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Diagnosis and management of colds and flu in children

Key learning points

  • Children with symptoms of the common cold should be evaluated for more serious illness
  • Under-fives with flu and fever are at increased risk of complications and hospitalisation
  • Parent/carer education on symptom relief is the primary treatment for viral upper respiratory tract infection
  • Antibiotic treatment is unnecessary and should be reserved for bacterial illness
  • In 2017/18 influenza vaccination for children in schools will be extended

Coughs and colds in children are common, self-limiting and generally uncomplicated. Yet anxious parents or carers frequently seek advice from nurses in primary care about symptoms and management, and some request treatment with antibiotics.As autumn approaches, with its predictable surge in respiratory viruses, it is timely to consider the diagnosis and management of colds and flu in children, as well as how to differentiate between the two infections.

How severe is the illness?

The common cold is a mild, self-limiting, viral, upper respiratory tract infection that occurs frequently in young children, probably because they have close contact with one another, act as reservoirs of infection, and have greater susceptibility.2 In contrast, flu-like illness tends to be worse, with a sudden onset and more severe symptoms.3

Young children and infants can be very unwell and are at greater risk of more serious illness, particularly if they have pre-existing conditions such as congenital cardiac problems, asthma or a history of chest infections.4 Hospitalisation rates due to flu are higher in children under five than in any other age range.5 This illustrates the importance of starting your assessment by listening carefully to parents’ concerns, and documenting a detailed medical history before undertaking an appropriate examination. This clinical detail is essential in order to inform your diagnosis and to rule out more serious illness.

What are the characteristics of a cold? 

A cold virus is characterised by nasal stuffiness and discharge, sneezing, fever, sore throat and cough and is more likely to affect children than any other age group.6 Infections are more common in the winter months but can occur throughout the year. There are many viruses that cause ‘common cold’ symptoms, including rhinoviruses, adenoviruses, respiratory syncytial virus (RSV) and coronaviruses.7 Children experience an average of five to six colds per year, but younger children who attend primary school or nursery may have up to 12 colds per year.6

The onset of symptoms after infection is sudden and peaks within two to three days. Following this, symptoms diminish and last for about a week (although in younger children it can be 10 to 14 days).5 A fever of 38-39oC is commonly seen in younger children with colds, although it’s less likely in older children and adolescents.8

Complications from a cold virus occasionally happen after viral spread to adjacent organs, or secondary bacterial infection such as lower respiratory tract infection, exacerbation of asthma, otitis media, bronchiolitis, pneumonia and croup.6

What are the characteristics of flu? 

Flu is characterised by sudden onset of fever, myalgia, headache, malaise, dry cough, sore throat and nasal congestion, and illness is often worse than with other viral infections.3 Children may also experience gastrointestinal symptoms including nausea, vomiting and diarrhoea.3 In infants and young children, the virus can cause lethargy, poor feeding, breathing difficulties and febrile convulsions and the risk of serious illness is higher under six months of age.4

Outbreaks of flu are likely to occur in a 10-week period each winter causing high morbidity and mortality in at-risk groups.9 For this reason flu vaccination has been offered to all children aged two to eight years since 2013, in addition to all those at increased risk.For otherwise healthy children, flu is an unpleasant but usually self-limiting disease with recovery usually within seven days. The illness is highly infectious with an incubation period of one to four days.4

Complications are usually respiratory in nature and include pneumonia, exacerbation of asthma, otitis media and bronchitis.5 Children under five years of age, especially infants, who have feverish symptoms are at increased risk of serious illness and require a low threshold for re-assessment.4 Although rare, more serious complications such as meningitis, encephalitis or meningoencephalitis can also occur. 

Initial assessment

A distressed, uncomfortable child causes parental concern and primary care nurses are well placed to offer reassurance and advice. Recognition of alarm features is dependent on detailed evaluation of the history, and nurses should recognise when to refer to specialist services. 

The initial approach in assessing an unwell child is especially important, as fear has a greater physiological effect in childhood than in any other age group.10 Establishing rapport and engaging children in conversation at the outset will set the scene for the consultation that follows. This may seem obvious, but young children often feel misunderstood by health professionals.11

The child’s age and development level should lead the approach to history taking and examination. Paediatric history taking requires not only a systematic investigation of the presenting symptoms, but also an exploration of parental anxiety and an overview of general medical history. For instance, it is necessary to ask specifically about previous respiratory problems (including asthma), hospital admissions, chest infections and medications. In younger children, perinatal history and immunisation status are relevant, as they may indicate greater risk of complications and illness severity.

