Nasopharyngitis in children: symptoms and treatment

Nasopharyngitis in children is an acute viral inflammation of the mucous membranes of the nose and pharynx, commonly known as the common cold. The illness is usually mild, self-limited, and lasts 7-10 days, although a cough may persist longer. The primary goals of management are to relieve symptoms, prevent complications, and avoid unnecessary antibiotic use. [1]

The predominant pathogens are rhinoviruses, coronaviruses, respiratory syncytial virus, parainfluenza, and other seasonal agents. Transmission is by contact and droplet transmission through contaminated surfaces, which explains the high prevalence in children's groups. Prevention relies on hand hygiene, teaching children proper cough etiquette, and appropriate isolation during fever and severe symptoms. [2]

In most children, the disease does not require laboratory verification or specific antiviral treatment. The key emphasis in the recommendations is on informing parents about the natural course of the disease and warning signs that require in-person evaluation. This reduces unnecessary emergency room visits and relieves pressure on the healthcare system. [3]

Prescribing antibiotics for uncomplicated viral colds is unhelpful and carries risks, including side effects and the development of bacterial resistance. Therefore, a "no antibiotics" strategy for typical colds is the standard of care today. [4]

Epidemiology

A preschooler may experience several episodes of nasopharyngitis per year, especially during the fall and winter seasons and when attending daycare. Symptoms typically worsen over the first 2-3 days, then gradually subside by the 7-10th day. This is important to explain to the family at the onset of the illness. [5]

Colds are a leading cause of missed days from preschool and school and frequent visits to the pediatrician. Despite their high frequency, the prognosis with proper symptomatic management is favorable, and serious outcomes are rare. [6]

Inappropriate antibiotic prescribing for colds remains a common problem and is linked to parental expectations, misinterpretation of mucus color, and the desire to "speed up recovery." Educational materials and shared decision-making help reduce unnecessary prescribing. [7]

Table 1. Epidemiological guidelines for nasopharyngitis in children

Indicator	Typical data
Peak of symptoms	2-3 day of illness
Duration of runny nose and congestion	Up to 7-10 days
Number of episodes per year	Several episodes, more often in preschoolers
The most common pathogens	Rhinoviruses, coronaviruses, RSV, parainfluenza
[8]

Reasons

The leading cause is viral upper respiratory tract infections. Bacterial complications are less common and typically manifest as acute otitis media or acute bacterial rhinosinusitis with characteristic clinical features and duration of symptoms. This fundamentally distinguishes uncomplicated colds from conditions that truly require antibiotics. [9]

The color of nasal mucus is not a reliable indicator of a bacterial infection. Thick yellow-green discharge can occur with a common viral cold and does not, by itself, require antibiotics. Instead, it's important to consider the course, duration, and "red flags." [10]

The combination of a viral infection with irritation of the mucous membranes from dry indoor air and dust particles increases swelling and congestion. Therefore, the indoor microclimate and regular air humidification are important for relieving symptoms. [11]

Risk factors

High crowding in children's groups, inadequate hand hygiene, and touching the face increase the risk of infection. Young children are more likely to become ill due to immature immune systems and behavioral characteristics. [12]

Seasonality plays a role: peaks occur in autumn and winter. Simultaneous viral outbreaks in the community lead to family clusters, requiring uniform hygiene practices at home. [13]

Allergic rhinitis and adenoid hypertrophy predispose to prolonged symptoms, as they contribute to swelling and obstruct nasal breathing, although they are not the cause of a viral infection. The management of such children requires greater adherence to local symptomatic therapy. [14]

Table 2. Factors increasing the risk and severity of symptoms

Category	Examples
Contact	Kindergarten, school, family clusters
Behavioral	Irregular hand hygiene, touching your face
Seasonal	Autumn and winter
Associated conditions	Allergic rhinitis, adenoids
[15]

Pathogenesis

Viruses infect the epithelium of the nose and pharynx, causing inflammation, mucus hypersecretion, and swelling. Inflammatory mediators lead to congestion, rhinorrhea, a scratchy throat, and coughing due to mucus dripping down the back of the throat. This is the typical mechanism of coughing associated with a cold. [16]

Damage to the ciliated epithelium temporarily reduces mucociliary clearance, which explains the thick mucus at the peak of the disease. As the epithelium recovers, clearance normalizes, and symptoms subside without specific therapy. [17]

