Article respiratory

The Common Cold and Decongestant Therapy

Diane E. Pappas, MD, JD,*
Objectives After completing this article, readers should be able to:
J. Owen Hendley, MD*
1. Discuss the clinical presentation, diagnosis, and complications of the common cold in
children.
Author Disclosure 2. Describe the viral causes and pathogenesis of the common cold.
Drs Pappas and 3. Describe transmission of the common cold.
Hendley have 4. Explain the systemic effects of oral decongestants and antihistamines in infants and
disclosed no financial young children.
relationships relevant 5. Recognize that over-the-counter cough and cold preparations have not been ade-
to this article. This quately studied in children younger than 6 years of age and are not recommended.
commentary does 6. List the active ingredients and potential toxicities of over-the-counter cough and cold
contain a discussion medications.
of an unapproved/
investigative use of a
commercial
Introduction
The common cold heralds the beginning of the fall and winter seasons for pediatricians.
product/device.
Almost every ill patient presents with the runny nose, cough, and congestion that are the
hallmarks of the common cold. Although colds are self-limited, most patients (and their
parents) are tired and uncomfortable as a result of these symptoms. No effective treatments
can be prescribed or recommended beyond ordinary supportive care.

Clinical Presentation
Children typically present with cough, sneezing, nasal congestion, and runny nose. Nasal
discharge may be clear initially but often turns yellow-green within a few days. Fever may
be present initially in preschool-age patients, but vomiting and diarrhea are uncommon.
Parents also may report sleep disturbance and increased fatigue. Symptoms persist for at
least 10 days in most children but should begin to lessen by this time. This clinical picture
differs substantially from colds in adults, which present with the typical nasal discharge,
cough, and congestion but no fever and a usual duration of only 5 to 7 days. Sore throat
or hoarseness also may be present in children and adults. (1)

Diagnosis
Common cold is a clinical diagnosis. Subjective complaints may include nasal stuffiness,
sore throat, and headache. Objective findings are few but may include fever, anterior
cervical lymphadenopathy, erythema of the nasal mucosa and oropharynx, and nasal
discharge. Laboratory tests are not helpful; commercially available rapid tests are available
for detection of respiratory syncytial virus (RSV) and influenza. Other conditions to
consider in the diagnosis include nasal foreign body, allergic rhinitis, vasomotor rhinitis,
bacterial sinusitis, rhinitis medicamentosa, and structural abnormalities of the nose or
sinuses. History and physical examination should be sufficient to differentiate these
conditions from the common cold.

Complications
Secondary bacterial infections and wheezing may complicate the common cold. Bacterial
infections include otitis media, sinusitis, and pneumonia. About 30% of colds in preschool-
age children may be complicated by otitis media, (2) and this risk is highest in children 6 to
11 months of age. Sinusitis may occur in 5% to 10% of children who have colds and may be

*Department of Pediatrics, University of Virginia, Charlottesville, VA.

