.

The US Food and Drug Administration (FDA) advisory panel has recommended against the use of these medications in children younger than six years [2]. We agree with this recommendation because these medications are not proven to be effective and have the potential to cause dangerous side effects. For children older than six years, cold medications may have fewer risks; however, there is still no proven benefit.

Caregivers may give acetaminophen (sample brand name: Tylenol) to treat a child (older than three months) who is uncomfortable because of fever during the first few days of a cold. Ibuprofen (sample brand names: Advil, Motrin) can be given to children older than six months. Aspirin should not be given to any child under age 18 years. There is no benefit of these medications if the child is comfortable. Caregivers should speak with their child's health care provider about when and how to treat fever. (See "Patient education: Fever in children (Beyond the Basics)".)

Humidified air may improve symptoms of nasal congestion and runny nose. For infants, caregivers can try saline nose drops to thin the mucus, followed by bulb suction to temporarily remove nasal secretions (table 2). An older child may try using a saline nose spray.

Honey may be helpful for nighttime cough in children older than 12 months.

Caregivers should encourage their child to drink an adequate amount of fluids; it is not necessary to drink extra fluids. Children often have a reduced appetite during a cold and may eat less than usual. If an infant or child completely refuses to eat or drink for a prolonged period, the caregiver should contact their child's health care provider.

Antibiotics — Antibiotics are not effective in treating colds. They are necessary only if the cold is complicated by a bacterial infection, like an ear infection, pneumonia, or sinusitis. Caregivers who think their child has developed one of these infections should contact their child's health care provider.

Inappropriate use of antibiotics can lead to the development of antibiotic resistance and can possibly lead to side effects, such as an allergic reaction.

Herbal and alternative treatments — A number of alternative products, including zinc and herbal products such as echinacea, are advertised to treat or prevent the common cold. There is some evidence that prophylactic use of vitamin C may decrease the duration of the common cold in children, but it is insufficient to recommend routine use of vitamin C. With the exception of vitamin C, none of these treatments have been proven to be effective in clinical trials; their use is not recommended.

COMMON COLD PREVENTION — Simple hygiene measures can help to prevent infection with the viruses that cause colds. These measures include:

●Hand washing is an essential and highly effective way to prevent the spread of infection. Hands should be wet with water and plain soap, and rubbed together for 15 to 30 seconds. It is not necessary to use antibacterial hand soap. Teach children to wash their hands before and after eating and after coughing or sneezing.

●Alcohol-based hand rubs are a good alternative for disinfecting hands if a sink is not available. Hand rubs should be spread over the entire surface of hands, fingers, and wrists until dry and may be used several times. These rubs can be used repeatedly without skin irritation or loss of effectiveness.

●It may be difficult or impossible to completely avoid people who are ill, although caregivers should try to limit direct contact.

●Keep all of the child's immunizations up to date, including [3]:

•Annual influenza (flu) vaccine (children aged six months and older)

•COVID-19 vaccine (children aged six months and older)

•Respiratory syncytial virus (RSV) monoclonal antibody shot (timing determined by the following):

-During an infant's first week of life if born during RSV season and birthing parent did not receive an RSV vaccination at least 14 days before delivery

-Upon entering first RSV season if not born during RSV season and less than eight months old

-Greater than eight months old at increased risk of severe RSV disease and did not receive immunizing shot on time

-Children 8 to 19 months old at increased risk of severe RSV disease upon entering their second RSV season

Evidence suggests that children who received a flu vaccine in the current flu season and were infected with COVID-19 were less likely to have symptoms and severe disease. Similarly, children who completed their pneumococcal vaccine series (sample brand name: Prevnar) were less likely to have symptoms when infected with COVID-19. The RSV monoclonal antibody shot reduces the risk of severe RSV infection by approximately 80 percent [4].

Maternal RSV vaccination during pregnancy at 32 to 36 weeks causes the mother's body to make antibodies against RSV that then pass on to the baby. This provides protection against RSV infection and reduces the risk of hospitalization due to RSV infection during the first six months of life by 57 percent [5].

●Isolate children with symptomatic respiratory infections (including known or suspected COVID-19, flu, and RSV infection) according to local and Centers for Disease Control and Prevention (CDC) guidance [6]. Current recommendations include:

•Stay at home for at least 24 hours after symptoms are improving and no fever is present (without fever-reducing medication)

•For the next five days, wear a mask, cover your mouth and nose with a tissue when sneezing or sneeze into your elbow when you don't have a tissue, and wash your hands frequently

●Using a household cleaner that kills viruses, such as phenol/alcohol (sample brand name: Lysol), may help to reduce viral transmission.

WHEN TO SEEK HELP — If a child develops any of the following features, the caregiver should call their health care provider, regardless of the time of day or night.

●Refusing to drink anything for a prolonged period

●Behavior changes, including irritability or lethargy (decreased responsiveness); this usually requires immediate medical attention

●Difficulty breathing, working hard to breathe, or breathing rapidly; this usually requires immediate medical attention

Caregivers should call the health care provider if the following symptoms develop or if there are general concerns about the child:

●Fever greater than 101°F (38.4°C) lasts more than three days. The table describes how to take a child's temperature (table 1).

●Nasal congestion worsens or does not improve over the course of 10 days.

●The eyes become red or develop yellow discharge.

●There are signs or symptoms of an ear infection (pain, ear pulling, fussiness).

