Expert Q&A: Rethink your approach to paediatric URTIs – practical advice from Dr Jonny Taitz

It’s important to know that it can be normal for preschool-aged children in childcare to have six to eight URTIs each year.¹ There are a few factors at play here. Firstly, babies and young children have an underdeveloped immune system.² Secondly, transmission of viral infections among children at childcare is common,³ as often children attend daycare or preschool while infectious. And so sometimes it feels like it’s a merry-go-round: a kid gets sick, goes home for a few days, comes back, gets sick from the next kid, and so on.

Anatomy also plays a role, as children’s sinonasal anatomy is very underdeveloped compared to adults, meaning that their airways can get blocked and congested more easily.⁴ So the exposure risk at childcare, combined with underdeveloped immunity and airway anatomy can heighten the risk for developing URTIs in preschoolers.

The most important thing is to assess the overall wellbeing of the child, starting with level of consciousness and their fluid intake and output over the previous 24 hours. Examine their chest and upper airway for congestion and look for any concerning features.⁴

The big three flags for an emergency presentation would be an unexplained rapid heart rate, persistent high respiratory rate, and lethargy.⁴ Other key signs include a returning high temperature after its settled, or a high temperature that lasts more than 5 to 7 days, because that would raise concern about a secondary bacterial infection.⁵

There are certain children who may be at greater risk of more severe URTIs or complications. Consider further assessment or closer follow-up in babies born prematurely, young children with underlying cardiac or respiratory conditions (e.g., cystic fibrosis), those with known or suspected immunodeficiency, and those with prior lengthy or complicated hospital stays.⁴

Luckily, most cases GPs will see are uncomplicated,⁵ but for those that are less straightforward or the GP is not sure, the gold standard of care is to ensure timely follow-up. That might be a phone call at the end of the day, getting them back the next day, or clear instructions for the parents on when to present. Particularly, ensure that parents from a non-English speaking or disadvantaged background know what to do and where to present, as sometimes that does get lost in translation.

Most babies and young children who come in are doing fine, so management is largely around reassurance for the parents and recommending supportive care. First, I recommend fluids. I say don’t stress about solids, because sick babies won’t eat; but keep up fluid intake, especially electrolyte-balanced solution, and monitor wet nappies.

Relieving nasal congestion is the other main thing to recommend to parents. Using nasal saline to clear out nasal passages and sinuses is very important, especially before feeding.⁴ It tends to be underutilised, as some people don’t feel that it can be used to treat nasal congestion, when in fact, studies show that it’s an effective and low-risk intervention.^6,7 So nasal saline plays an important role in symptom relief, especially in infants and children under 6 years of age for whom medicated decongestant options are limited.⁵

I also stress the role of immunisation. While you can’t stop kids getting viruses, you can immunise where appropriate and take preventive measures. The flu vaccine is recommended annually for all eligible children over 6 months of age (now available in nasal administration) and RSV immunisation is also available for eligible young children.^8,9

Some parents will insist on a swab to test for the source of infection, which we will do sometimes depending on the child’s background. But whether the URTI is caused by a rhinovirus, influenza, or parainfluenza – or not, it doesn’t really change patient management. Most URTI care involves symptomatic treatment.

Unfortunately, we live in an era where many doctors feel that they have to prescribe an antibiotic for what is almost always a viral infection, which is just increasing antibiotic resistance. Addressing this issue requires reassurance and education.

Explain to parents the difference between viral and bacterial infections, and that antibiotics will do nothing to a virus. So, in the absence of red flags or concerns around sepsis, there’s no indication for an antibiotic. Sometimes there are demands from parents for antibiotics, but if you take the time to explain why, most parents are not keen to have inappropriate antibiotics either.

When recommending nasal saline, it’s important that parents understand that there are age-specific products available. Due to changes in sinonasal anatomy over time, nasal saline drops will work better for infants and very young children, while nasal saline sprays will work better for older children.^10,11 Simple education for parents can help them understand their options and select the right nasal saline for their child. Also, make sure you explain to parents how to correctly position the nozzle to effectively administer the nasal saline drops or spray into the nasal cavity.¹¹ Samples are always handy to have available to help with this.

It’s also important to cover what red flags parents should look out for, so they know when they need to seek urgent medical care. Key concerning features in children under 3 years include lethargy, reduced fluid intake and urine output (i.e., few wet nappies), rapid heart rate, rapid breathing or increased work of breathing (recession), and altered consciousness.^4,5 I tell parents to trust their intuition – their child may look fine now, but things can change in 6 or 12 hours, and they should visit the emergency department or 24/7 urgent care centre if they deteriorate.

Follow the three pillars of symptomatic therapy, education, and immunisation. Prescribe fewer antibiotics and recommend more nasal saline, because it provides symptomatic relief and can help reduce the length of infection.