The development of bacterial complications is associated with impaired ventilation of the paranasal sinuses and middle ear, as well as secondary colonization. However, this occurs with a characteristic course of symptoms and is not the norm for a typical cold. [18]

Symptoms

The main symptoms are a runny nose, congestion, sneezing, a scratchy or sore throat, low-grade fever, loss of appetite, and sometimes fatigue and headache. The cough often worsens at night due to mucus dripping down the back of the throat. The condition usually improves within 7-10 days. [19]

Fever in the first few days is normal, but its duration beyond three days or the return of fever despite improvement requires re-evaluation for complications. Increasing ear pain, facial pain, or purulent discharge also warrants an in-person evaluation. [20]

Younger children may experience irritability, sleep disturbances, and decreased fluid intake. It is important to educate parents about care and the signs of dehydration. If lethargy and fluid refusal persist, an examination is necessary. [21]

Forms and stages

Typical nasopharyngitis has an initial catarrhal period with sneezing and a sore throat, peaking symptoms around day 2-3, and gradually resolving by the end of the first week. Cough and congestion may persist longer, which does not always indicate a bacterial process. [22]

Complicated forms are associated with the addition of acute otitis media or acute bacterial rhinosinusitis and require separate management. Criteria vary in duration and severity of symptoms and are described in the sections on diagnosis and differential diagnosis. [23]

Complications and consequences

Common complications include acute otitis media and acute bacterial rhinosinusitis, but these develop in a minority of children. Early recognition is based on the duration of symptoms, severe pain, and a "second wave" of deterioration.[24]

Unnecessary antibiotic use for uncomplicated colds increases the risk of side effects, including rash, diarrhea, and rare serious reactions, and contributes to the spread of resistance. Therefore, antibiotic therapy for the common viral cold is not indicated. [25]

Table 3. Red flags requiring in-person assessment

Sign	Explanation
Fever lasting more than 3 days or "second wave"	Possible complication
Severe pain in the ear or face	Probability of otitis or sinusitis
Persistent vomiting, lethargy, refusal to drink	Risk of dehydration
Shortness of breath, chest retractions, wheezing	Lower respiratory tract, not a cold
[26]

Diagnostics

(methods are listed with brief explanations)

• Clinical assessment: Diagnosis is based on the typical presentation of acute rhinitis, congestion, and sore throat with gradual self-resolving symptoms. Laboratory tests are not necessary for uncomplicated colds. [27]
• Risk assessment for complications: attention is paid to duration of more than 10 days without improvement, a “second wave” of deterioration, severe pain in the ear or face, which may indicate acute bacterial sinusitis or otitis. [28]
• Influenza and coronavirus testing is performed based on epidemiological indications: in the presence of fever, severe intoxication, contact, or during seasonal outbreaks, when the results influence the patient's response to the virus and isolation measures. For a typical mild cold without risk factors, testing is not required. [29]
• Exclusion of streptococcal pharyngitis: A rapid antigen test and culture are indicated for patients with a sore throat without a runny nose or cough. With rhinorrhea and cough, the likelihood of streptococcal pharyngitis is low. [30]
• Imaging and blood tests: For uncomplicated colds, they are not informative and are not indicated. They are prescribed only if the course of the disease is atypical or complications are suspected. [31]

Table 4. When to think about bacterial sinusitis and otitis

Scenario	Tips
Acute bacterial sinusitis	Symptoms lasting more than 10 days without improvement or severe onset with high fever and severe pain, or a “second wave” of worsening
Acute otitis media	Acute ear pain, bulging eardrum, hearing loss, especially after a cold
[32]

Differential diagnosis

It is important to distinguish nasopharyngitis from allergic rhinitis, which is characterized by itching, sneezing, and clear discharge upon contact with an allergen, and is absent of fever. Allergic rhinitis is chronic or seasonal and requires a different approach. [33]

Bacterial tonsillitis is more likely with a high fever, pain when swallowing, swollen and painful neck nodes, and plaque on the tonsils without a runny nose or cough. In this case, testing for group A streptococcus is indicated. [34]

Influenza and other acute respiratory viral infections with systemic intoxication and myalgia require different tactics and may require testing and antiviral treatment as indicated. The severity of systemic symptoms and the epidemiological situation aid in differentiation. [35]

