Upper Respiratory Infections (URIs)
by Warren P. Silberstein, M.D.
Upper Respiratory Infections (URIs) are one of the most common causes of illness in childhood. The average child has 6-12 URIs per year. With symptoms that can last a week or more, some children seem to spend the entire winter with a URI. The best known and most frequent URI to afflict mankind is the common cold. URIs include any infection in the nose, throat, sinuses, and ears. Most are caused by viruses. Technically, Streptococcal pharyngitis (Strep throat) is a URI, but since Strep is primarily a throat infection without respiratory symptoms, doctors don't generally include Strep throat when talking about URIs. Sinus infections and ear infections are usually bacterial complications of viral URIs. For the most part, when doctors talk about URIs they are talking about the common cold, influenza, croup (which we'll talk about in a separate article), and a large variety of viruses that cause cold symptoms but make you sicker than the common cold. The major symptoms of URIs include fever, cough, runny or stuffy nose, sore throat, loss of appetite, headache, body aches, and fatigue. Lower Respiratory Tract Infections such as bronchitis, pneumonia, and bronchiolitis are not URIs although they may start with a URI or develop as a complication of a URI.
Many patients visit their doctor for URIs because they believe that they need antibiotics to get better. Since virus infections don't respond to treatment with antibiotics, that is a misconception. However, URIs can sometimes lead to bacterial complications like sinusitis, bronchitis, and pneumonia, and many of the symptoms of these complications such as stuffy head, nasal discharge, cough, and fever, are the same as the symptoms caused by the URI. The only distinction may be that the symptoms are more severe or last longer.
There are many myths and misconceptions about URIs including the following:
- Myth: You catch a cold from being out in the cold or not being dressed warmly.
- Fact: Colds are virus infections. You catch them by being exposed to the germ, usually by being with someone else who has a cold.
- Myth: If you don't treat a cold it will develop into pneumonia.
- Fact: Treatments for colds only provide symptomatic relief (see below for details). Medicines that relieve URI symptoms do nothing to alter the natural course of the illness or prevent complications.
- Myth: Green or discolored mucus means you need antibiotics for an infection.
- Fact: As the nasal discharge begins to dry up it may thicken and discolor. This is not the same as purulent rhinitis (a continuous drainage of pus from the nose) which can be seen with sinusitis.
- Myth: Milk causes mucus.
- Fact: Milk has no effect on mucus or colds. But sick children do sometimes vomit, and milk will aggravate that.
- Misconception: Chest colds are not really in the chest. Coughing can be provoked by irritation of any part of the respiratory tract. Most children with URIs cough from post nasal drip or mucus in the upper airways around the throat. When the lower respiratory tract becomes involved, meaning the bronchial tree and lungs which are what is in the chest, you are dealing with something more than a URI and cold medicines aren't enough.
- Misconception: Most people with colds in social situations tell you not to kiss them to avoid spreading their colds. But then they offer to shake your hand instead. When you consider that most people with colds cough into their hands to avoid spreading their germs and that they handle their dirty tissues and handkerchiefs, unless they make a point of washing their hands constantly, the greatest risk of catching their colds would come from shaking their hand.
If you pay any attention to the TV ads for cold medicines, the advertisers would have you believe that there is a special medicine that works wonders for each of the different varieties of cold symptoms. The first and most important thing that you should understand about cold medicines is that the only thing they do is relieve symptoms. Cold medicines do not cure colds. They cannot make you get better faster. It is not necessary to take a cold medicine just because you have a cold. All medicines have side effects, so if a person's cold symptoms are not very bothersome, he shouldn't take unnecessary medicine and risk its side effects. This is an especially important point with regard to infants because cold medicines can make infants extremely irritable.