SUMMARY

●The common cold is a group of symptoms caused by a number of different viruses, including SARS-CoV-2, the virus that causes COVID-19. Children under six years average six to eight colds per year (up to one per month, September through April), with symptoms lasting an average of 14 days. This means that a child could be ill with intermittent cold symptoms for nearly half of the days in this time period, without cause for concern.

●Colds are most contagious during the first two to four days. People with colds typically carry the cold virus on their hands, where it is capable of infecting another person for at least two hours. Some cold viruses can live on surfaces (such as countertops, door handles, or toys) for as long as one day. Droplets containing viral particles can be exhaled into the air by breathing, coughing, or sneezing.

●The signs and symptoms of a cold usually begin one to two days after exposure. In children, nasal congestion is the most prominent symptom. Children can also have clear, yellow, or green-colored nasal discharge. Fever (temperature higher than 100.4°F or 38°C) is common during the first three days of the illness. Other symptoms may include sore throat, cough, irritability, difficulty sleeping, and decreased appetite.

●COVID-19 infection in children is frequently either asymptomatic or results in a mild cold with fever and a cough (although runny nose, abdominal pain, vomiting, or other symptoms may occur). Infection caused by COVID-19 typically begins four to six days after exposure but may occur as long as 14 days after exposure. Severe infection, hospitalization, and death are less common in children than adults.

A cold caused by COVID-19 in a child looks like a cold caused by any other cold virus and can only be diagnosed with a COVID-19 test.

●Children with known or suspected COVID-19 infection should stay home according to local and Centers for Disease Control and Prevention (CDC) guidance. Updated guidance from the CDC recommends that a child with any respiratory illness stay home at least 24 hours after symptoms are improving and the child is free of fever (without fever-reducing medication) for at least 24 hours.

●Most children who have colds do not develop complications. However, caregivers should be aware of the signs and symptoms of potential complications, including ear infections, asthma, sinusitis, pneumonia, multisystem inflammatory syndrome in children (MIS-C), myocarditis, and pericarditis.

●Student athletes with cardiac symptoms during a viral illness, those with severe illness (hospitalization, MIS-C, organ damage, etc), and those who have evidence of injury to the heart (eg, myocarditis, abnormal cardiac testing during the viral infection) should be evaluated by a cardiologist before returning to sports practice or competition.

●There have been few clinical trials of cold medications (antihistamines, decongestants, cough medicines, and expectorants) in infants and children. We do not recommend their use in infants and children because of the lack of proven efficacy and the potential risk of dangerous side effects.

●Caregivers may give acetaminophen (sample brand name: Tylenol) to children older than three months or ibuprofen (sample brand names: Advil, Motrin) to children older than six months to treat discomfort associated with fever. Humidified air can improve symptoms of nasal congestion and runny nose. Honey may be helpful for nighttime cough in children older than 12 months.

●Caregivers should encourage their child to drink an adequate amount of fluids; it is not necessary to drink extra fluids.

●Antibiotics are not effective in treating colds. They are necessary only if the cold is complicated by a bacterial infection, like an ear infection, pneumonia, or sinusitis. Caregivers who think their child has developed one of these infections should contact their child's health care provider. Inappropriate use of antibiotics can lead to the development of antibiotic resistance and can possibly lead to side effects, such as an allergic reaction.

●A number of alternative products, including zinc, vitamin C, and herbal products such as echinacea, are advertised to treat or prevent the common cold. None of these treatments is recommended. With the possible exception of vitamin C, none of these treatments have been proven to be effective in clinical trials. Although there is some evidence that prophylactic use of vitamin C may decrease the duration of the common cold in children, it is insufficient to recommend routine use.

●Simple hygiene measures can help to prevent infection with the viruses that cause colds, including hand washing or use of an alcohol-based hand rub and limiting contact with others who are ill.

●Keep all immunizations up to date.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients and caregivers, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Cough, runny nose, and the common cold (The Basics)
Patient education: Sore throat in children (The Basics)
Patient education: Sinusitis in adults (The Basics)
Patient education: Giving your child over-the-counter medicines (The Basics)
Patient education: Eustachian tube problems (The Basics)
Patient education: Pneumonia in children (The Basics)
Patient education: Swollen neck nodes in children (The Basics)
Patient education: Adenovirus infections (The Basics)
Patient education: Mycoplasma pneumonia in children (The Basics)
Patient education: Enterovirus D68 (The Basics)
Patient education: COVID-19 and children (The Basics)
Patient education: How to wash your hands (The Basics)
Patient education: Lowering the risk of spreading infection (The Basics)
Patient education: How to use nasal medicines (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: The common cold in adults (Beyond the Basics)
Patient education: Fever in children (Beyond the Basics)
Patient education: Ear infections (otitis media) in children (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

The common cold in children: Clinical features and diagnosis
The common cold in children: Management and prevention
Acute bacterial rhinosinusitis in children: Clinical features and diagnosis
Acute bacterial rhinosinusitis in children: Microbiology and management
Approach to the child with recurrent infections
Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis
Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections
The common cold in adults: Treatment and prevention
Zinc deficiency and supplementation in children

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

●National Institute of Allergy and Infectious Diseases

(www.niaid.nih.gov/)

●Centers for Disease Control and Prevention (CDC)

Phone: (404) 639-3534

Toll-free: (800) 311-3435

(www.cdc.gov)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges J Owen Hendley, MD, who contributed to earlier versions of this topic review.

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