Pediatrics in Review Vol.32 No.2 February 2011 47

respiratory common cold

considered when symptoms are not improving after occur. Cold season begins in September after children
10 days, although diagnostic criteria and the benefit of are back in school, at which time their frequency sharply
antimicrobial therapy are controversial. (3)(4) Other po- elevates and remains at a constant level until spring
tential complications include peritonsillar cellulitis and returns. This epidemic results not from a single cold virus
abscess, conjunctivitis, mastoiditis, and meningitis. but from a number of viruses moving through the com-
Infants and children who have histories of reactive munity during the fall and winter seasons. In the early
airway disease or asthma are at particular risk for compli- fall, rhinovirus begins to increase; parainfluenza viruses
cations, (5) most importantly for increased severity and follow in late fall, with RSV and coronavirus infections
duration of respiratory symptoms. As many as 50% of increasing during the winter months. Cold season con-
asthma exacerbations in children are associated with viral cludes with a final surge of rhinovirus infections in the
infections, especially rhinovirus. Children who have ele- spring. Only a few rhinovirus and enterovirus infections
vated immunoglobulin E concentrations and rhinovirus are still present in the community in the summer.
infection experience more severe respiratory symptoms Colds are most common in children younger than the
than do other children. Studies in adults suggest that an age of 6 years, who routinely experience six to eight colds
impaired cellular response to rhinovirus infection results annually. This frequency may result from susceptibility
in increased viral replication, leading to severe and pro- due to lack of previous exposure as well as from the
longed symptoms. RSV also is associated with wheezing natural attributes of childhood, namely, curious explora-
exacerbations. tion of the world with concomitant poor hygiene. Child
care attendance increases the number of colds experi-
Causes enced by young children as a result of repeated exposure
Rhinoviruses cause at least 50% of the colds in children to other children. By the teenage years, the frequency
and adults and, thus, are the most common sources of decreases to four to five colds every year, with parents of
cold infections. Other causes of the common cold in- young children experiencing only three to four colds
clude adenoviruses, influenza viruses, enteroviruses, annually. Adults who live with young children experience
RSV, and coronaviruses. Cold viruses are not part of the more colds than other adults living without young chil-
normal human flora but are transferred from person to dren in the home.
person and cause the appearance of symptoms 1 to 2 days
after inoculation. Pathogenesis
Some of these viral infections may present as a com- Viral infection of the nasopharyngeal mucosa does not
mon cold or as a more specific syndrome. For example, cause the symptoms of the common cold directly, instead
RSV infection in older children and adults typically pre- initiating a host inflammatory response that produces the
sents the same as any other cold, but RSV may produce symptoms. Cold virus is deposited on the mucosa of the
bronchiolitis involving the lower respiratory tract in in- nose or conjunctivae. Virus then attaches to receptors on
fants and toddlers and can produce a severe presentation. cells in the nasopharynx and enters the cells. Only a small
Similarly, infection with parainfluenza viruses may number of cells become infected. The infected cells
present as croup in younger children and as a typical cold release potent cytokines, including interleukin (IL)-8,
in the older child. Adenoviral infection may present as a which is a chemoattractant for polymorphonuclear cells
common cold or as pharyngoconjunctival fever, with (PMNs). PMNs accumulate in large numbers in the nasal
injected palpebral conjunctivae, watery eye discharge, secretions. Vascular permeability increases and plasma
and erythema of the oropharynx in addition to the usual proteins, including albumin and bradykinin, leak into the
fever and upper respiratory tract symptoms. Enterovi- nasal secretions, increasing the volume of secretions pro-
ruses may produce aseptic meningitis. Coxsackievirus A, duced.
an enterovirus, may cause herpangina, with fever and Bradykinin can cause rhinitis and sore throat, which
ulcerated papules on the posterior oropharynx. Infection may contribute further to the discomfort caused by the
with influenza viruses may present as a febrile respiratory cold. Mucociliary clearance is slowed. Histamine concen-
illness involving the lower respiratory tract, fatigue, and trations do not increase during the course of the com-
muscle aches. mon cold. The nasal mucosa is not destroyed during
rhinovirus and coronavirus infections, but adenovirus
Epidemiology and influenza viruses do destroy the nasal mucosa. Symp-
The occurrence of the common cold is predictable in tom severity correlates with IL-8 concentration over the
terms of who is most affected and when colds usually course of the infection.

