The common cold often involves the paranasal sinuses, middle ear, and nasopharynx. Direct contact with infectious secretions by the hands, fomites, or droplets leads to viral proliferation in the mucosa and a subsequent inflammatory response. Inflammatory cytokines are thought to be of central importance in the pathogenesis of this inflammation in the respiratory tract as regulators of proliferation, chemotaxis, and activation of inflammatory cells (Nicod, 1993). Mucosal swelling and increased production of phlegm result. The swelling may then obstruct normal sinus drainage and interfere with normal aeration and drainage of the middle ear cavity.

More than 200 million cases of URI occur each year in the United States, and primary care practitioners treat more than 75 million of these cases. These infections account for 26 million missed school days annually. After otitis media, URI is the most common diagnosis made by office-based clinicians.

The number of colds varies considerably among children (Katcher, 1996). Preschoolers generally have three to nine colds annually, or approximately one every 6 weeks, with increased frequency during winter months. Colds are more common among infants and young children who are enrolled in child care programs than among children who are cared for at home (Bauchner, Pellon, & Klein, 1999). Viruses that account for the vast majority of URIs in infants and children include influenza viruses, parainfluenza viruses, adenoviruses, coronaviruses, rhinovirus, and respiratory syncytial virus (Meissner, 1994). Human rhinovirus is the most common cause of cold (American Academy of Pediatrics [AAP], 1997).

Symptoms consist primarily of rhinorrhea, nasal congestion, cough, and low-grade fever (usually less than 102.2°F [39°C]). If fever occurs, it usually is present at the onset of the illness and is associated with other constitutional symptoms, such as myalgias and headache. Fever often subsides when respiratory symptoms become prominent (Wald, 1995). In addition, occasional sneezing, chills, and scratchy throat may occur.

On physical examination, the provider observes inflammation and redness of the nasal mucosa. A clear mucous or mucopurulent discharge is present. During the course of an uncomplicated viral URI, the quality of nasal discharge changes (Gohd, 1954). It begins as a watery discharge and becomes thicker, colored, and opaque after a few days. Most often the discharge remains purulent for several days and then clears to a mucoid or watery consistency before resolving (Wald, 1995).

Often, pharyngeal irritation and inflammation are noted as part of the clinical spectrum of the primary disease or secondary to postnasal drip. The duration of illness is usually about 1 week, but nasal discharge and cough may persist to the end of the second week.

Diagnosis may be based on the following:

If the illness lasts beyond 10 to 14 days and shows no signs of resolving, the clinician should consider sinusitis, especially if daytime cough, fever, facial tenderness, or swelling is present. Some differential diagnoses are allergic rhinitis, sinusitis, the beginning manifestations of measles or pertussis, and less frequently poliomyelitis, hepatitis, and mumps.
Providers also should consider the possibility of drug abuse, especially inhaled solvents, cocaine, and marijuana, in older children and adolescents (Behrman et al., 1996). They also should consider rhinitis medicamentosa from the overuse of certain nasal sprays and decongestants when nasal discharge persists.

There are no definitive diagnostic studies for the common cold. Diagnosis is based on clinical findings.

Home treatment involving OTC medications is an important part of the U.S. health care industry (Kogen, Pappas, Yu, & Kotelchuck, 1994). More than 800 OTC medications are available for treating the common cold (Lowenstein & Parrino, 1987). Consumers in the United States spend almost $2 billion per year on cough and cold remedies alone (Rosendahl, 1988). The OTC availability of numerous cold preparations promotes the perception that such medications are safe and efficacious (AAP, 1997).

Demonstration of the efficacy of antitussive preparations in children is lacking, and these medications may be potentially harmful (Godomski & Horton, 1992). Decongestant components of these mixtures administered to children have been associated with irritability, restlessness, lethargy, hallucination, hypertension, and dystonic reactions (Godomski & Horton, 1992). The clearance and metabolism of the components of cough mixtures may vary with age (Kearns & Reed, 1989) and disease state (Spielberg & Schulman, 1977; Larrey et al., 1989). The relative immaturity in young children of hepatic enzyme systems that metabolize drugs may enhance the risk of adverse effects of such medications, especially in those younger than 6 months (Kearns & Reed, 1989). Concurrent use of medications, such as acetaminophen, also may alter metabolism or toxicity (American Medical Association, 1995).

