Acute respiratory viral infections in children: symptoms and treatment

Acute respiratory viral infection (ARVI) in children is a group of acute upper respiratory tract infections caused by various viruses and characterized by runny nose, sore throat, cough, fever, and malaise. Most episodes are mild and self-limited, lasting approximately 5 to 10 days, with recovery occurring gradually: initially, the fever and body aches subside, followed by the runny nose and cough. Parents are often concerned about a "lingering cough" after a cold—this is a common residual symptom that can persist for another 1 to 2 weeks. [1]

Dozens of viruses cause these diseases: rhinoviruses, influenza viruses, respiratory syncytial virus, parainfluenza, coronaviruses, human metapneumovirus, and others. Their prevalence varies seasonally and yearly, and local "peaks" depend on community circulation and the level of herd immunity. Outside of hospitals, most children experience the disease limited to the upper respiratory tract and do not require special investigations. [2]

Although the prognosis is favorable for healthy children, even a "common cold" can become severe for infants, premature babies, children with chronic lung diseases, congenital heart defects, and immunodeficiencies. For this group, timely risk assessment, prevention, and early initiation of supportive therapy when the condition worsens are essential. In recent years, new tools have emerged for preventing severe forms of respiratory syncytial infection in infants. [3]

The current approach to management is based on an explanation of the expected course, symptomatic therapy, the appropriate use of testing, and avoidance of antibiotics unless there are signs of bacterial complications. Exceptions include confirmed influenza in children at risk, where antiviral drugs are indicated, and isolated cases where diagnosis of another cause of fever or respiratory symptoms is required. [4]

Code according to ICD-10 and ICD-11

In the International Classification of Diseases, Tenth Revision, acute respiratory viral infection is classified under the class "Diseases of the Respiratory System," section "Acute Upper Respiratory Tract Infections." Specific categories are used for clinical coding in children: acute nasopharyngitis (cold), acute pharyngitis, acute laryngitis and tracheitis, and acute infections of multiple and unspecified sites. This allows for the identification of a dominant syndrome without necessarily specifying a specific virus. [5]

The eleventh revision of the Classification of Diseases includes a section on "Upper Respiratory Tract Disorders" with a more flexible post-coordination system: localization, etiology, and clinical features can be specified by combining codes. In practice, the "localization + severity" approach remains in place in outpatient pediatrics, with a specific pathogen identified only with laboratory confirmation and clinical necessity. [6]

Table 1. Frequently used ICD-10 codes for acute upper respiratory tract infections in children

Code	Name
J00	Acute nasopharyngitis (cold)
J02	Acute pharyngitis
J03	Acute tonsillitis
J04	Acute laryngitis and tracheitis
J06.0	Acute laryngopharyngitis
J06.9	Acute upper respiratory tract infection, unspecified
Source: official reference books ICD-10. [7]

Table 2. Examples of coding in ICD-11 (semantic correspondences)

ICD-11 block	Example of a recording	Comment
Upper respiratory tract disorders	Acute nasopharyngitis, viral	It is possible to post-coordinate "viral etiology"
Upper respiratory tract disorders	Acute laryngitis	Severity modifiers are added
Upper respiratory tract disorders	Acute upper respiratory tract infection, unspecified	Used for typical presentations without specified localization
Source: ICD-11 manual. [8]

Epidemiology

Preschool-aged children experience 6 to 8 episodes of acute respiratory viral infection per year, while schoolchildren experience an average of 4 to 6 episodes. Symptoms typically last 7 to 10 days, with a residual cough that can persist for up to 14 days or longer. Peak incidence occurs in the fall and winter months and early spring. [9]

The seasonal dynamics of specific viruses vary: rhinoviruses circulate almost year-round and dominate in the off-season, respiratory syncytial virus and influenza viruses produce pronounced winter waves, and metapneumovirus is more common in winter and spring. The burden on the healthcare system increases during periods of simultaneous circulation of multiple pathogens. [10]

Respiratory syncytial virus (RSV) is particularly significant in children under 2 years of age and in preterm infants. RSV is estimated to account for a significant proportion of hospitalizations from acute lower respiratory infections in young children; in 2019 global estimates, the virus was associated with high mortality among infants, particularly in low- and middle-income countries. [11]

