Upper Respiratory Tract Infections: Best Practices for Managing Fever, Cough, and Congestion

Introduction

Upper respiratory tract infections (URTIs) are among the most common conditions encountered by both pediatricians and family physicians. Globally, these infections are recognized as one of the leading causes of disruption to daily life [1]. URTIs include non-specific inflammatory diseases affecting the nose, paranasal sinuses, pharynx, throat, larynx, trachea, and bronchi. Consequently, their clinical presentation can vary considerably [1,2].

Table 1. Signs of Dehydration in a Child With Fever [7]

Table 2. Signs Indicating That a Child With Fever Requires Medical Attention [7]

Symptoms of uncomplicated acute upper respiratory tract infection (AURI) include nasal congestion, rhinorrhea, sneezing, sore throat, cough, wheezing, fever, headache, general weakness, and fatigue. Patients may also experience vomiting, decreased appetite, and watery eyes. In more severe cases, symptoms of acute rhinosinusitis, pharyngotonsillitis, laryngitis, or tracheitis may develop. Symptoms usually last 7–10 days but may persist longer in some patients [1,3]. Most AURIs are caused by viral infections, while bacterial infections are considerably less common. The most common viral pathogens include rhinoviruses, respiratory syncytial virus (RSV), coronaviruses, adenoviruses, influenza viruses, and parainfluenza viruses. Only a small proportion of patients with AURI have bacterial pathogens such as Streptococcus pneumoniae or Haemophilus influenzae isolated from nasopharyngeal swabs [2]. Because the vast majority of AURIs are viral, antibiotic therapy is generally not indicated. Inappropriate antibiotic use increases the risk of adverse drug reactions, promotes antimicrobial resistance, and raises healthcare costs [4]. One of the main reasons for inappropriate antibiotic prescribing in children with AURI is the inability to rapidly and accurately distinguish viral from bacterial infections based on clinical findings alone. Consequently, differential diagnosis remains one of the greatest challenges in everyday pediatric practice. During the autumn season, AURI presents a significant challenge for pediatricians. In most cases, symptomatic pharmacological and non-pharmacological treatment is recommended to improve the child's condition and shorten the duration of symptoms [5].

Fever Reduction

Fever in infants and young children is one of the most common reasons for seeking medical care. Nearly half of pediatric emergency department visits involve children aged 3–36 months, and approximately 15–25% of these patients present with fever. In most cases, fever is a normal physiological response to a viral infection. Fever is defined as an elevation in core body temperature above normal levels caused by inflammatory mediators. Fever is generally defined as a body temperature above 38.0°C in infants younger than 3 months, above 38.1°C in children aged 3–36 months, and above 38.4°C in children older than 3 years [6,7]. Fever is a natural defense mechanism that activates the body's immune response. Elevated body temperature inhibits the growth of many viruses and bacteria. The main adverse effect of fever is the discomfort it causes. Fever may also pose additional risks for children with underlying cardiac or pulmonary disease because it increases metabolic rate, cardiac output, and oxygen consumption.

Measures to Reduce Fever

Measures to reduce fever can be divided into two categories:

• Physical measures. These include cooling the child's skin with a damp towel or cloth using water at approximately 30°C. Alcohol-containing solutions should never be used. Physical cooling should not be used routinely and is recommended only for children with good peripheral circulation or for those who cannot receive antipyretic medications. The greatest benefit is achieved when cooling is applied approximately 30 minutes after administering an antipyretic.
• Antipyretic medications. Paracetamol (acetaminophen) and ibuprofen are recommended for infants and children. Aspirin should not be used because of the risk of potentially fatal Reye's syndrome, which affects the liver and brain. Metamizole (Analgin) is contraindicated because of its potentially serious adverse effects. Antipyretics should be administered when fever causes significant discomfort, when body temperature exceeds 40°C, in the presence of fluid or electrolyte imbalance, signs of shock, neurological or cardiopulmonary disease, or other conditions associated with increased metabolic demand.

Antipyretics should not be administered solely to reduce body temperature or prevent febrile seizures. Likewise, they should not routinely be given to febrile infants younger than 6 months without medical advice. Because dosing errors are common, antipyretics should always be dosed according to body weight rather than age.

Paracetamol

Paracetamol reduces both fever and pain. The recommended dose is 10–15 mg/kg every 4 hours, with no more than five doses within 24 hours. The maximum daily dose is 60 mg/kg for infants younger than 3 months and 80 mg/kg for children older than 3 months. Its onset of action is typically within 30–60 minutes, peak effect occurs after 3–4 hours, and the duration of action is approximately 6 hours. Oral administration provides optimal absorption. Paracetamol overdose may cause severe liver injury. It should not be administered to infants younger than 3 months without medical supervision.

Ibuprofen

Ibuprofen has potent antipyretic, analgesic, and anti-inflammatory properties. The recommended dose is 5–10 mg/kg every 6 hours, with a maximum daily dose of 40 mg/kg. It begins working within approximately 60 minutes, reaches peak effect after 3–4 hours, and remains effective for 6–8 hours. Ibuprofen may be prescribed for infants older than 3 months who weigh more than 5 kg. It is not recommended for children with impaired renal function or severe dehydration [6,7].