Perhaps even more dangerous than the indiscriminate use of OTC cold and cough preparations is the misuse of antimicrobials for URI management. From 1980 to 1996, antibiotic prescriptions by primary care practitioners increased by almost 50% from 86 to 128 million (Nyquist, 1999). The common cold or URI is the second leading condition associated with the prescription of antibiotics (McCaig & Hughes, 1995). Overuse of antibiotics has led to new patterns of resistance in virtually all the common pediatric respiratory pathogens but especially in pneumococci. Refer to Chapter 33 for a complete description of emerging drug resistance.

According to Nyquist, Gonzalez, Steiner, and Sande (1998), who reviewed the 1992 National Ambulatory Medical Care Survey, antibiotics were prescribed unnecessarily to 44% of patients with colds and to 75% of patients with bronchitis. The reasons ranged from practitioners’ desire to shorten the natural course of the illness, to prevent possible superinfection, to ease diagnostic uncertainty, and, most commonly, to deal with parents’ unrealistic expectations. Parental pressure may account for more than half of the inappropriate prescriptions of antibiotics (Bauchner et al., 1999). Educational pamphlets available from the AAP attempt to fill this parental educational gap.

Effective treatment modalities for infants include using a cool mist vaporizer, sleeping with the head elevated, and administering saline drops. Clinicians should encourage fluid intake and can recommend throat lozenges for older children. The common cold rarely develops into a more serious illness. The usual duration of illness is approximately 7 to 10 days, with complete or near complete resolution of all symptomatology.

Completely preventing the spread of this illness is nearly impossible, especially with present economics dictating two-income families and group day care for many children. Families should make attempts to limit unnecessary contacts for their sick children. Frequent hand washing, teaching children to cover their noses and mouths with a tissue when coughing or sneezing, and appropriately disposing contaminated materials are all measures for preventing spread of this illness.

Humans are the only host to the virus, which is a Paramyxovirus. The organism enters the host through the respiratory tree. A susceptible person who comes into contact with infectious secretions and droplets is highly likely to contract the illness. After entering the respiratory mucosa, the organism immediately begins to replicate.

Three stages characterize the illness: an incubation period, a prodromal stage, and the rash itself. Mortality generally is low, except in the case of immunocompromised patients or patients who develop encephalitis. With measles encephalitis, mortality can be as high as 15%.

More than 90% of susceptible household contacts of a patient with an acute case of measles will acquire the disease. The most infectious period is during the prodromal phase before the rash appears, although infectivity extends from 7 days after exposure to 5 days after the rash appears. The last major outbreak of measles in the United States was from 1989 to 1991. Most cases were in unvaccinated children; however, more cases were among vaccinated children than the predicted percentage of vaccine nonresponders. Such developments suggested that immunity waned and prompted the establishment of the present immunization requirement of two measles vaccines (Centers for Disease Control and Prevention [CDC], 1997a).

The incubation period lasts for 10 to 12 days. The prodromal phase follows with the classic triad of symptoms: cough, coryza, and conjunctivitis. The cough may continue to worsen and could represent measles pneumonitis or bronchopneumonia from a bacterial superinfection. A low to moderate fever is present at this time. These symptoms last for 3 to 5 days and progressively worsen.

Children with classic measles appear ill. Koplik spots develop on the buccal mucosa at the end of the prodromal phase, lasting for 12 to 18 hours. These small, whitish-gray spots with surrounding redness most commonly are adjacent to the lower molars but may appear anywhere on the buccal mucosa. They are pathognomonic for measles. Immediately thereafter, high fevers of up to 104°F (40°C) appear along with the classic rash. At first macular then maculopapular, these red spots begin around the neck, cheeks, and face and rapidly spread to the trunk and extremities over the subsequent 3 days. In mild cases, they remain as individual spots, but in most cases, the individual lesions coalesce, covering most of the body, including the palms and soles. The rash fades thereafter in the order in which it appeared. Occasionally, petechiae or other evidence of hemorrhage are in the skin lesions. An urticarial rash sometimes occurs with measles. Splenomegaly can accompany the illness. Gastrointestinal symptoms, such as vomiting and diarrhea, are more common in infants and young children.