Table 3. Estimates of epidemiological indicators

Indicator	Grade
Number of episodes per year in preschoolers	6-8
Duration of a typical episode	7-10 days
Contribution of respiratory syncytial virus to severe cases in children under 5 years of age	Significant; high proportion of hospitalizations
Seasonal peaks	Autumn-winter, early spring
Sources: WHO pediatric resources and reviews. [12]

Reasons

The main pathogens are rhinoviruses (mostly), influenza A and B viruses, respiratory syncytial virus, parainfluenza, human metapneumovirus, adenoviruses, and "common" coronaviruses. More than one virus may be detected in a single child in a single episode, and some children are asymptomatic carriers of rhinoviruses, which is important to remember when interpreting PCR results. [13]

In some children, especially in the first years of life, the same viruses produce different phenotypes: in one child, rhinovirus will cause a "runny nose and sneezing," while in another, it will cause an episode of wheezing. This reflects differences in the innate and adaptive immune response, local antiviral defense, and associated factors. [14]

In infants, respiratory syncytial virus (RSV) can spread lower down the respiratory tract and cause bronchiolitis or pneumonia, whereas in older children it is more likely to result in upper respiratory symptoms. Similarly, influenza viruses in high-risk children increase the likelihood of severe illness and require early antiviral therapy. [15]

Risk factors

Risk factors for frequent episodes include attending a children's playgroup, passive smoking, crowded living conditions, and poor ventilation. These factors increase the likelihood of infection and the severity of symptoms in susceptible children. [16]

Severe disease risk factors include age under 6 months, prematurity, congenital heart defects, chronic lung disease, and immunodeficiency. It is for this group that modern preventive measures against respiratory syncytial virus have been implemented. [17]

Air pollution with fine particles and nitrogen dioxide, as well as household dampness and mold, increase the inflammatory burden on the respiratory tract. At the population level, this is manifested by an increase in hospital visits during the season of adverse environmental conditions. [18]

Table 4. Risk factors and their clinical significance

Factor	Why is it important?	What to do
Children's group	High intensity of contacts	Hygiene training, ventilation
Passive smoking	Additional irritation of the mucous membrane	Completely stop smoking in homes and cars
Age < 6 months, prematurity	Immaturity of the immune system, small airway lumen	Low threshold for treatment, RSV prevention
Chronic diseases	Higher risk of complications	Individual action plan
Sources: manuals and reviews. [19]

Pathogenesis

Viruses invade the epithelial cells of the upper respiratory tract mucosa, causing a local inflammatory response: cytokine release, swelling, and increased secretion. This explains the runny nose, sore throat, and cough—the body removes viral particles and restores the epithelial surface. [20]

Rhinoviruses alter the reactivity of nerve endings and vascular tone, causing sneezing, itching, and a feeling of congestion. In infants with respiratory syncytial virus, inflammation can spread to the lower respiratory tract, affecting the bronchioles and impairing ventilation. [21]

The immune response in young children differs from that of adults: innate mechanisms predominate, while adaptive mechanisms are still "learning." Therefore, the course of the disease is often "stormy" in terms of symptoms, but short-lived. Past episodes create partial and short-lived immunity to specific viral variants. [22]

Symptoms

The typical scenario begins with a sore throat and sneezing, followed by clear nasal discharge, moderate weakness, and loss of appetite. After 1-2 days, a fever may develop, more often in preschoolers. Some children experience headaches and body aches. [23]

The cough is usually dry and scratchy in the first few days, then becomes wet. It intensifies at night and in dry air. A residual cough often persists for 10-14 days after the fever subsides—this is due to the restoration of the ciliated epithelium. [24]

Newborns and infants may present with nonspecific symptoms, including refusal to feed, lethargy, sleep disturbances, and episodes of apnea associated with severe respiratory syncytial virus infection. Any signs of difficulty breathing in this group warrant urgent evaluation. [25]