Even though colds are not serious illnesses newborns have a very hard time dealing with them. Newborns are obligate nose breathers which means that they try to breathe through their noses no matter how stuffed their noses are. Older infants have learned to breathe through their mouths, but they still have an extremely hard time nursing and sleeping when they have colds. Since cold medicines can make infants extremely irritable, the best way to manage infants' cold symptoms is without medication except for the treatment of fever. A vaporizer or cool mist humidifier at the bedside can help relieve nasal stuffiness. Normal saline (salt water) nose drops are also helpful to relieve stuffiness. When the nasal stuffiness is most severe, the best thing to do is to suction the baby's nose with a bulb syringe. The bulb syringe usually has a broad removable tip that looks too big for the baby's nostrils. Before suctioning you should put a drop or two of saline (salt water) nose drops into the nostril. Squeeze the bulb and then insert the tip into the nostril. Pinch both nostrils closed around the tip of the bulb and then slowly release the suction to pull the mucus down from above. When the infant is sleeping, keep the head of the crib slightly elevated by putting a pillow or rolled blanket under the head of the mattress.
There are only a few basic ingredients in cold medicines so let's try to make some sense of them.
- Decongestants: These include ingredients like pseudoephedrine (Sudafed) and phenylpropanolamine. They shrink the swollen nasal membrane and decrease mucus production. They are most useful for nasal stuffiness. They have some stimulant properties. They may increase the heart rate and blood pressure.
- Antihistamines: These include ingredients like diphenhydramine (Benadryl), chlorpheniramine maleate (Chlor-Trimeton), and brompheniramine maleate (Dimetane). They dry membranes. They are most useful for runny nose and sneezing. They are also useful for allergy symptoms. They may cause drowsiness but young infants may be more irritable than drowsy from antihistamines. Drying of the nasal membrane may aggravate stuffiness so I usually recommend avoiding antihistamines except for very runny noses and severe sneezing. The newer, non-sedating antihistamines like Seldane are not approved for children below the age of 12, but they are not useful for cold symptoms anyway, because they don't dry the nasal membrane.
- Expectorants: The main expectorant ingredient out there is guaifenesin. It is an ingredient in all the Robitussin products but is available in many other brands. I recommend staying away from iodine compounds as expectorants for children. Expectorants are used to loosen a tight cough. Drinking lots of liquids will accomplish the same thing. Guaifenesin may sometimes upset the stomach in large doses but is usually well tolerated.
- Cough suppressants: The main over the counter cough suppressant is dextromethorphan. Narcotics are more potent cough suppressants but should be used with caution in children under two years of age. Cough suppressants are used to quiet irritating coughs. They are especially important in children who cough repetitively, whose sleep is disturbed by coughing, or who vomit from coughing. Narcotics may cause constipation or nausea. The dose of narcotic in cough medicine is not usually high enough to cause drowsiness. Dextromethorphan is generally well tolerated.
- Pain relievers: These include ingredients like acetaminophen (Tylenol, Tempra) or ibuprofen (Advil, Motrin). They are usually found in multi-symptom cold medicines. They are the magic ingredients that turn ordinary cold medicines into Sinus formulas or Sore Throat formulas. I prefer to administer these ingredients separately for control of pain and fever. If you are treating a sick child for fever it is very important to be sure that his cold medicine doesn't have a dose of the same fever medicine in it.
URIs are usually minor illnesses even though they may be major nuisances. The symptoms can often be managed at home without a doctor visit. Even if your child has many URIs each year it usually just means that he is unfortunate enough to be exposed to lots of them. Frequent colds don't suggest any underlying medical problem. The best way to prevent colds is to wash your hands and teach your children to wash their hands, especially before touching your face if you've been with someone who has a cold.
For some children colds are more than just a nuisance. Children with asthma may have increased asthma symptoms with URIs. Children who are prone to ear infections are more likely to have an ear infection if they get a cold. Influenza can make children and adults much sicker than colds and has a higher rate of complications such as pneumonia. Any child who seems very sick or has any worrisome symptom with a URI should see the pediatrician. Persistent symptoms such as cough or fever require evaluation to be sure that the child doesn't have bronchitis, pneumonia, or sinusitis. Sore throats with swollen glands may be part of a viral URI, but should be evaluated to rule out Strep throat since Strep should be treated with antibiotics to prevent complications.