What Parents Need
to Know About the
Common Cold
September 2009
Provider: American Pharmacists Association
Target Audience: Pharmacists
Release Date: September 1, 2009
Expiration Date: September 1, 2012
ACPE Number: 202-000-09-222-H01-P
CPE Credit Hours: 0.5 hour (0.05 CEU)
ACPE Activity Type: Knowledge-based
Fee: There is no fee associated with this activity.
Learning Objectives
At the completion of this activity, the pharmacist will be able to:
• Recall the epidemiology and clinical presentation of the
common cold in pediatric patients.
• Discuss appropriate age-specific strategies for managing
common cold symptoms in pediatric patients.
• Review methods of preventing transmission of the viruses
that cause the common cold.
Advisor
Bella Mehta, PharmD
Associate Professor of Pharmacy and Family Medicine
Pharmacy Practice and Administration
Director, Clinical Partners Program
The Ohio State University College of Pharmacy
Columbus, Ohio
Accreditation Information
The American Pharmacists Association is accredited by
the Accreditation Council for Pharmacy Education as a
provider of continuing pharmacy education (CPE). The
ACPE Universal Activity Number assigned to this activity by the
accredited provider is 202-000-09-222-H01-P.
To obtain 0.5 hour of CPE credit (0.05 CEU) for this
activity, complete the CPE exam and submit it online at
www.pharmacist.com/education. A Statement of Credit will
be awarded for a passing grade of 70% or better. You have two
opportunities to successfully complete the CPE exam. Pharmacists
who successfully complete this activity before September 1, 2012,
can receive credit.
Your Statement of Credit will be available online immediately
upon successful completion of the CPE exam.
Development
This home-study CPE activity
was developed by the American
Pharmacists Association.
Support
This activity is supported by an
independent educational grant
from the Consumer Healthcare
Products Association.
Disclosures
Bella Mehta, PharmD, discloses that her spouse is a stock holder in
Pfizer, Inc. APhA’s editorial staff declares no conflicts of interest
or financial interests in any product or service mentioned in this
activity, including grants, employment, gifts, stock holdings, and
honoraria.
This publication was prepared by Cynthia Knapp Dlugosz,
BSPharm, of CKD Associates, LLC, on behalf of the American
Pharmacists Association.
© 2009 by the American Pharmacists Association. All rights
reserved. Printed in U.S.A.
Supplement to Pharmacy Today
An estimated 1 billion cases of the common cold occur in the United States each year.1
Children are likely to have more colds than any other illness.2 It is not unusual for a child
to have 8 to 10 colds just within the first 2 years of life.2
Recent changes in the nonprescription pediatric cough and cold market may have left
both pharmacists and parents unsure about the best way to manage common cold symp-
toms in children. This newsletter reviews important information about the common cold
and summarizes options for symptomatic treatment.
Etiologyand
Etiology andEpidemiology
Epidemiology
The common cold is a viral infection of the upper respiratory tract.1 More than 200 viruses
can cause the common cold, but the majority of colds in both children and adults are caused
by rhinoviruses.3 In the United States, the incidence of rhinovirus infection peaks in the early
fall (August to October) and late spring (April and May), although it is possible for the
common cold to occur year-round.3
Setting
Myth Things Straight
vs Fact
Young children have an average of 6 to 8
• Antibiotics have no effect
colds per year; 10% to 15% of children
on either the course or the
have at least 12 colds annually. Children
1,3-6
outcome of the common cold.
who attend day care centers during the first
In addition, antimicrobial
year of life have 50% more colds than do
therapy is not an effective
children who are cared for at home, and
strategy for preventing
continue to have more colds for several
bacterial complications.6
years (i.e., through at least 3 years of age).1,3
• Susceptibility to the common
The incidence of the common cold decreas-
cold is not increased by
es with age, to the point that adolescents
sudden chills; changes in
average 2 to 4 colds per year.3,5
weather; exposure to cold
temperatures, central heating,
Pathogenesis
Pathogenesis
or drafty windows; going
Rhinoviruses are spread most efficiently by outside without a hat or shoes;
direct contact and large-particle aerosols.3 going outside with wet hair;
Because the virus can persist for at least teething; or enlarged tonsils or
several hours on hands and environmental adenoids.1,4,7
surfaces (e.g., toys, doorknobs), infection • During the normal course
occurs primarily through self-inoculation— of the common cold,
a healthy person touches an infected hand or polymorphonuclear cells
surface, then touches his or her nose (there- release myeloperoxidase that
by transferring the virus to the nasal mucosa) turns nasal secretions from
or eye (thereby transferring the virus to the clear to yellow or green. This
conjunctival membranes).1,3,4,7,8 A healthy discoloration usually does
person also may become infected through not indicate the presence
prolonged contact with aerosols produced of secondary bacterial sinus
by coughing, sneezing, or talking.3 infection unless it fails to
resolve after 10 to 14 days.6,7
Natural History
History
In older children and adults, the common cold follows a predictable, self-limited course.