48 Pediatrics in Review Vol.32 No.2 February 2011

 respiratory common cold

Infected cells are extruded and washed away with the Transmission
secreted inflammatory mediators, preventing spread of There are three proposed mechanisms for transmission of
the virus to nearby cells. Viral replication declines, the the common cold: small particle aerosols produced from
inflammatory response decreases, and symptoms begin coughing that are inhaled by another person, large par-
to subside. Although symptoms are improved, virus still ticle droplets produced from saliva expelled during a
can be recovered from the nasopharynx for at least sneeze that land on the conjunctivae or nasal mucosa of
2 weeks after inoculation. Finally, after 2 to 3 weeks, another person, or self-inoculation of one’s own con-
adequate neutralizing antibody is available to end the junctivae or nasal mucosa after touching a person or
infection. object contaminated with cold virus. In the experimental
As shown in healthy adults who have experimentally setting, sneezing (large-particle aerosol) has been shown
induced rhinovirus colds, bradykinins and PMNs accu- to be a very inefficient method of transmission of rhino-
mulate in nasal secretions at the onset and for the dura- virus. (6) Small-particle aerosol transmission of rhinovi-
tion of cold symptoms. It is believed that the presence of rus has been shown to occur but also appears to be
PMNs in the nasal secretions, as well as their enzymatic inefficient. (7)
activity, may be the source of the yellow-green color Substantial evidence from the experimental setting
typical of the nasal discharge of the common cold. The suggests that rhinovirus can be transmitted efficiently via
nasal mucosa in children has more secretory capacity than self-inoculation. Rhinovirus is excreted in nasal secre-
that in adults, which may contribute to significant nasal tions but is only present minimally in saliva. Fingers and
discharge for days. hands are frequently contaminated with rhinovirus, as are
Viral rhinosinusitis is a frequent finding during the telephones and other everyday objects. (8) In experimen-
course of the common cold. Imaging of the paranasal tal settings, hand-to-hand transfer and hand-to-surface-
sinuses in children who have uncomplicated colds dem- to-hand transfer have been shown to be feasible mecha-
onstrates abnormalities of the paranasal sinuses in about nisms for transfer of rhinovirus to susceptible individuals.
two thirds of children, most commonly the maxillary and Once the hands are contaminated with cold virus, self-
ethmoidal sinuses. Significant resolution occurs within inoculation readily occurs when a person touches his own
2 weeks. This finding implies that accumulation of fluid nose or eyes with the contaminated hand or fingers. (6)(9)
in sinus cavities may be part of the cold and is not Self-inoculation also appears to be an effective
diagnostic of a bacterial infection. It is not known if sinus method of rhinovirus transmission in the home environ-
involvement results from actual viral infection of the ment because secondary transmission in the home can be
sinus mucosa or from impaired mucus clearance. reduced if self-inoculation is interrupted. In one study,
Abnormal middle ear pressures also occur commonly mothers whose fingertips were treated with virucidal 2%
during the course of illness in both adults and children. aqueous iodine were much less likely to become infected
Abnormal middle ear pressures may be present in up to than mothers whose fingertips were treated with placebo.
two thirds of school-age children during the course of a (9) Similarly, the use of virucidal tissues to interrupt viral
cold. This effect occurs most frequently during the first transfer has been shown to decrease secondary transmis-
several days of illness and resolves within 2 to 3 weeks. sion of colds in the home modestly. (10)
Influenza viruses and coronaviruses can be transmit-
Immunity ted by small-particle aerosol. RSV is not transmitted by
The frequency of colds may be due either to their lack of small-particle aerosol but has been shown to be transmis-
producing lasting immunity or because there are so many sible by large-particle aerosol. RSV and rhinoviruses are
serotypes that immunity to some viral strains has no real not transmissible by oral inoculation.
impact. Viruses that do not produce lasting immunity
after infection include RSV, parainfluenza viruses, and Treatment
coronaviruses, resulting in an individual possibly suffer- Although much desired, effective treatments for the
ing recurrent infection with these same agents. Other common cold remain elusive. Over-the-counter (OTC)
viruses, such as rhinoviruses, adenoviruses, influenza vi- cough and cold medications are readily available for
ruses, and enteroviruses, do produce lasting immunity, children and are sold in various combinations to address
but there are so many serotypes that this immunity has no symptoms. Antihistamines, antitussives, expectorants,
real impact on reducing the frequency of cold infections. decongestants, and antipyretics/analgesics are com-
As a result, an effective vaccine for the common cold is monly sold in combinations. Every week, more than 10%
unlikely. of children in the United States are treated with a cough