Combination Therapy

The combination of paracetamol and ibuprofen is frequently used in febrile children. Studies have shown that the initial reduction in body temperature is similar between children receiving a single agent and those receiving combination therapy. However, approximately 4–5 hours after administration, body temperature may be lower in children receiving both medications. Despite these findings, the effectiveness and safety of combination therapy remain uncertain. Parents often find alternating or combining medications confusing, increasing the risk of dosing errors and overdose. Furthermore, there is insufficient evidence that combination therapy provides greater overall comfort than treatment with a single antipyretic. Additional studies are needed before routine combination therapy can be recommended [8]. Parents caring for a febrile child at home should ensure adequate fluid intake. Breastfed infants should continue breastfeeding whenever possible. Parents should also monitor for signs of dehydration (Table 1) and receive appropriate education regarding fever management. Situations requiring medical attention are summarized in Table 2. Parents should seek further medical evaluation if the child's condition has not improved within two days of the initial consultation [6,7].

Suppression of Rhinitis Symptoms

Rhinitis symptoms, including nasal congestion and rhinorrhea, can be particularly troublesome for children, especially infants, because they interfere with normal nasal breathing. Non-pharmacological measures are considered the first-line treatment. Initially, the nasal passages should be cleared using a twisted cotton swab or a dedicated nasal aspirator. Particular attention should be paid to cleaning the noses of young children, as they are unable to do so themselves. When helping a child blow their nose, one nostril should be closed while the other is blown. This helps prevent nasal secretions from entering the middle ear and causing otitis media [9]. Non-pharmacological treatment also includes sterile saline nasal sprays as well as isotonic and hypertonic saline solutions. Nasal irrigation temporarily removes excess secretions, moisturizes the nasal mucosa, improves mucociliary clearance, and promotes vasoconstriction [9,10]. Saline preparations are especially useful for infants and children younger than 2 years because they cannot clear nasal secretions independently. However, these preparations may occasionally irritate the nasal mucosa or cause epistaxis. A 2015 systematic review including five randomized controlled trials concluded that saline nasal irrigation may help reduce the symptoms of upper respiratory tract infections [11]. Topical nasal decongestants produce vasoconstriction by stimulating alpha-1 and alpha-2 adrenergic receptors in the nasal mucosa, thereby reducing mucosal swelling. They are administered as nasal drops or sprays, with onset of action occurring within 1–3 minutes. Prolonged use for more than 5–10 days may cause irreversible damage to the ciliated epithelium, resulting in rhinitis medicamentosa. Therefore, treatment should generally not exceed 3 days. If a child accidentally swallows topical decongestants, systemic toxicity may develop, presenting with nausea, headache, tachycardia, circulatory collapse, and, in severe cases, seizures or coma. Xylometazoline, an alpha-2 adrenergic agonist, is most commonly prescribed for children older than 7 years. Oxymetazoline, another alpha-2 adrenergic agonist, is approved for children aged 6 years and older. In Lithuania, lower-dose xylometazoline preparations are also available for children aged 2–11 years [9,12]. Combination oral cold medications often contain systemic decongestants such as pseudoephedrine. These preparations are recommended only for children aged 12 years and older [12]. Antihistamines act by blocking H1 histamine receptors without activating them. First-generation antihistamines, including chlorpheniramine and triprolidine, are commonly found in combination cold preparations. Their anticholinergic properties reduce nasal, lacrimal, and salivary gland secretions, thereby decreasing rhinorrhea and sneezing. However, they are frequently associated with sedation and other central nervous system adverse effects. Second-generation antihistamines, such as loratadine and cetirizine, selectively block H1 receptors but lack significant anticholinergic activity and therefore have little effect on symptoms of viral upper respiratory tract infections [9,13]. Antihistamines are generally recommended for children older than 6 years, whereas combination products containing chlorpheniramine or triprolidine are approved only for children aged 12 years and older [9,12].

