How can I tell if my child has a cold or sinus infection?

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Everyday, parents come into the office wondering if their child has a sinus infection.

Typical scenario: Somewhere between days 3 to 9 of cold symptoms.  Parents have bags under their eyes.  Kids have bags under their eyes.  The parents have been up late with a coughing, cranky, snotty-nosed child and are looking for something (“anything!”) to make their child’s symptoms and sleep improve.  “Will antibiotics help? Cough and cold medicine?” desperate parents ask.  Frequently, I hear that mom/dad/cousin/accountant/neighbor/facebook friend will have gone to urgent care recently with similar symptoms, received an antibiotic, and improved within a few days.

Let me set the record straight: the vast majority of children that come in with that story do not have a sinus infection.  Most kids truly just have a viral upper respiratory tract infection (common cold). Sometimes (still more common than a sinus infection), they even have two colds OR catch a new cold as the first one is resolving.

I spend a good deal of time talking to parents about the natural history (aka the typical course) of cold.  Most are swayed into “waiting it out” or at least giving it a few more days to tease out which direction it is going.

The natural history of a typical cold (viral URI):viraluri
Day 1 – Runny watery nose, fevers (101-105), feeling crummy
Day 2 – Same as day one but more coughing less sleep the previous night so more fussy (child and parents!)
Day 3 – Nose still running.  Fever starting to improve.  Snot is thicker. Cough Cough Cough.
Day 4 – Nose still running. Congested.  Fever improving. Snot is GREEN (or yellow or any other delightful color).  Lots of coughing.
Day 5 – Nose still running (notice a trend?). Fever improved or resolved. Snot still colored and thick.  Still coughing.
Day 6-9 – Nose STILL running.  Snot beginning to transition back from thick/colored to thin/clear. Still coughing.

Day 10-14 – Nose still running, but improving.  Snot clear/thin/improving.  Still some cough.  (The neighbor boy who went to urgent care got a antibiotic around day 7 and he’s improving by this point, too.)

Bottom line: It takes a long time (& a lot of sniffling and coughing) to get over a cold!

The tricky aspect is that many children have LOTS of colds.  It can be tough to distinguish when one starts/ends and the next begins.  Kids have, on average, about one viral infection per month for the first two years of life.   As you can see from the natural history of a cold, it can take 2+ weeks to resolve.   With those numbers, many children are snotty for more than 50% of their first two years of life!

As I said above, I see a lot of children who’ve been treated at urgent care (first mistake!) in the past. They went in on day 5-7 of illness, got antibiotics and got better.  Did they have a sinus infection and need antibiotics?  Unlikely!! Look at the natural history above – they were already getting better but happened to get antibiotics on the tail end of their illness. The antibiotics didn’t make them better – time did.  Not only did antibiotics do NOTHING to improve their cold symptoms, they exposed the child to lots of nasty side effects, contributed to antibiotic resistance, and set up trusting parents that they need to get antibiotics the next month when similar symptoms start up.

I’m not a big lab tester, but I truly wish their was a sinus infection test. It would make my job so much easier.  Unfortunately, there’s little in the way of history or exam to help distinguish between a cold and a sinus infection.  Many parents worry that green or yellow snot means a sinus infection – it doesn’t.   Thick or thin snot doesn’t help distinguish, either.  The amount of snot, or the frequency of coughing doesn’t help.

So how do you know when you’re child has a bonafide sinus infection rather than just a bad cold?  There are three situations in which I will say “OK I think this is a sinus infection and we should consider trying antibiotics to make things better”.  These aren’t just my personal opinion – these are the guidelines from the American Academy of Pediatrics and Otolaryngologists (ENTs):

  1. Persistent symptoms (most common but less than 6% of kids who have colds).  If a child has a runny nose, cough, and doesn’t have any (I mean not even a teeny bit) of improvement for 10-14 straight days, that would meet criteria.  I spend the most time teasing out if they have persistent symptoms or a brand new cold.  If they improved even a little bit, then typically “persistent” doesn’t usually apply.  A lot of kiddos will catch a new cold
  2. Severe symptoms (least common).  More than three days of significant fever (102+) and pus draining from the nose would qualify as severe.  By pus, I don’t mean snot. By pus, I don’t mean green or yellow snot.  By pus, I don’t mean thick stretchy snot.  Pus is the stuff that comes out of an abscess or a popped zit – thick, creamy, STINKY. Gross, I know.  Most kids do not have pus draining from their nose.  There symptoms may seem severe because of how crummy they feel and in turn how crummy you feel, but severe means fevers + pus for at least 3 days (meaning no child has a sinus infection on day 1 or 2 of runny nose and fever!)
  3. Worsening symptoms.  It’s day 6, your child’s nose has started to clear up, fevers have resolved and then BOOM!  New fevers, nose acutely gets worse, worsening cough.  Those symptoms suggest a shift from a viral upper respiratory infection to a bacterial sinusitis.  This form is the trickiest to tease out – new colds are common around that time and look nearly identical to a sinus infection.

So why does all this matter? Why not just give everyone antibiotics – the ones that have colds will get better on their own and the ones that have sinus infections will get better, too!  That’s a topic for another day, but the overuse of unnecessary antibiotics is a HUGE problem – costs a lot of money, contributes to worsening antibiotic resistance, exposes children to the nasty side effects (and long term consequences) of antibiotic use, and it makes parents feel like they need an antibiotic to get over every cold.

Luckily (for me), most parents don’t just want an antibiotic for their child.  They want to know that they’re doing everything they can to make them feel better and to hear that THEY WILL GET BETTER….just stock up on tissues in the meantime.

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