Pediatrics in Review Vol.32 No.2 February 2011 49

respiratory common cold

and cold medication, and most of these preparations are Antibiotics

multiple-ingredient products. Symptomatic relief is the pri- The common cold is a viral infection, and there is no role
mary goal of treatment, although preventing disease spread for antibiotics. Antibiotics cannot treat the underlying
and reducing the likelihood of secondary bacterial infec- infection and will not decrease the likelihood of bacterial
tions are also considerations. However, little scientific evi- complications. Antibiotics are indicated only when sec-
dence supports their use, and there is increasing evidence of ondary bacterial complications are diagnosed.
potential adverse effects that may result from their use.
In the past few years, the use of OTC cough and cold Antiviral Agents
medications for children and infants has been under Except in the case of influenza, no antiviral drugs are
intense scrutiny. A total of 123 deaths in children available to treat the common cold. For influenza, a
younger than the age of 6 years have resulted from OTC number of antiviral agents are available and provide
cough and cold medications in the past 20 years. OTC modest reduction in symptoms and duration, including
medications also are a common cause of emergency oseltamivir, amantadine, rimantadine, and zanamivir.
department visits because of adverse effects or accidental These medications inhibit release of virus from infected
ingestions. Poison control centers reported more than cells.
750,000 calls related to the use of OTC cough and cold
medications since 2000. Antihistamines (H1 Receptor Blockers)
The risk for accidental overdose and adverse effects is First-generation antihistamines are common ingredients
likely the result of many factors. Dosing guidelines for in OTC cough and cold medications. Triprolidine, di-
children have not been established but are extrapolated phenhydramine, hydroxyzine, and chlorpheniramine are
from adult data. Parents may be easily confused by prod- all in this class of medications. These medications are
uct labeling. The availability of multi-ingredient prod- well-absorbed, with onset of action within 15 to 30 min-
ucts may increase the likelihood of inadvertent overdose utes and duration of action of 3 to 6 hours or more.
because parents may not understand what they have Because these medications are also anticholinergic, they
given to their child. Finally, multiple caregivers for young decrease mucus secretion. In addition, anticholinergic
children may increase the risk of accidental overdose and action may result in dry mouth, blurred vision, and
adverse reactions further. urinary retention. Gastrointestinal upset may occur. Car-
As a result of a citizen petition filed in March 2007, diac effects have been reported, including tachycardia,
the United States Food and Drug Administration (FDA) prolongation of the QTc interval, heart block, and ar-
initiated a review of the safety and effectiveness of cough rhythmias. Central nervous system (CNS) effects such as
and cold medications for children. In October 2007, sedation, paradoxic excitability, respiratory depression,
FDA advisers voted to recommend that OTC cough and and hallucinations may result, especially in cases of over-
cold medications not be used for treatment of children dose. Dystonic reactions have been reported.
younger than the age of 2 years. Since then, the number Second-generation antihistamines (egs, terfenadine,
of emergency department visits for adverse events related astemizole, loratadine, and cetirizine) lack anticholin-
to the use of cough and cold medications in children ergic activity. These medications have fewer CNS effects
younger than 2 years of age has decreased by more than than first-generation antihistamines. Cardiac effects, al-
half. (11) Drug manufacturers voluntarily discontinued though rare, may occur, including prolonged QT inter-
marketing these products for children younger than age val, ventricular arrhythmia, and heart block.
2 years. The FDA has since issued a public health advisory In adults, several studies show that first-generation
recommending that cough and cold medications not be antihistamines (chlorpheniramine) provide some symp-
used in children younger than age 2 years. FDA advisory tomatic relief of cold symptoms, specifically, decreased
committees have voted to ban OTC cough and cold sneezing and increased mucociliary clearance. Another
medications for use in children younger than age 6 years. study showed decreased nasal discharge and duration of
FDA review of this recommendation is underway. Some symptoms when first-generation antihistamines (chlor-
manufacturers have changed the labeling of their prod- pheniramine) were used to treat adults who had the
ucts to recommend against their use in children younger common cold.
than the age of 4 years. (12) The American Academy of There are few studies of antihistamine use in children.
Pediatrics recommends against the use of OTC cough (14) In one study, children treated with an antihistamine-
and cold medications in children younger than the age of decongestant combination (brompheniramine maleate/
6 years. (13) phenylpropanolamine hydrochloride) showed no improve-