Diagnosis rests on recognition of the classical symptoms. Clinicians often delay diagnosis until the rash appears. Prodrome includes cough, coryza, and conjunctivitis. Fever ranges between 101°F and 104°F. Diagnosis often is based on the ill appearance of the child, Koplik spots on buccal mucosa, and the erythematous macular then maculopapular rash that begins on the face and cheeks and extends downward and outward to trunk and extremities.

The white blood cell (WBC) count is lowered, with lymphocyte predominance. Acute and convalescent sera (im-munoglobulin M [IgM] and IgG) will demonstrate a rise in antibody titers to measles. In encephalitis, cerebrospinal fluid (CSF) protein and presence of lymphocytes are increased (Behrman et al., 1996).

The patient with clinically apparent measles infection should be isolated from contact with susceptible children and adults. Preventing the spread of this illness is extremely difficult due to its infectious nature. Maintaining a high level of protection through vaccination is the only way to control outbreaks. The currently licensed MMR vaccine is 90% to 95% protective. Refer to Chapter 13 for a complete discussion of measles vaccine, which normally is given at 1 year with a booster given before school entry.

In cases of endemic or epidemic outbreaks, local health departments may decide to vaccinate infants from ages 6 to 12 months, even though the efficacy of the vaccine in this age group is diminished because of the infant’s competing maternal antibodies. Passive immunization using gamma globulin is effective in preventing the development of acute measles if used within 6 days of exposure. In fact, active immunization with MMR postexposure also may provide protection from development of disease if given within 72 hours of exposure (AAP, 1997).

Treatment consists of supportive therapy, including antipyretics, adequate oral fluid intake, humidified air, and prompt treatment of any complications (eg, antibiotics for bronchopneumonia). Vitamin A has been shown to ameliorate symptoms of acute infection in children in developing countries (Hussey & Klein, 1995). Most childhood cases of measles result in complete recovery.

Complication rates are highest in children younger than 1 year and in adults. Complications include pneumonia, which may be fatal in the setting of an immunocompromised patient; otitis media; and encephalitis. Encephalitis, the most feared complication, occurs at a rate of 1 to 2/1000 cases and may be demyelinating. Of those who develop encephalitis, two thirds may recover completely, one sixth may die, and one fourth may suffer permanent brain damage. Other neurologic sequelae also can occur. Disseminated intravascular coagulation may follow the acute illness but is uncommon. In adults, liver enzymes can be elevated, and jaundice may occur. Laryngitis, tracheitis, and bronchitis are frequent. Myocarditis is uncommon. Subacute sclerosing panencephalitis, a rare sequela, can appear years after the primary infection and is a devastating complication.

The differential diagnosis includes rubella, roseola, enterovirus, adenovirus, and coxsackievirus infections; infectious mononucleosis; meningococcemia; rickettsial illness; scarlet fever; Kawasaki syndrome; and drug rash. With an accompanying history of a recent infusion, serum sickness also is a consideration.

The virus is spread through direct contact with airborne droplets, fomites contaminated by saliva, and possibly urine. Virus has been isolated from saliva as long as 6 days before and up to 9 days after appearance of salivary gland swelling. Transmission does not seem to occur more than 24 hours before the appearance of parotid swelling or later than 3 days after swelling has subsided. Virus has been isolated from urine from the first to 14th day after the onset of salivary gland swelling. Fever lasting for 3 or 4 days is accompanied by parotid gland swelling, which usually lasts for 7 to 10 days. Rare complications include acquired sensorineural hearing loss in children and mumps-associated encephalitis. Symptomatic meningoencephalitis may occur in 10% of cases and follows the course of benign aseptic meningitis without sequelae. According to Bang and Bang’s classic study in 1944, up to 60% of cases are asymptomatic. In addition, orchitis develops in up to 38% of postpubertal male patients. Although it is often bilateral, orchitis rarely causes sterility. Rare complications include oophoritis, pancreatitis, and permanent sequelae, such as paralysis, seizures, cranial nerve palsies, aqueductal stenoses, and hydrocephalus. Deaths from mumps are rare. Although mumps infection in the first trimester of pregnancy may result in fetal loss, no evidence shows that mumps during pregnancy causes congenital malformations.

