Introduction

Nasopharyngitis or the common cold is a viral illness of the upper respiratory tract. This is commonly called an upper respiratory tract infection (URTI) even though it only affects part of the upper respiratory tract. An URTI is usually caused by rhino- and coronaviruses, but during the winter season, parainfluenza, respiratory syncytial virus (RSV) and metapneumovirus are also common. These later viruses may progress to croup, bronchiolitis or pneumonia. Other specific infections may begin with URTI symptoms and progress to involve the lower respiratory tract, e.g. influenza, Bordetella pertussis. If symptoms are persistent, an open mind regarding alternative diagnoses is required. In their first 6 years, children generally have between six and eight URTIs per year and children attending day care may have more. Not infrequently these may occur one after the other, leading to the impression of persistent symptoms rather than two to three separate infections. Breast feeding of babies may offer some protection, particularly in the first 6 months.

History

This illness is characterised by mild to moderate fever, blocked or runny nose, sneezing, mild cough (generally dry in the first few days) with an irritating sore throat if the child is able to verbalise this symptom. Infants may also become restless and irritable. Nasal congestion may interfere with feeding in infants under 6 months due to mechanical obstruction. Over the first few days the watery nasal discharge will become thicker and more mucopurulent. Nasal obstruction leads to mouth breathing and increased throat discomfort. The characteristic of the cough may change, becoming moist after a few days. Sputum production occurs but in small children is generally swallowed rather than expectorated and hence will not be reported by parents. The child is not particularly unwell. If a child has significant constitutional symptoms, one needs to consider alternative diagnoses such as lower respiratory infection or an influenza-like illness. Other family members may have or be recovering from cold symptoms. Symptoms usually peak around 1–3 days and disappear by 7–10 days although the cough may persist (up to 8 weeks – postviral cough). Bacterial complications are uncommon but should be considered if fever persist for longer than 3–5 days, ongoing mucopurulent nasal discharge for more than 2 weeks, child appears unwell or has lower respiratory tract signs (e.g. tachypnoea, grunting, wheeze, O₂ requirement).

Examination

The child appears well with nasal discharge, which may cause obstruction (particularly in babies). Mucopurulent discharge does not indicate a bacterial cause. The tympanic membranes may be slightly dull or pink in appearance with no evidence of fluid in the middle ear. The throat may be red but not associated with exudate or cervical lymphadenopathy. The chest is clear to auscultation, although there may be transmitted upper airway sounds, originating from the nasal passages. The cough may be dry or moist depending on the length of symptoms.

Investigations

There is no indication for investigations in a child with common cold.

Treatment

Therapy is supportive, with explanation and a management plan for parents. Parents need to ensure the child has adequate rest and fluids to maintain hydration. Nasal congestion/obstruction in infants may be improved with saline drops (one teaspoon salt in one cup boiled water and allowed to cool and kept in refrigerator for a few days only or commercial saline preparations) into the nares prior to feeds or sleeping. In addition, aspiration of mucus using a bulb suction device is generally helpful. While feeding difficulty may occur due to nasal obstruction, infants with a presumed simple URTI who are unable to take normal feeds need to be carefully checked for features of lower respiratory tract (LRT) involvement.

The routine use of oral decongestants in infants is generally unhelpful and may cause side effects. In older children symptomatic of nasal obstruction, topical or oral decongestants may be used judiciously and topical decongestants never longer than 3 days, to avoid rebound nasal mucosal swelling.

There is no indication for antibiotics in this setting. Pharyngitis or tonsillitis associated with a URTI is viral in nature and will not respond to antibiotics. The inappropriate use of antibiotics in these patients may be a contributory factor to antibiotic resistance. Herbal remedies such as echinacea, vitamin C, or zinc have not been shown to benefit resolution of symptoms.

An explanation to parents of the expected natural history may decrease the likelihood of inappropriate seeking of antibiotics. Early review should be encouraged if their child’s course deviates from that expected. Paracetamol is indicated if a child is symptomatic of fever or to diminish the discomfort of a sore throat.

Introduction

Children with stomatitis often present to emergency due to difficulties in drinking. In children it is most commonly caused by herpes simplex virus (gingivostomatitis) or Coxsackie virus (e.g. hand, foot and mouth (HFM)). These viral infections cause vesicular lesions, which may involve the buccal mucosa, gingiva, tongue, palate and pharynx. Fungal infection with Candida albicans (thrush) may be seen in neonates or immunosuppressed children.

History

Primary herpes simplex produces a severe gingivostomatitis involving most of the mouth and characteristically has a few lesions on the outer lip area. Fever is prominent and can last for 7–10 days. The associated mouth pain can result in drooling, decreased oral intake and subsequent dehydration. Oral herpes can be spread to the digits in patients who suck their fingers, leading to a herpetic whitlow. Coxsackie virus can produce ulcers involving the oral mucosa and skin areas (hands, feet and buttock areas). Thrush, generally seen in infants under 3 months, involves the tongue and buccal mucosa. It can cause feeding difficulties if severe but other issues need to be considered if mild.