Treatment of Cough

Cough is one of the most common and distressing symptoms experienced by children. Nocturnal cough, in particular, disrupts sleep and significantly worsens quality of life [14]. When cough causes substantial discomfort or exhaustion, cough suppressants may be considered. Antitussive medications are indicated for the treatment of dry, non-productive cough. In Lithuania, several preparations suitable for pediatric use are available. Levodropropizine is a non-opioid peripheral antitussive administered as a syrup for children older than 2 years. Codeine is an opioid centrally acting antitussive. Combination preparations containing codeine are approved only for children aged 12 years and older [9,12]. A meta-analysis of seven clinical trials comparing levodropropizine with centrally acting antitussives found that levodropropizine provided significantly greater reductions in cough severity, cough frequency, and nocturnal awakenings. These findings suggest that peripheral antitussives may be more effective than centrally acting agents for suppressing cough [15]. A prospective study compared treatment with cough suppressants alone, antibiotics alone, and a combination of both. Peripheral antitussives were significantly more effective than antibiotics in relieving cough symptoms. Furthermore, cough duration did not differ between children receiving cough suppressants alone and those receiving both cough suppressants and antibiotics [16]. Expectorants that stimulate the cough reflex are primarily herbal preparations containing ingredients such as ivy, thyme, licorice, and elderberry. Their mechanism of action relies on reflex stimulation of cough receptors. These products are available as herbal teas, syrups, creams, balms, or ointments applied to the chest and back. Their use is also subject to age restrictions [9,12]. Mucolytic agents reduce the viscosity of respiratory secretions by breaking down mucopolysaccharides and disulfide bonds within mucus glycoproteins. They are indicated when thick, tenacious secretions are difficult to expectorate and are most commonly used for lower respiratory tract infections. They may also benefit patients with rhinosinusitis by reducing mucus viscosity and facilitating sinus drainage. Acetylcysteine, bromhexine, carbocysteine, and ambroxol may be administered orally from the age of 2 years [9,12]. Nevertheless, adequate hydration remains the safest and most effective natural expectorant in pediatric practice. Sufficient fluid intake helps thin respiratory secretions and facilitates mucus clearance [13].

Treatment of Sore Throat with Antiseptics

Throat lozenges, pastilles, and local sprays containing topical anesthetics such as lidocaine or benzocaine may help relieve sore throat pain. These products are generally recommended for children older than 6 years [9,17]. Preparations containing antiseptic agents such as ambazone, dichlorobenzyl alcohol, chlorhexidine, or chlorquinaldol may also reduce inflammation and soothe throat discomfort. Lozenges and tablets should generally be used only in children aged 5–7 years and older because of the risk of choking [9,12]. There is also evidence supporting the effectiveness of certain herbal preparations for relieving sore throat symptoms [5].

Etiological Treatment

Antibiotic Therapy

The overuse of antibiotics remains a major concern in clinical practice. Because URTIs are predominantly viral, antibiotics are frequently unnecessary. Before prescribing antibiotics, clinicians should carefully assess the likelihood of bacterial infection and ensure that the expected benefits outweigh the potential risks. Inappropriate antibiotic use contributes not only to adverse drug reactions but also to the growing problem of antimicrobial resistance [4,9]. Antibiotics should be prescribed only when a bacterial etiology is suspected or confirmed, such as in streptococcal pharyngotonsillitis, or when symptoms persist longer than expected despite appropriate symptomatic treatment and the patient's condition deteriorates [9,17]. Another important factor contributing to antibiotic overuse is parental expectation. A survey involving more than 600 pediatricians found that parents requested antibiotics in 96% of cases in which antibiotic therapy was not clinically indicated [18].

Antiviral Therapy

Antiviral medications are rarely required in immunocompetent children. Agents such as rimantadine, zanamivir, and oseltamivir are primarily indicated for influenza treatment and prophylaxis. Antiviral therapy for URTIs is generally reserved for immunocompromised children, including those with primary immunodeficiency, patients undergoing chemotherapy, bone marrow transplant recipients, and children with hematological or oncological diseases [9,17]. Published reports indicate that delayed antiviral treatment in these high-risk patients may be associated with increased mortality. A retrospective study evaluating ribavirin therapy in patients who developed parainfluenza infection following hematopoietic stem cell transplantation found no significant mortality difference between treated and untreated patients. The authors suggested that this finding may reflect the administration of ribavirin primarily in patients with advanced or particularly severe infections [19].

Prevention of Acute Respiratory Tract Infections (ARTIs)

Preventive measures include:

• Adequate sleep. Sleep supports normal immune function. Younger children require longer sleep duration than older children. Approximately 10–12 hours of sleep per night is generally recommended [15].
• Breastfeeding. Maternal antibodies transferred through breast milk provide passive immunity and may continue to offer protection against infections even after breastfeeding has ended.
• Avoidance of passive smoking and air pollutants. Exposure to tobacco smoke has been associated with impaired respiratory health in children. Studies have shown that children living in smoking households experience significantly more ARTI episodes than those living in smoke-free environments [20].
• Vitamin D supplementation. In a randomized study involving approximately 600 students, participants receiving vitamin D3 experienced significantly fewer laboratory-confirmed ARTIs than those receiving placebo or performing gargling alone. These findings suggest that vitamin D supplementation may represent an effective preventive strategy against ARTIs [21].

Summary

Most children with acute respiratory tract infections recover spontaneously. Nevertheless, comprehensive supportive care helps relieve symptoms and improve patient comfort. Treatment should be individualized according to the predominant symptoms, with non-pharmacological measures serving as first-line therapy whenever appropriate. Adequate hydration should always be maintained to meet the child's fluid requirements. Because the vast majority of ARTIs are viral, unnecessary antibiotic use should be avoided. Antibiotics should be reserved for children with clear evidence of bacterial infection, as inappropriate antibiotic use may cause more harm than benefit.

Source: "Pediatrics" 2016 / 3 (75)