50 Pediatrics in Review Vol.32 No.2 February 2011

 respiratory common cold

ment in cough over placebo other than the treated children tis medicamentosa) when the medication is discontin-
being more likely to be asleep 2 hours after receiving med- ued.
ication. A study of clemastine treatment in children who No information supports the effectiveness of either oral
had colds showed no decrease in nasal discharge, although or topical decongestants in children who have colds. In
the color of the nasal discharge changed from yellow to children ages 6 months to 5 years, one study of a
white. In another study, diphenhydramine at bedtime was decongestant/antihistamine combination (phenyl-
no better than placebo or dextromethorphan in reducing propanolamine/brompheniramine) compared with pla-
cough or improving sleep. Few adverse effects are reported cebo found no improvement in nasal congestion, rhinor-
from first-generation antihistamine use in children. rhea, or cough. (15) In a study of children 6 to 18 months
of age treated with topical phenylephrine, neither nasal
obstruction nor abnormal middle ear pressures improved.
Decongestants (16) In another study in children, xylometazoline had no
Oral sympathomimetic decongestants are available and effect on eustachian tube function. (17) Because infants are
are common ingredients in OTC cough and cold medi- obligate nose-breathers, there is much concern about the
cations. A significant proportion of children (1 in potential dangers of these agents. Deaths in infants and
20) have taken pseudoephedrine in any given week, with young children treated with pseudoephedrine have been
the greatest use in children younger than the age of 2 reported.
years (1 in 12). Oral decongestants include pseudo-
ephedrine, phenylpropanolamine, and phenylephrine. Antitussives
These compounds are vasoconstrictors, acting on adren- Although cough is a protective action that clears airway
ergic receptors to decrease blood flow in the mucosa. secretions to maintain airway patency, it remains one of
Unfortunately, not only the nasal mucosa is affected; the the most bothersome symptoms of the common cold.
use of oral decongestants also results in generalized Suppressing cough effectively may actually be harmful
vasoconstriction with a resultant increase in blood pres- for some children, especially the child who has asthma
sure. Other adverse effects include headaches, seizures, and is unable to clear his or her airway. Nevertheless, a
nausea, vomiting, decreased appetite, agitation, tachy- multitude of OTC preparations are available purporting
cardia, nervousness, irritability, dystonia, and dysrhyth- to suppress cough in children.
mias. One of the most common antitussive ingredients is
Evidence in adults shows that both pseudoephedrine dextromethorphan, a narcotic analog that does not have
and phenylpropanolamine effectively reduce nasal symp- CNS effects unless excessive doses are used. Dextro-
toms, including nasal congestion and sneezing. Phenyl- methorphan is well tolerated at therapeutic doses, with
ephrine undergoes extensive biotransformation, result- few adverse effects. Unfortunately, there are few studies
ing in variable bioavailability, which limits its usefulness. of antitussives in children. In one study of children 18
Increasing governmental control has greatly limited months to 12 years of age, there was no difference in
the availability of oral decongestants. Phenylpropanol- cough between the placebo-, dextromethorphan-, or
amine has been associated with intracranial hemorrhage codeine-treated groups. Furthermore, cough decreased
and was removed from the market in 2000 after being in all three groups after 3 days. (18) Another study in
classified as “unsafe” by the FDA. As a result of the 2005 children ages 2 to 18 years who had acute cough treated
Combat Methamphetamine Act and potential for abuse with dextromethorphan found no improvement in
of the agent, products containing pseudoephedrine are cough with increasing dose. (19)
now kept behind pharmacy counters with monitoring Accidental overdose can cause respiratory depression,
who is purchasing such products. and there are reports of death in infants younger than 12
Topical decongestants act on the adrenergic receptors months of age after dextromethorphan ingestion. In one
in the nasal mucosa to cause vasoconstriction, causing series of accidental ingestions in children younger than 5
nasal tissues to shrink. Onset is rapid, within a few years old (average age, 28 months), the children re-
minutes, and may last several hours. Systemic absorption mained stable hemodynamically, although some experi-
is minimal. Common topical decongestants include enced sedation. Because of the lack of efficacy and the
oxymetazoline, xylometazoline, and phenylephrine. risk of serious adverse effects, the American Academy of
These topical agents can reduce nasal congestion in Pediatrics does not recommend the use of dextrometho-
adults, but their usefulness is limited to only a few days rphan in children. (20)
because of their potential for rebound congestion (rhini- Dextromethorphan can have serious CNS effects, es-