Table 5. Approximate dynamics of symptoms

Day of illness	Common symptoms	Comments
1-2	Sore throat, sneezing, clear runny nose	The onset is mild, and fever may be absent.
3-4	Fever, worsening runny nose, dry cough	Peak of expression
5-7	Temperature decreases, cough becomes wet	Improving overall well-being
8-14	Residual cough, fatigue	Gradual recovery
Source: Pediatric Guidelines for Parents. [26]

Classification, forms and stages

Based on localization, forms are distinguished with a predominance of rhinitis, pharyngitis, and laryngitis; in young children, rapid involvement of the lower respiratory tract is possible. Severity is classified as mild, moderate, and severe, based on the severity of fever, respiratory distress, and refusal to drink. [27]

Based on etiology, a distinction is made between virally suspected and laboratory-confirmed episodes (e.g., confirmed influenza). In outpatient practice, diagnosis is often based on the clinical picture, and testing is performed selectively, depending on the season, risk factors, and the implications for treatment. [28]

The stage is generally defined as the peak period (the first 3-5 days), the period of symptom regression, and recovery with a residual cough. It's important to discuss this with the family—understanding the chronology reduces anxiety and helps with the rational use of medications. [29]

Complications and consequences

Common complications include acute otitis media, acute rhinosinusitis, exacerbation of bronchial hyperreactivity, and, in infants, bronchiolitis. These conditions are suspected with recurrent fever, ear pain, localized facial pain, noisy breathing, or intercostal retractions. [30]

Influenza can be more severe in infants and children with chronic illnesses; in such cases, early initiation of antiviral therapy shortens the duration of symptoms and reduces the risk of complications. Respiratory syncytial virus (RSV) infection in infants requires monitoring of breathing and hydration. [31]

Long-term sequelae following a typical acute respiratory viral infection in healthy children are unlikely. The greatest risks are associated with repeated severe episodes in vulnerable groups and with unfavorable environmental factors such as tobacco smoke and poor ventilation. [32]

When to see a doctor

Seek immediate medical attention if signs of respiratory distress occur: noisy inhalation, retractions between the ribs, cyanosis of the lips, apnea, or severe drowsiness. In infants, a warning sign is refusal to drink and repeated vomiting. [33]

Reasons for an unscheduled consultation: temperature above 39°C for more than 3 days, severe ear or facial pain, return of fever after a period of improvement, worsening cough with difficulty breathing, signs of dehydration. For children at risk, the threshold for seeking medical attention is always lower. [34]

In a typical picture without alarming signs, home care, monitoring temperature, fluid intake, and sleep, with an understanding of the expected duration, are sufficient. It is helpful for parents to obtain "red flags" and a plan for communicating with the pediatrician in advance. [35]

Diagnostics

The first step is a clinical assessment: a questionnaire and examination. The doctor will determine the duration of symptoms, contacts, vaccinations, and the presence of risk factors. The nose, oropharynx, and ears will be examined; breathing, respiratory rate, and oxygen saturation (if a pulse oximeter is available) will be assessed. In most cases, this is sufficient to make a clinical diagnosis. [36]

The second step is deciding on testing. Routine blood tests are unnecessary for typical cases: they cannot distinguish between viral and bacterial infections in everyday settings. Influenza testing is indicated for children at risk and when there are implications for treatment (such as early initiation of antiviral medications). Testing for respiratory syncytial virus in infants can aid in routing, but does not always change treatment. [37]

The third step is assessing for complications. For ear pain, an otoscopy is performed; for localized facial pain and purulent rhinitis after 10 days of symptoms, the likelihood of acute bacterial rhinosinusitis is assessed. For respiratory distress, auscultation, assessment of respiratory muscle function, and, if necessary, saturation are performed. [38]

The fourth step is observation and feedback. The family receives written care recommendations and a list of warning signs, as well as timeframes for follow-up contact with the doctor. This approach reduces unnecessary appointments and improves safety. [39]

Table 6. Diagnostic algorithm in 4 steps

Step	What are we doing?	For what
1	Questioning, examination of ENT organs and respiration	Confirm the typical picture
2	Deciding on tests (selectively)	Do results influence tactics?
3	We are looking for complications	Don't miss otitis, rhinosinusitis, bronchiolitis
4	We provide a care plan and feedback	Safety and rationality
Source: Clinical guidelines for outpatient management. [40]