Physical examination 

While the features of the common cold are familiar to most parents and carers, it is important to bear in mind that symptoms can be vague and may overlap with more severe illnesses. Children younger than five years of age (especially infants) who have feverish symptoms are at increased risk of serious illness and require a full clinical examination.12 The approach, technique and findings of physical assessment vary considerably between birth and adolescence, and competence in examination of all age groups is required when undertaking paediatric consultations.13

Examination should be opportunistic rather than sequential (for example, respiratory and heart rates should be measured while the child is settled), and structured in order to perform the least (potentially) distressing elements first. Examination of the ears and throat should always be left until the final stage.10 Remember that if a child is unwell, feverish and drooling it is essential that throat examination is not performed, as symptoms may indicate epiglottitis (a serious bacterial infection that requires urgent paediatric referral).13

Quality standards on fever in under-fives14 state that, as a minimum, health professionals must record temperature, heart rate, respiratory rate and capillary refill time if fever is suspected. Serious illness such as pneumonia or meningitis may have ‘cold-like’ symptoms at onset, and in very young children it is wise to have a low threshold of suspicion. 

Guidelines on recognition of sepsis have been published by NICE15 and provide a clear indication of risk factors, including low oxygen saturations. Full assessment must be undertaken of an unwell, feverish child to exclude non-blanching rash, skin mottling, cold hands and feet, painful extremities, headache, neck stiffness or altered behaviour.13 

Any indication of upper airway distress (acute cough, stridor, drooling, difficulty swallowing, increased respiratory rate) or lower airway distress (laboured breathing, accessory muscle usage or history of apnoea) must be urgently reviewed.  

Remember there is also a clear association between viral respiratory infections and acute exacerbations of asthma in children. Primary care nurses need to be aware of indicative signs and ensure that parents of asthmatic children have clear guidance on the recognition and management of worsening features.16 

What treatments are available for a cold? 

No known treatment reduces the duration of infection.6 The main focus of advice is education to assist parents and carers to be competent and comfortable with home care of respiratory illness.5 Consistency of advice is important, and it is essential to refer to evidenced-based guidelines and not rely on personal opinion. One example of this is the use of zinc supplements, which some studies have suggested may reduce the frequency of colds.8 This recommendation was based on just two trials and both had methodological concerns, therefore evidence is weak.2

Parents and carers should be reassured that although symptoms may be distressing, complications are rare and the illness usually resolves within seven days. Symptom relief is the most appropriate management for children, including the use of paracetamol or ibuprofen as an antipyretic or analgesic if needed.6 Guidelines regarding analgesia18 and management of febrile illness in children under five12 have clear instruction on the advice to give. This can be summarised as follows:

  • Do not give both agents simultaneously.
  • Continue only as long as the child appears distressed.
  • Consider changing to the other agent if the child’s distress is not alleviated.
  • Only consider alternating these agents if the distress persists or recurs before the next dose is due.

Parents and carers may be tempted to try over-the-counter remedies, and it is important to reiterate that antitussives, expectorants, nasal decongestants and antihistamines should not be used in children under six years.19 Remember also that parents should be advised not to use aspirin in children under 16 years because of the risk of Reye’s syndrome.20 In young babies who are having difficulty feeding, simple nasal saline drops are available to help thin and clear secretions.6

Antibiotics should not be prescribed for the common cold as the cause is viral. In the past, some practitioners used antibiotics when a purulent nasal discharge was present,21 but parents should be reassured that in cases of uncomplicated illness the symptoms will resolve spontaneously.2

What treatments are available for flu? 

Although unpleasant, flu is usually self-limiting in otherwise healthy children. Treatment of uncomplicated disease is directed at the presenting symptoms and, like the strategies described above, includes antipyretics, analgesia, adequate fluid intake, rest, and staying off school or nursery until 24 hours after resolution of fever, to limit spread to others.4 But it is important to advise parents and carers of the potential risk of complications and to give clear guidance on recognising deteriorating or prolonged symptoms. The natural history of influenza indicates that symptoms should be improving after one week4 and, if they are not, reassessment of the diagnosis should be considered. 

