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Upper Respiratory Infections (Colds) & Ear Infections: A Brief Overview

On average, children get six to eight colds, or acute upper respiratory infections (URIs) per year. URIs are more common during the winter months but occur all year round. A URI on average will last 3-14 days. However, URIs are also among the leading causes of morbidity and mortality in children due in large part to comorbidities like otitis media (ear infections), sinusitis, bronchitis, and pneumonia. Every week I find myself telling patients' families "It started with a virus...". The most common of these causal agents are rhinovirus and adenovirus. Others include influenza, respiratory syncytial virus (RSV), parainfluenza, and enteroviruses.

How do these viruses take hold? At any point in time, almost one in three asymptomatic and healthy children carry respiratory viruses. The first line of defense against such viruses causing symptoms is the epithelial layer of the respiratory mucosa. The local microbiome and cilia of the healthy airway help prevent pathogenic viruses and bacteria from invading. If viruses or bacteria do breach the mucosa, the inflammatory response is upregulated to combat the infection. Then begin the symptoms: cough, sore throat, runny nose, sneezing, facial pressure, low-grade fever, nasal congestion and fatigue. Other commonly seen symptoms are conjunctivitis, scratchy throat, abdominal symptoms and mild dehydration.

The common cold is a clinical diagnosis. Rapid antigen testing for influenza A and B and RSV can be done in the office. Testing for rhinovirus, for example, takes at least 24-48 hours, is not as widely available, and is only done if the diagnosis is uncertain.

To prevent the common cold, rest and good hand washing go a long way.

Other remedies that have been studied include zinc, probiotics and vitamin C. These will each be revisited and expanded upon in future posts as well.

Data compiled in a 2011 Cochrane Database Systematic Review showed that oral zinc sulfate, when taken within the first 24 hours of illness, was associated with a decrease in duration and severity of cold symptoms. Some families choose to take zinc as a preventative during the fall and winter. If taken over a time span averaging at least 5 months, zinc was associated with fewer school absences and fewer prescriptions. Some downsides reported included metallic taste and nausea. I recommend taking zinc with a meal to avoid nausea and abdominal discomfort.

As of 2019, evidence is conflicting regarding whether probiotics should be taken to prevent URIs. Difficulty lies in the wide variety of strains, dosing, and duration of treatment. A 2017 review article compiled several studies and found that for preventing URIs specifically, Lactobacillus rhamnosus (LGG) was the only effective strain, so I recommend including this strain in any probiotic supplement children take. These kids' probiotics contain LGG and others that have been studied in GI illnesses. Not all brands of yogurt contain this strand, but Stonyfield Farms says it "sometimes" does.

Vitamin C helps the immune system function, so it would make sense that supplementation with vitamin C would be effective in prevention and treatment of URIs. Some studies agree, others have found no difference. However, vitamin C supplements have been used in treatment and prevention of the common cold for decades. Vitamin C is very safe; the upper limit of dosing is limited only by GI tolerance (diarrhea).

Treatment of the common cold focuses on decreasing symptoms, preventing complications while the illness passes. Evidence-based treatment includes nasal irrigation, humidified air, and for ages two and up, menthol vapor rub. The American Academy of Pediatrics also recommends warm liquids given at intervals to help thin mucous. Honey has been shown to be more effective than OTC cough suppressants. Lastly, black elderberry has been shown to help specifically in cases of influenza infection, group A, C and G Streptococci infections.

Antibiotics are not effective against URIs but can treat comorbidities like ear infections. Still, not all ear infections are bacterial. Viruses (or allergies) cause fluid in the middle ear space (otitis media with effusion, OME), then bacteria can grow in the middle ear space, causing acute otitis media (AOM). AOM is often evidenced by pus in the middle ear space, bulging ear drums and fever. AOM and OME can cause ear pain and a clogged feeling.

Policy of the American Academy of Pediatrics is that antibiotics be reserved for children under the age of two years with bilateral infection or unilateral infection with tympanic membrane perforation. In other cases, pain management is the goal and ideally a recheck after a watchful waiting period of 2-3 days.

Breastfeeding helps prevent ear infections. If formula fed, not letting an infant lie down or sleep with a bottle also helps. Avoiding secondhand smoke helps as well. Ensuring your child is up to date on vaccinations also protects against influenza as well as Streptococcus pneumoniae, a bacteria which can cause ear infections.

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