Eighty-five percent of mumps infections occur in children younger than 15 years. People with mumps are considered infectious from 2 days before until 9 days after onset of parotitis. Because mumps can be asymptomatic, clinicians can easily miss the diagnosis. Epidemics appear to be primarily related to lack of immunization rather than to waning immunity. Epidemics occur during all seasons but usually are more frequent in late winter and spring. Sources of infection may be difficult to trace because 30% to 40% of infections are subclinical. Lifelong immunity usually follows clinical or subclinical infection, although second infections have been documented (Behrman et al., 1996).

The incubation period is from 14 to 24 days, peaking between 17 and 18 days. In children, prodromal manifestations are rare but may include low-grade fever, malaise, muscular pain, and headache. Although the parotid glands alone are affected in most patients, swelling of the submandibular glands occurs frequently, usually accompanying or closely following swelling of the parotids. In 10% to 15% of patients, only the submandibular glands are swollen. Little pain is associated with submandibular infection, but swelling subsides more slowly there than in the parotids. Redness and swelling at the orifice of the Wharton duct frequently accompany gland swelling. Least commonly, the sublingual glands are infected, usually bilaterally; the swelling is evident in the submental region and in the floor of the mouth. A maculopapular erythematous rash, most prominent on the trunk, occurs infrequently; rarely it is urticarial. Some differential diagnoses include infectious mononucleosis, chronic adenitis, cat-scratch fever, leukemia, thyroglossal duct cyst, and acute cervical adenitis (Feigin & Cherry, 1998).

Diagnosis may be based on the acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland, lasting more than 2 days, without other apparent cause. These tests should be considered for the diagnosis of complicated cases:

Treatment of acute mumps infection is entirely supportive. Complications are rare. The illness is self-limited. Primary prevention through vaccination is the most effective means of controlling outbreaks of disease in communities. Mumps vaccine should be given as MMR to children age 1 year and again at age 4 years.

The rubella virus is shed through respiratory secretions from an infected person and comes into contact with the epithelial surface of the nasopharynx of the susceptible person. The virus propagates in the epithelium and spreads through lymphatics and possibly by transient viremia to regional lymph nodes (Green et al., 1965).

Rubella virus is a togavirus and is transmitted through direct droplet contact from infected nasopharyngeal secretions. Its peak incidence is in the late winter and early spring. The proportion of cases among adults has risen steadily from 28% in 1991 to 73% in 1996. In 1996, 68% of reported rubella cases of known ethnicity were among Hispanics (CDC, 1997c). Vaccine use has effectively controlled the incidence of disease in children, but rubella outbreaks continue among adults and religious groups who refuse vaccination (CDC, 1994).

Once viral innoculation has occurred, rubella virus incubates for 14 to 21 days, after which symptoms begin. Adults with rubella usually experience prodromal symptoms; however, children with rubella typically do not. Eye pain, sore throat, headache, swollen glands, fever, aches, chills, anorexia, and nausea are frequent prodromal symptoms in adolescents and adults (Finklea, Sandifer, & Moore, 1968). Prodromal symptoms precede the rash by 1 to 5 days; lymph node enlargement may be present from 5 to 10 days before the rash appears. An erythematous maculopapular rash of small, fine lesions follows, which then fades and coalesces, lasting for 2 to 3 days. Lymphadenopathy, especially postauricular, suboccipital, and cervical, is present. Mild fever and transient polyarthralgia and polyarthritis, especially in adolescents and fe-males, accompany the illness. Clinical diagnosis of rubella is difficult because of the overlap of symptoms with other viral illnesses. Encephalitis and thrombocytopenia are rare complications.

Rubella acquired by the fetus during the first trimester of gestation often results in fetal death by spontaneous abortion. Congenital rubella syndrome is a multiorgan system infection. The most common manifestations include intrauterine growth retardation, cataracts, microphthalmia, structural cardiac defects and myocarditis, sensorineural hearing loss, and mental retardation (Feigin & Cherry, 1998).

The clinical symptomatology is suggestive but not diagnostic of rubella. Diagnosis is based on clinical findings plus diagnostic studies.

The laboratory criteria used for diagnosis generally are not clinically useful in individual cases. Providers should use them only to investigate outbreaks for public health reasons. The following are diagnostic tests: