A Lingering Cold
Dear Dr. Lanny:
How can I tell when my child’s cold has become a bacterial infection and might require antibiotics? I tend to think a little sniffling and coughing is nothing to worry about, but the last time I ignored my kid’s cold it didn’t go away and he left the doctor’s office with a prescription. And I felt guilty for not realizing he was “really” sick.
A: Before answering the question part of your question, I’d like to address your feeling “guilty for not realizing he was really sick.” You knew he was really sick, and your holding off to watch how things would go, was perfectly appropriate. A full-blown cold can include fever, pain and true misery, even though it’s not bacterial. Viruses can be as bad as the worst bacteria—think flu or AIDS. So, we’ll have no guilt around here.
When is a cold not a cold? Not an easy question. I say that a lot, but it’s true. A cold, also known as an upper respiratory infection (URI ), is caused by any one of a host of different viruses. A cold is likely to include cough, nasal discharge, headache and fever. The nasal discharge tends to be clear initially, but may become green or yellow. Yes, that’s right, a viral cold—the only kind there is—can give green or yellow discharge. Colored discharge does not necessarily mean bacteria. Children, as opposed to adults, do not tend to get facial pain or tenderness. The frontal sinuses (the ones just above your eyes) don’t develop until sometime after 5 years of age. When asking children about symptoms, remember that direct questions tend to lead the witness and produce misleading information.
A cold may get worse over a several-day period before starting to get better. It is reasonable to not expect clear improvement before a week has passed. The child who seems sick but not unusually so, and has symptoms for less than a week, has a cold until proven otherwise. Antibiotics are not needed, and are INAPPROPRIATE in a typical cold. At about a week, gradual improvement should be noted.
If your child is not getting better after seven to 10 days, particularly if there is some sign of worsening—for instance fever when there had not been any until now, or increasing rather than improving cough—then you may be dealing with a bacterial infection, specifically sinusitis. For the doctor, sinusitis is very hard to confidently diagnose, particularly in younger children. The symptoms are vague and similar to a cold, and there is nothing you can examine. You can see ears and throats, but you can’t see sinuses. I will always say to parents, “This is compatible with a diagnosis of sinusitis, but it is really an educated guess.”
So now we’ve arrived at the antibiotic … or not. Cough, nasal discharge, maybe a little fever and three, four, five days’ duration. No drugs yet. The same scenario, but more than a week, now an antibiotic seems a reasonable course of action.
Children still ask for that “bubble gum” medicine—Amoxicillin—and they are still right. Amoxicillin remains the first-line drug. Alternatives include Augmentin (works well but often with impressive diarrhea) and Omnicef (cefdinir) or Ceftin (cefuroxime). Zithromax, at once a day for only five days, seems a nice alternative, but is only recommended in severely penicillin-allergic children.
So, once again, I would counsel you to go slow rather than fast with antibiotics. It is often hard to separate a cold from a bacterial infection, but unless the illness seems distinctly worse than the many other colds your child has had, give it a little more time. A day or two without antibiotics is unlikely to make a major difference, and it is certainly not a reason for guilt.
Dr. Alan Freshman, father of two grown sons, practices at Syracuse Pediatrics. Consult your own physician before making decisions about your family’s health care. Send e-mail to him at firstname.lastname@example.org.
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