Differential diagnosis

It's important to distinguish between a typical viral infection and conditions that require a different approach. A sore throat without a cough or runny nose, accompanied by fever and tender neck nodes, is a reason to test for group A streptococcus and, if confirmed, prescribe antibiotics. [41]

A persistent runny nose with facial pain lasting more than 10 days, especially with a "second wave" of worsening symptoms, suggests acute bacterial rhinosinusitis. Ear pain, hearing loss, and crying in young children are signs of otitis media. A noisy inhalation and a "barking" cough in a preschooler are signs of laryngotracheitis. [42]

During flu season and with high fever with an abrupt onset in children at risk, it is reasonable to confirm influenza and consider antiviral therapy. In the presence of exposure to the flu and systemic symptoms, coronavirus infection is considered, especially if there is loss of smell, cough, and fever. [43]

Table 7. What distinguishes the main scenarios

State	Key Features	What helps to distinguish
Viral upper respiratory tract infection	Runny nose, cough, hoarseness	Self-limiting course, no tests needed
Streptococcal sore throat	Sore throat without cough, high fever	Smear and rapid test; if negative, culture in children
Acute bacterial rhinosinusitis	Symptoms > 10 days, "second wave", facial pain	Clinic, selective - visualization
Flu	Abrupt onset, myalgia, high fever	Confirmation by test when influencing tactics
Laryngotracheitis (false croup)	"Barking" cough, stridor	Assessment of respiratory failure
Sources: NICE and CDC. [44]

Treatment

The mainstay of treatment is symptomatic therapy and rest. The child should be provided with sleep, warm drinks in small sips, cool, humidified air in the room, and a calm regimen. These measures reduce mucosal irritation, improve mucociliary clearance, and alleviate coughing. It is important for parents to know the expected duration of symptoms to avoid overloading the child with medications. [45]

Antipyretics are used to treat discomfort associated with fever. The goal is to improve well-being, not to bring the temperature down to normal at any cost. Age-appropriate dosages and intervals should be followed. If you feel well but have a low fever, antipyretics are not necessary. [46]

Nasal irrigation with isotonic solutions and short courses of nasal decongestants (strictly age-appropriate) reduce ear and nasal congestion. Nasal steroids are not routinely used for brief episodes of viral rhinitis in healthy children. Centrally acting antitussives are not recommended for children under 6 years of age. [47]

In children over 1 year of age, honey may moderately reduce nighttime coughing and improve sleep compared to no treatment or some syrups. Honey is contraindicated in children under 1 year of age due to the risk of botulism. The effect of honey is small, but for families who prefer "natural" remedies, it is a safe option, provided age restrictions are observed. [48]

Antibiotics are not indicated for typical acute respiratory viral infections. They do not shorten the duration of symptoms and increase the risk of side effects and bacterial resistance. Antibiotics are only prescribed for confirmed bacterial complications (e.g., streptococcal sore throat, acute bacterial rhinosinusitis) according to specialized guidelines. [49]

Antiviral drugs for influenza are indicated for children with risk factors for severe illness and for all hospitalized patients. They can also be considered in healthy children with early onset of symptoms. Oseltamivir is the preferred drug for children; it shortens the duration of symptoms and reduces the risk of complications when onset occurs within the first 48 hours. Dosage and duration are determined based on age and body weight. [50]

Warm steam inhalation is not recommended due to the risk of burns and the lack of proven benefit. Humidifying the air with a properly maintained room humidifier may alleviate dry mouth symptoms. Vitamin C, zinc, and echinacea have not been shown to have a convincing preventive benefit; for zinc, a recent evaluation indicates no significant preventive effect and an inconclusive effect on duration. [51]

For children with bronchial hyperreactivity, a doctor may recommend an inhaled bronchodilator "as needed" for a cough with signs of bronchospasm. This is not a routine measure for all children with a cold, but rather targeted assistance for those whose cough is accompanied by wheezing and prolonged exhalation. The doctor makes the decision after an examination. [52]

If signs of dehydration occur, small doses of oral rehydration solutions are important, especially in children with fever and decreased appetite. In the hospital, infusion therapy is administered if necessary. Monitoring urination is a simple everyday indicator of adequate fluid intake. [53]