Remember that children who have previously been admitted to hospital for lower respiratory tract disease are at higher risk of flu complications, as are those with chronic disease such as asthma or diabetes. Post-exposure antiviral medication is not normally recommended for children, although it may be indicated if they are in a high-risk category, and further advice should be sought from a paediatric specialist.4

Advise parents and carers that routine follow-up is not necessary, but they should: 

  • Seek urgent attention if the child has breathing difficulties, develops chest pain, or starts to cough up blood.
  • Arrange a follow-up appointment if there is no improvement after one week, or if they are deteriorating.4

It is important to emphasise that there should be a lower threshold for seeking help with infants or toddlers with influenza, as these children cannot accurately communicate their symptoms.

References

1 Courtney M, Rowbotham S, Lim R et al. Antibiotics for acute respiratory tract infections: a mixed-methods study of patient experiences of non medical prescriber management. BMJ Open 2017 7:e013515 http://bmjopen.bmj.com/content/7/3/e013515

2 Best practice – common cold. BMJ Best practice. 2016 bestpractice.bmj.com/best-practice/welcome.html

3 PHE guidance on use of antiviral agents for the treatment and prophylaxis of influenza v7.0. October 2016. researchgate.net/profile/Rob_Shulman/publication/309431017_PHE_guidance_on_use_of_antiviral_agents_for_the_treatment_and_prophylaxis_of_seasonal_influenza/links/5810c92808aee15d4914f78f/PHE-guidance-on-use-of-antiviral-agents-for-the-treatment-and-prophylaxis-of-seasonal-influenza.pdf

4 NICE. Influenza-Seasonal. October 2015. cks.nice.org.uk/influenza-seasonal

5 Diagnosis and treatment of respiratory illness in children and adults. Institute for Clinical Systems Improvement 2013. icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_respiratory_guidelines/respiratory_illness/

6 NICE. Common Cold. August 2016. cks.nice.org.uk/common-cold

7 Kesson A. Respiratory virus infections. Paediatr Respir Rev 2007;8:240-8

8 Allan G, Arroll B. Prevention and treatment of the common cold: making sense of the evidence. Canadian Medical Association Journal 2014;186:190-9 

9 Influenza – Chapter 19. In: Immunisation against infectious disease – The Green Book. Department of Health 2013 gov.uk/government/publications/influenza-the-green-book-chapter-19

10 Engel J. Pocket Guide to Pediatric Assessment. Mosby 2006

11 Howells R, Lopez T. Better communication with children and parents. Paediatrics and Child Health 2008;18:381-5

12. NICE. Fever in under 5s: assessment and initial management. NICE CG 160. 2013 nice.org.uk/guidance/cg160

13 DH, Health Education England. Spotting the Sick Child 2015. spottingthesickchild.com

14 NICE. Fever in under 5s. NICE QS64 2014 nice.org.uk/guidance/qs64

15 NICE. Sepsis: recognition, definition and early management. NICE NG51 2016. pathways.nice.org.uk/pathways/sepsis#path=view%3A/pathways/sepsis/assessing-under-5s-with-suspected-sepsis.xml&content=view-node%3Anodes-when-to-transfer-immediately-to-an-acute-setting

16 BTS, SIGN. British guideline on the management of asthma – a national clinical guideline. BTS SIGN 2016. brit-thoracic.org.uk

17 NICE. Cough – acute with chest signs in children. February 2017. cks.nice.org.uk/cough-acute-with-chest-signs-in-children

18 NICE. Analgesia – mild-to-moderate pain. September 2015. cks.nice.org.uk/analgesia-mild-to-moderate-pain

19 Over-the-counter cough and cold medicines for children. Medicines and Healthcare products Regulatory Agency 2009 gov.uk/drug-safety-update/over-the-counter-cough-and-cold-medicines-for-children

20 Joint Formulary Committee. British National Formulary 58. BMJ Group and RPS Publishing. 2009

21 Arroll B. Common cold. BMJ Clinical Evidence 2011;3:1-27

22 DH. The national flu immunisation programme 2017/18. March 2017. gov.uk/government/publications/national-flu-immunisation-programme-plan