viral upper respiratory infections, allergies and bacterial sinusitis
Let's face it -- if whoever invented snot had color-coded it for me, my job would be a lot easier.
The heart of the matter is the ongoing problem of figuring out who has a virus and who has a bacteria as the cause of their infection. Or if it even is an infection-- allergies play an important role in runny noses and sinusitis. Antibiotics only cure bacterial infections. They don't do anything for viral infections. The overuse of antibiotics (and the misuse of them when treating viral infections) has contributed to all sorts of bad things, including antibiotic resistance and escalating health care costs.
Allergic Rhinitis, the term for the runny nose, itchy, watery eyes, sneezing, and post-nasal drip, can happen all year (from dust mites, cockroaches, animal dander, and mold), seasonally ( as with pollen from grass, trees, and weeds) or episodically (from aunt Martha's cat). Tobacco smoke is a big problem and should be eliminated from the environment of all kids. Children with allergic rhinitis can have sleep problems and other "quality of life" issues, such as problems with exercise, and academic performance.
Nasal congestion from environmental allergies is pretty rare in kids under 6 months of age, and even more rare in breastfed kids. The usual time that we see allergies is in kids older than 3 years. If younger kids have symptoms, we need to think about the possibility of food allergy.
Children who have one parent with allergies have a good chance (like 25-40%) of also having allergies. And when both parents have allergies, the chance of the child having them is really good (50-70%).
Treatment: environmental control
Treatment really hinges on a long-term commitment to improve the child's environment:
Antihistamines can help. Ones like diphenhydramine (Dimetapp) can cause big time sedation. And there is a small percentage of people who have an irritable, restless, stimulated response to these medications ( ask me to tell you about my dad's plane trip to Australia). Zyrtec or Claritin help without sedation. The "D" in Claritin -D and Zyrtec- D tends to be pseudoephedrine, which is a stimulant and not recommended for children.
Prescription topical nasal steroids (not those kind of steroids) work very well by decreasing all the inflammation in the nose and sinuses. They don't work too well for eye symptoms. They usually work within 3 days to 2 weeks. They have really no side effects, something that we worry about with the use of steroids, because they are given in a small dose which is delivered topically. Over the counter nasal sprays should be avoided as you can get dependent on them, and it fact, make symptoms worse.
Over the counter decongestants, like sudafed, contain ingredients that cause irritability, sleeplessness, nervousness, increased heart rate and palpitations and should never be used in kids under 2 because of this "psycho baby" effect. (I'm not even sure they work or should be used at all, but that's a speech for the over the counter medications page)
Upper Respiratory Infections
Most kids will have between 3 and 8 viral infections a year. In Wisconsin, kids can get even more, especially during the winter because of close quarters at school or day care.
The common cold usually goes like this: stuffiness and scratchy throat, followed by sneezing and watery eyes, maybe fever, fatigue, headache, lack of appetite and generalized ache. Cough happens about about 60-80% of the time. One to three days into the infection, the drainage gets thicker. By 7-10 days into the illness, everything, with perhaps the exception of the cough, is better. We treat it with tender loving care, popsicles and a remote control-- meaning rest and fluid. The cough is expected to last awhile, and, if everything else is getting better, isn't a thing to worry about.
The common cold also involves changes in the color of nasal drainage-- hence the name of this segment. A thick, cloudy, green, yellow , or purple polka-dotted drainage is not an indication for antibiotics
The drainage has been there for more than 10-14 days.
Little kids and stuffy noses
Children under the age of about 9 months don't do very well with nasal congestion and colds because they have to breathe with their nose.
When we have nasal congestion, we open our mouths and get air in. Little kids open their mouth and most of the air hits their tongue (which, in this age group, is too big for the size of their mouth). Then, when they lay on their back, their already too big tongue falls into the back of their throat completely, eliminating the ability to mouth breathe. So if their nose is clogged, and their tongue is in the way, the only way to breath is to cry, moving the tongue out the way and making parents crazy.
In much the same way, when we give them a breast or a bottle in the mouth, they have to choose between eating and breathing. Breathing will win. Trust me. So kids in this age group, when they are sick, will not eat well, will be crabby because they are hungry and can't breathe, and won't sleep well. (It follows that kids who are happy, smiling, sleeping and eating well are doing just fine.)
So what do we do? Suck out their noses with a bulb syringe, stay away from over the counter medications (remember the psycho baby!!!), wash out the nose with saline drops, keep the baby propped (elevate the mattress) and watch their mood.
The common cold usually involves the sinuses. If we would check xrays and CT scans of the sinuses during the common cold, we would usually find something wrong. (Even if you've only been sick for a day.) That means that there is an element of "sinusitis" very frequently during the common cold, but not necessarily caused by bacteria.
Kids are born with a few of their sinuses developed, but with no air in them, so "sinus infection" in a baby is hard to do (they would need a sinus to get infected!) It's kids in school and day care, and especially adolescents who have the most trouble with bacterial sinus infections.
Upper respiratory infections will usually run their course in 10-14 days. Any longer than that, we have to suspect a bacterial cause (bacterial infections don't get better on their own.). Colds are perfect set-ups for bacterial invasion. Bacteria can creep in during nose blowing and snuffling, settle in the warm, moist environment of a clogged sinus and then start to grow. The biggest culprit bacteria are streptococcus pneumoniae, non-typeable h. influenzae and moraxella caterrhalis, the same bacteria that are responsible for most of the ear infections in children. Why did I list those long words? Well, we have an immunization for strep pneumoniae, and we're giving it to all kids in our practice under 5 years of age. And all three bacteria have become smarter and more sneaky because of antibiotic overuse, knowing how, about 15% of the time, to beat amoxicillin.
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