Pediatrics in Review Vol.32 No.2 February 2011 51

respiratory common cold

pecially when ingested in large doses. Once ingested, larly susceptible to these effects and the subsequent
absorption from the gastrointestinal tract occurs quickly. development of apnea. Infants and young children may
Dextromethorphan crosses the blood-brain barrier, be at risk for toxicity due to their immature hepatic
where it blocks serotonin uptake while stimulating sero- enzyme systems because codeine is inactivated by conju-
tonin release. These effects may result in a serious adverse gation in the liver. Drug clearance is also reduced in
reaction called serotonin syndrome, characterized by infants and may increase the risk of toxic effects. Infants
autonomic instability, altered mental status, and neuro- who have impaired lung function (such as those who
muscular abnormalities. Dextromethorphan is also an have bronchiolitis) may have increased susceptibility to
N-methyl-d-aspartate receptor antagonist and inhibits respiratory depression. Death due to accidental overdose
the neurotransmitter glutamate, which can cause a disso- in young infants has been reported. Codeine may cause
ciative state and hallucinations. Dextromethorphan is CNS depression that is reversible with naloxone. Adverse
metabolized via the cytochrome P450 pathway in the effects in children treated with appropriate doses of co-
liver. Some people are “slow metabolizers” and have deine include nausea, vomiting, constipation, and dizzi-
difficulty metabolizing dextromethorphan due to ge- ness.
netic differences. Due to cross-reactivity, rapid immuno- First-generation antihistamines are also marketed to
assay drug screens may incorrectly report excessive dex- suppress cough. Studies in patients who have chronic
tromethorphan ingestion as phencyclidine. cough have reported a decrease in cough frequency when
In recent years, dextromethorphan has increasingly doses causing sedation are employed. These medications
become a drug of abuse for adolescents and young adults may cause thickening of bronchial secretions, and some
because of its ability to produce intoxication, hallucina- believe that their use is contraindicated in children who
tions, and dissociation. DXM, Dex, Skittles, Robo, and have acute wheezing or asthma. Studies in children of
Triple-c are slang terms for dextromethorphan. A num- antihistamine treatment alone or of decongestant/
ber of factors make dextromethorphan an attractive antihistamine combinations have found no improvement
choice for abuse: it is readily available OTC at drug and in cough when compared with placebo.
grocery stores, it is legal to purchase, it is inexpensive, A recent study suggests that honey may provide some
and it is considered harmless. It is also available in pow- relief from nighttime cough in children who have colds.
der form over the internet. With mild intoxication, dex- (22) In this study, a bedtime dose of honey was better
tromethorphan causes a mild stimulant effect that in- than no treatment in children who had cough from colds.
volves euphoria, stupor, and hyperexcitability. Other The generalizability of the results of this single study is
effects may include diaphoresis, nausea, vomiting, nys- limited. Honey is not recommended for children
tagmus, and mydriasis. At higher doses, dextromethor- younger than age 12 months because of the risk of
phan can cause hallucinations, delusions, an ataxic gait, exposure to botulinum spores.
and somnolence. At extreme doses, dextromethorphan
may cause a dissociative state, with paranoia, coma, and
Expectorants
death. (21) The reports in the literature of death in
Expectorants are medications intended to increase mu-
otherwise healthy adolescents and young adults as a
cus production. Guaifenesin is the most commonly avail-
result of dextromethorphan abuse is increasing.
able expectorant. In young adults who have colds, treat-
Codeine often is used as an antitussive. Codeine is a
ment with guaifenesin failed to decrease cough
narcotic that is believed to act centrally on the cough
frequency, but patients did report subjective improve-
center. It is also a mild analgesic and sedative. Although
ment in thickness and quantity of sputum. (23) Other
codeine is the “gold standard” antitussive, no studies in
studies in adults suggest that guaifenesin may reduce
adults or children support the antitussive properties
cough frequency. Studies in children demonstrating ef-
of codeine for treatment of cough associated with the
fectiveness do not exist.
common cold. In fact, in one study of patients ages
18 months to 12 years, codeine was no more effective
than placebo for cough suppression in children who Analgesics/Antipyretics
had nighttime cough due to a cold. (18) The American Analgesics/antipyretics such as acetaminophen, aspirin,
Academy of Pediatrics recommends against the use of and ibuprofen may be useful for the fever and general
codeine in children who have cough. (20) discomfort of the common cold. However, both aspirin
Narcotics such as codeine may cause dose-dependent and acetaminophen suppress the neutralizing antibody
respiratory depression, and infants seem to be particu- response, which results in increased nasal symptoms and