Family education is part of the treatment: proper nose blowing, hand hygiene, ventilation, separating utensils, and reasonable activity restrictions during the fever period. The doctor, together with the parents, plans criteria for re-exposure and reintegration into the children's group. This reduces anxiety and prevents unnecessary emergency room visits. [54]

Table 8. Treatment options and comments

Direction	Example	Comment
Symptomatic care	Drink, sleep, hydration	Care base
Antipyretics	By age doses	For comfort, not necessarily always
Nasal measures	Isotonic solutions, short course of vasoconstrictors	Reduces congestion
Honey > 1 year	Night, 1-2 teaspoons before bedtime	Little effect on cough
Antibiotics	Only in case of bacterial complications	Not with a typical viral infection
Antivirals for influenza	Oseltamivir	Early start for risk groups
Sources: AAP, CDC, Cochrane, NICE. [55]

Prevention

The most effective specific measure is annual influenza vaccination for children, starting at the established age threshold, which reduces the risk of severe illness and hospitalization. Monoclonal antibodies against the respiratory syncytial virus have been developed for infants and are administered once before the flu season. Vaccination of pregnant women is also recommended to protect the newborn. The choice of vaccine and timing is determined by a physician based on the season and availability. [56]

Hand hygiene, cough etiquette, ventilation, and avoiding contact with others when feverish or symptomatic are simple measures that effectively reduce the transmission of infections. During seasonal flu seasons, regular damp cleaning and humidity control are helpful. It's important for families to have a "home plan" to avoid sending a sick child to a playgroup. [57]

Quitting smoking in the home and car is a critical preventative measure. Smoke increases mucosal inflammation and increases the incidence of illness and complications in children. This is one of the most cost-effective family measures. [58]

Table 9. Key preventive measures

Measure	Who is it especially indicated for?	Expected effect
Influenza vaccination	All children according to the calendar	Reduction in severe cases and hospitalizations
Monoclonal antibodies against RSV	For infants before the season, children at risk	Prevention of severe RSV
Maternal RSV vaccination	For pregnant women at 32-36 weeks	Protecting the newborn
Hygiene, ventilation, "don't go out sick"	To all families	Fewer transmissions and flashes
Sources: CDC, AAP. [59]

Forecast

Most children experience a mild course of the disease, with full recovery. The apparent "length" of the illness is not related to danger, but to the slow fading of individual symptoms, primarily cough and runny nose. Mindful anticipation and proper home care are more important than "searching for a magic pill." [60]

The poor prognosis is often associated not with the viral infection itself, but with complications in infants and children with chronic illnesses. For them, prevention, early assessment, and action planning are particularly important. Expanding seasonal respiratory syncytial virus prophylaxis improves population outcomes. [61]

Regular flu vaccinations, smoking cessation in the family, and basic hygiene can reduce the frequency and severity of episodes. During peak flu seasons, it's helpful to discuss a communication plan with your pediatrician in advance in case of a worsening illness. [62]

FAQ (frequently asked questions)

How long should a common cold last in a child?
Typically 7 to 10 days; a cough can linger for up to 14 days. If a fever persists for more than 3 days or red flags appear (difficulty breathing, refusal to drink, severe lethargy), an in-person evaluation is necessary. [63]

When are antibiotics needed?
Not for typical viral infections. They are indicated only for confirmed bacterial complications (e.g., streptococcal sore throat, bacterial rhinosinusitis) according to the relevant recommendations. [64]

Should you give honey for a cough?
Honey can be given to children over 1 year old; it may slightly reduce nighttime coughing and improve sleep. Honey should not be given to children under 1 year old due to the risk of botulism. [65]

When are antiviral drugs needed?
For confirmed or suspected influenza in children at risk and in hospitalized patients; in healthy children, they can be considered at the early onset of symptoms. Oseltamivir is the preferred drug in pediatrics if started within the first 48 hours. [66]

Is it possible to "get over it and forget about it"?
Most episodes resolve without sequelae. However, in infants and vulnerable children, certain viruses (such as respiratory syncytial virus) can be severe. Prevention and early assessment are key to a favorable outcome. [67]