Examination

Children may be distressed by mouth pain and have a high fever. Hydration should be assessed. Herpes causes multiple shallow ulcers of the oral mucosa and associated gingival inflammation. Hence, the oral features of herpes simplex virus infection tend to be more anterior on the gums, inner lips and tongue initially, and progress in a posterior direction. Coxsackie tends to cause fewer ulcers in the mouth, more on the palatal mucosa and is less likely to cause gingivitis. It is classically associated with vesicular lesions on the hands, feet and buttocks. Oral thrush presents with characteristic white plaques on the buccal mucosa and tongue. Clinical confusion may arise in the baby who has recently taken milk, which may give a similar appearance. Differentiation can be made by trying to scrape off the plaques, which either causes bleeding or they are unable to be removed.

Investigation

Diagnosis is clinical and usually requires no investigations. Immunofluorescence for herpes simplex may be required for isolation purposes or in the immunosuppressed.

Treatment

Viral stomatitis is self-limiting and symptomatic treatment to reduce pain and allow eating and drinking is the mainstay of therapy. Topical anaesthetic treatment such as Xylocaine viscous or gel 2% applied sparingly to the lesions, half an hour prior to drinking, may be beneficial. In addition, oral analgesics such as paracetamol ± codeine should also be used regularly. Icy poles (ice lollies), cool drinks or a soft diet may also be an effective way to achieve an adequate fluid intake. Frequent review is required to assess a patient’s hydration status. The child with severe stomatitis, who is dehydrated, may require admission for intravenous fluids. Aciclovir has been used to hasten the resolution in immunocompromised patients, but it has not been proven to be effective in normal patients admitted to hospital for hydration.

Treatment for oral thrush is either topical antifungal gel or oral drops four times a day for 10 to 14 days. Drops should be applied after a feed and inserted onto the buccal mucosa, not into the general oral cavity. Systemic antifungals are only indicated in immunocompromised patients.

Introduction

Pharyngitis/tonsillitis is a common infection involving the throat, including the tonsils. In children, particularly in the first 4 years, a viral aetiology is most likely. Viruses that can cause pharyngitis include adenovirus, enterovirus, parainfluenza, or Epstein–Barr virus (EBV).

Group A Streptococcus is the most common bacterial infection of the throat, but only accounts for up to 20% of tonsillopharyngitis. The incidence is age related and is uncommon in children under 4 years of age. Twenty percent of children are colonised by Group A Streptococcus, hence, a positive throat swab may be incidental in a child with an acute viral infection. The clinical dilemma is distinguishing viral from acute bacterial infections.

History

Older children may complain of sore throat, headache, dysphagia or have referred abdominal pain. Younger children may present with less localising symptomatology with fever, decreased oral intake, drooling or clinging to parents. Patients presenting with associated coryzal symptoms (e.g. cough, nasal congestion, etc.) are unlikely to have a bacterial cause for their pharyngitis. In high-risk children (e.g. indigenous), one needs to consider the potential of post-streptococcal glomerulonephritis as a sequela.

Examination

Group A Streptococcus is most likely in the older child with fever, swollen tender cervical nodes, isolated sore throat and florid exudative tonsillopharyngitis. The presence of a scarlatiniform rash (red, sandpaper-textured skin) or a strawberry tongue is supportive of streptococcal infection. Enterovirus can cause, in infants/toddlers, an ulcerative or exudative pharyngitis associated with high fever, drooling and may be associated with vomiting/diarrhoea or a fine macular rash. EBV (infectious mononucleosis) is common in adolescents and can have a similar pharyngeal appearance to bacterial infection. The patient may have general swelling of the neck and face, due to marked cervical lymphadenopathy and enlargement of the spleen and liver (Table 6.1.1).

Table 6.1.1 Features of viral and bacterial tonsillitis

Viral Bacterial Age <4 years Age >4 years Associated cough, coryza, conjunctivitis, diarrhoea Tender cervical lymphadenopathy Lymphadenopathy, splenomegaly (e.g. EBV) Scarlatiniform rash, oedematous tonsils or exudates Oropharyngeal features of EBV Absence of cough

Investigations

The use of throat swabs in the ED remains controversial due to the Streptococcus A colonisation that occurs in up to 20% of children and since treatment with antibiotics only decreases symptoms by 1 day. A rapid strep test is very specific for Streptococcus A infection, but not very sensitive. If a rapid strep test is positive, this obviates the need for further testing. If one suspects EBV, a full blood examination (atypical lymphocytes) or monospot or EBV serology may be helpful, although the early monospot (within 1 week of onset of symptoms) can be falsely negative, particularly in younger children.

Treatment

Treatment of confirmed Group A streptococcal infection with antibiotics will decrease the length of symptoms approximately by 1 day (3 vs. 4 days) and decreases the likelihood of rheumatic fever. Oral penicillin is the drug of choice, either 250 mg bd (age <10 years) or 500 mg bd (age >10 years) given for 10 days. A long-acting parenteral penicillin (benzathine benzylpenicillin) is also effective in children who are refusing oral medication.

Most children with a sore throat have a viral infection and do not require antibiotics. Symptomatic relief using paracetamol or soluble aspirin/salt-water gargles may be helpful. Topical anaesthetic and oral steroids have been shown to decrease the throat pain. Ensuring adequate hydration improves the patient’s general well-being. In those unable to drink and who are dehydrated, admission for intravenous fluids may be required. Children with severe tonsillomegaly and neck swelling from EBV can develop airway obstruction and may benefit from steroids. The threshold for antibiotic treatment needs to be lower in high-risk children (indigenous) who have an increased risk of glomerulonephritis.