52 Pediatrics in Review Vol.32 No.2 February 2011

 respiratory common cold

prolonged viral shedding. The use of aspirin is not rec- Vaporizers

ommended in children because of its association with Efforts to establish steam inhalation as an effective treat-
Reye syndrome. ment for nasal congestion due to the common cold have
failed to demonstrate benefit. Some studies in adults have
Echinacea even shown that the duration and severity of symptoms
Echinacea is a common herbal therapy recommended for may increase after treatment with humidified air. Inhala-
treatment of the common cold, but few well-controlled tion of steam has not been shown to increase nasal
studies have evaluated its safety and effectiveness. The patency, although many people report subjective im-
most complete and well-controlled study to date dem- provement in nasal obstruction following inhalation. Be-
onstrated no effect of echinacea on severity of symptoms cause rhinoviruses replicate best at 33 to 34°C, inhala-
or rate of infection in adults. (24) tion of steam was hypothesized to reduce rhinovirus
replication, but steam did not reduce viral titers in nasal
secretions during rhinovirus infection.
Menthol
Menthol is a common ingredient in vapor therapies.
Objective evaluation of nasal resistance in adults before Saline Nose Drops/Bulb Suction
and after menthol inhalation showed no effect, although Saline drops with bulb suction are often used to moisten
patients did report a sense of improved air flow. In a the nasal mucosa and loosen secretions for removal from
recent study in school-age children, inhalation of men- infants and children. Adults may use saline nose sprays for
thol did not decrease cough or increase nasal patency, similar purposes. A recent study in school-age children
but patient perception of improved nasal patency was suggests that nasal symptoms and sore throat improve
reported. (25) In a recent study, bedtime application more quickly with daily saline washes. (28)
of a vapor rub (camphor, menthol, and eucalyptus oils)
to the chest and neck of children ages 2 to 11 years Prevention
resulted in symptomatic relief of nighttime cough, con- The best treatment of a cold is prevention. Annual influ-
gestion, and sleep difficulty when compared with petro- enza vaccination is recommended and is the only vaccine
latum or no treatment. (26) Chemical irritation of the available to prevent a respiratory viral infection. Hand-
nasal mucosa may result from topical treatment with washing effectively removes cold viruses from the hands.
menthol preparations. Gastrointestinal and CNS effects Virucidal tissues have been shown to reduce secondary
may result from accidental ingestion. transmission modestly in the home. Virucidal hand gels
are also available, but there are no published studies
Ipratropium Bromide evaluating their usefulness. Alcohol-based hand sanitiz-
Ipratropium bromide is a nasal spray that decreases nasal ers have not been shown to reduce secondary transmis-
discharge of the common cold via its anticholinergic sion of colds in the home or school environment, likely
activity. Unfortunately, its usefulness is limited to chil- because rhinovirus is not affected by these products.
dren older than age 5 years, and adverse effects include Limiting contact with one’s own nasal and conjunctival
nosebleeds, nasal dryness, and headache. mucosa can reduce self-inoculation.

Zinc References
Zinc often is proposed as a treatment for cold symptoms 1. Pappas DE, Hendley JO, Hayden FG, Winther B. Symptom
because in vitro studies have demonstrated that zinc profile of common colds in school-aged children. Pediatr Infect Dis
inhibits rhinovirus replication. Adverse effects include J. 2008;27:8 –11
nausea, bad taste, diarrhea, and mouth or throat irrita- 2. Revai K, Dobbs LA, Nair S, Patel JA, Grady JJ, Chonmaitree T.
Incidence of acute otitis media and sinusitis complicating upper
tion. Some studies in adults suggest that early treatment respiratory tract infection: the effect of age. Pediatrics. 2007;119:
with zinc gluconate can reduce the duration of cold e1408 – e1423
symptoms. Usefulness may be limited by the need for 3. Wald ER, Nash D, Eickhoff J. Effectiveness of amoxicillin/
frequent administration (5 to 6 times/day) and common clavulanate potassium in the treatment of acute bacterial sinusitis in
children. Pediatrics. 2009;124:9 –15
adverse effects, including bad taste and gastrointestinal
4. Garbutt JM, Goldstein M, Gellman E, Shannon W, Littenberg
upset. In schoolchildren (first through twelfth grade), B. A randomized, placebo-controlled trial of antimicrobial treat-
treatment with zinc lozenges did not decrease the dura- ment for children with clinically diagnosed acute sinusitis. Pediat-
tion of cold symptoms. (27) rics. 2001;107:619 – 625