Treatment

The basic strategy is symptomatic relief and rest. Nasal irrigation with saline solutions, particularly hypertonic ones, has been shown to be effective in children, shortening the duration of colds in randomized trials and presentations at major congresses. Regular use, using age-appropriate techniques, improves nasal breathing and sleep. [36]

According to systematic reviews and randomized trials, honey given to children over one year of age at night reduces the frequency and severity of nighttime coughs and improves sleep. It is important to remember that honey is contraindicated in children under one year of age due to the risk of botulism. Doses are typically about half a teaspoon before bedtime. [37]

Fluids as needed, cool, humidified air in the room, head elevation during sleep, and gentle suctioning of mucus in infants can help manage symptoms. Antipyretics are used for fever and severe discomfort according to age-appropriate doses. [38]

Over-the-counter combination cold remedies containing cough suppressants, antihistamines, and decongestants have not demonstrated convincing efficacy in children and may cause side effects. Recent reviews and guidelines emphasize caution and limit the use of such medications in children, especially those under six years of age. [39]

Antibiotics are not prescribed for uncomplicated viral colds. They do not speed recovery, but they increase the risk of adverse reactions and promote resistance. The exception is the development of complications, in which case antibiotics are indicated according to specific criteria and regimens. Educating the family on this principle is an important part of the visit. [40]

Table 5. Symptomatic measures with the best benefit-risk ratio

Measure	Comment
Saline solutions for the nose	Proven to reduce the duration and severity of symptoms in some children
Honey for the night over one year old	Reduces nighttime coughing and improves sleep
Humidification and adequate hydration	They help to cope with symptoms and are safe.
Antipyretics as indicated	Use according to age-appropriate dosages
[41]

Table 6. What usually does not help or is undesirable in children

Approach	Why it is not recommended
Combination "anti-cold" syrups	Unproven effectiveness, risk of side effects
Routine antibiotics	Viral etiology, risk of resistance and adverse reactions
Aggressive vasoconstrictor sprays	Risk of tachyphylaxis and rhinitis medicamentosa with improper use
Hot steam inhalation	Risk of burns, no convincing benefit
[42]

Table 7. When and what antibiotics may be needed
(not for a cold, but for complications)

Complication	First line
Acute bacterial rhinosinusitis in children with severe or worsening course	Amoxicillin or amoxicillin with clavulanic acid by age doses
Acute otitis media in children according to indications	Amoxicillin according to age regimens; observation is permissible in some children
[43]

Prevention

Hand hygiene training, using tissues when coughing and sneezing, ventilation, and sensible isolation during fever reduce the spread of infection within families and groups of children. Vaccination against influenza and other vaccine-preventable diseases helps reduce the overall burden of respiratory illnesses, although there are no vaccines for typical "cold" viruses. [44]

Maintaining an optimal indoor climate, adequate humidity, and sleep patterns reduces the severity of symptoms during cold and flu season. Regular educational reminders for parents and children have been shown to reduce unnecessary visits and antimicrobial waits. [45]

Forecast

The prognosis is favorable. With a typical course, improvement occurs within the first week; a residual cough may persist longer without signs of bacterial infection. Informing the family about the natural course and timing helps avoid anxiety and unnecessary medication. [46]

A doctor should be consulted if signs of complications or severe symptoms develop, or if symptoms persist for more than 10 days without improvement. A timely reassessment allows one to distinguish a common cold from conditions requiring a different approach. [47]

FAQ

• How long does a child's cold last?

Typically 7-10 days, with symptoms peaking on days 2-3. The cough may persist longer without signs of a bacterial infection. [48]

• Should I give antibiotics for green snot?

No. The color of the mucus does not prove a bacterial infection. Duration and red flags are more important. [49]

• What really helps with congestion and coughing at night?

Saline nasal sprays and honey at night have been shown to be beneficial for children over one year of age. Maintain proper air humidification and sleep. [50]

• Are children's "cold" syrups dangerous?

Their effectiveness in children has not been proven, and side effects are possible. It is better to focus on measures with proven benefits. [51]

When to see a doctor?

Fever for more than three days, a "second wave" of deterioration, severe ear or facial pain, signs of dehydration, shortness of breath and wheezing are reasons for an in-person assessment. [52]