Pediatrics in Review Vol.32 No.2 February 2011 53

respiratory common cold

11. Shehab N, Schaefer MK, Kegler SR, Budnitz DS. Adverse

Summary events from cough and cold medications after a market withdrawal
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• Although colds are self-limited viral infections that 12. Kuehn BM. Debate continues over the safety of cold and
generally resolve in 10 to 14 days, they are a cough medicines for children. JAMA. 2008;300:2354 –2356
common cause of discomfort and distress for 13. American Academy of Pediatrics Urges Caution in Use of
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• Complications can occur, including secondary 2008. Accessed November 2010 at: http://www.aap.org/
bacterial infections and wheezing exacerbations. advocacy/releases/jan08coughandcold.htm
• Given the lack of proven benefit and the risk of 14. Smith SM, Schroeder K, Fahey T. Over-the-counter medica-
significant adverse effects, no prescription or OTC tions for acute cough in children and adults in ambulatory settings.
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care remains the only recommended treatment. 15. Clemens CJ, Taylor JA, Almquist JR, Quinn HC, et al. Is an
• Education of parents should include the current antihistamine-decongestant combination effective in temporarily
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• Although colds may be spread through large-particle Pediatr Infect Dis J. 1996;15:621– 624
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54 Pediatrics in Review Vol.32 No.2 February 2011

 respiratory common cold

PIR Quiz
Quiz also available online at http://pedsinreview.aappublications.org.

1. A 5-year-old boy is brought to your office because of clear nasal discharge, nasal congestion, sore throat,
and temperature of 38.2°C for 2 days. He appears well on physical examination, although his nasal mucosa
and pharynx are erythematous and he has yellowish nasal discharge. Which of the following is the most
likely etiologic agent causing his symptoms?
A. Adenovirus.
B. Haemophilus influenzae.
C. Respiratory syncytial virus.
D. Rhinovirus.
E. Streptococcus pneumoniae.

2. You are evaluating a 2-year-old girl who has a 3-day history of nasal congestion and clear rhinorrhea.
Findings on physical examination reveal erythema of the nasal mucosa and no other abnormalities. You
diagnose a simple viral upper respiratory tract infection. Which of the following is the most likely
complication of this condition?
A. Conjunctivitis.
B. Mastoiditis.
C. Meningitis.
D. Otitis media.
E. Reactive airway disease.

3. A mother brings in her 18-month-old daughter because of a runny nose and congestion for the sixth time
since she started child care 12 months ago. She is worried about the number of “colds” that her daughter
has had and is concerned that something else is wrong. The girl has grown well, and findings on physical
examination are normal except for mild nasal congestion and clear rhinorrhea. Which of the following is
the most likely reason for her recurrent symptoms?
A. Anatomic abnormality of the sinuses.
B. Bacterial colonization of her nasopharynx.
C. Immunoglobulin subclass deficiency.
D. Repetitive exposure to infected children who are coughing or sneezing.
E. Transmission of illness from child care staff.

4. A 3-year-old girl who has the acute onset of nasal congestion, sore throat, and cough presents to the
emergency department in the middle of the night because the cough is keeping her awake. Her parents are
upset because both they and the girl are losing sleep, and they request something to “get rid of the cough.”
Which of the following is the most appropriate recommendation at this time?
A. Oral codeine.
B. Oral dextromethorphan.
C. Oral diphenhydramine.
D. Topical (nasal) phenylephrine.
E. Topical (nasal) saline drops.

Pediatrics in Review Vol.32 No.2 February 2011 55