Symptoms typically begin 1 to 3 days after viral infection with a sore or “scratchy” throat.1,3
The sore throat usually resolves quickly, and nasal obstruction and rhinorrhea predominate
by day 2 or 3.3 Nasal secretions generally start out clear, thin, and watery; become thicker
and appear yellow or green as the infection progresses; then return to being clear, thin, and
watery as the infection begins to resolve.1,7 Only about one third of patients experience
cough; when present, it usually appears after the onset of nasal symptoms, on day 4 or 5.1,3
Systemic symptoms such as fever, headache, and myalgia are mild or absent.1-3,7 Symptoms
typically disappear gradually after 7 to 10 days but may persist for 14 days or longer.1,9
The clinical presentation of the common cold may deviate from this pattern in infants
and young children.5,7 Fever may be one of the first symptoms in these age groups and
may be more noticeable in the evening.2,5,7 Infants
may be fussy and unable to sleep; they sometimes
have vomiting and diarrhea.5,7 In young children,
irritability and restlessness may predominate along
with nasal symptoms.2,7 Young children also may be
more likely to experience sore throat with difficulty
swallowing, muscle aches and pains, mild fatigue,
or decreased appetite.2,5
Treatment
Treatment
There is no known cure for the common cold.
Treatment is primarily symptomatic, with a goal
of reducing patient discomfort until the infection
completes its natural course.3,7
Nonprescription pediatric cough and cold medica-
tions are used widely for symptomatic treatment
in children. Data from the Slone Survey—a
random-digit-dial telephone survey of medica-
tion use among the U.S. population—showed that
10% of children up to 18 years of age had used a
nonprescription cough and cold product during a
given week.10 Use was highest among children 2 to
5 years of age, followed by children younger than
2 years of age. Most (64.2%) of the products used
contained multiple active ingredients.
Recent changes in the nonprescription pediatric
cough and cold market have affected the avail-
ability of these popular products. In October 2007,
manufacturers voluntarily withdrew nonprescription
“infant” oral cough and cold medications (i.e., prod-
ucts intended and labeled for use in children younger
than 2 years of age).11 In October 2008, manufactur-
ers voluntarily began transitioning the labeling on oral
nonprescription pediatric cough and cold medica-
tions to state “do not use” in children younger than
4 years of age.12 These changes were made to prevent
possible misuse (e.g., dosing errors, accidental inges-
tions) and avoid potentially serious adverse effects.11,12
For the purposes of treatment recommendations,
these changes effectively divide children into three
groups:
• Children younger than 4 years of age, who should
not be treated with nonprescription cough and cold
medications (unless a primary care provider recom-
mends such use). Pharmacists may recommend
nondrug measures for children in this age group.
• Children 4 or 5 years of age, who may be treated
with nondrug measures or nonprescription
medications.
• Children 6 to 11 years of age, who may be
treated with nondrug measures or nonprescrip-
tion medications.
The latter two groups are differentiated primarily by
age-appropriate medication doses.
It is critical that parents or caregivers of infants 3
months of age or younger contact their pediatrician
at the first sign of illness.2 A suspected common cold
in young infants may evolve rapidly into more serious
ailments such as bronchiolitis, croup, or pneumonia.2
Nondrug Measures
A number of nondrug measures may be used to
relieve common cold symptoms in children
2 American Pharmacists Association
Table 1. Recommended
Nondrug Nondrug
Measures for Measures
Relieving for Relieving
Common Cold Symptoms
Cold Symptoms
General Measures
• Make sure children with the common cold get plenty of rest.
• Encourage normal intake of fluids to help keep the lining of the nose and throat
moist and to prevent dehydration.
• Place a cool-mist humidifier in the child’s room to increase the humidity of
inspired air. (Hot-water vaporizers should be used with caution because they
can cause serious scalds or burns.) Humidifiers should be cleaned and dried
thoroughly each day to prevent bacterial or mold contamination.
• Maintain a nutritious diet as tolerated.
• Protect children from passive (secondhand) smoke to prevent further irritation to
the nose and throat.
Nasal Congestion
• Use saline nasal drops (or saline nasal spray in older children) to liquefy thick
nasal secretions. Drops can be made by adding ½ teaspoon of salt to 8 oz of
warm water. Use two to three drops per nostril at least four times a day or as
often as needed for children 1 year of age or older. Use one drop per nostril for
children younger than 1 year of age. The nasal dropper should be cleaned with
soap and water and rinsed well with plain water.
• Use a suction bulb to clear the nose of children too young to blow their own
nose (usually children younger than 4 years of age). Squeeze the bulb part of
the syringe, insert the rubber tip gently about ¼ to ½ inch into one nostril,
then release the bulb slowly. Empty the contents onto a tissue, then repeat the
suctioning as needed for each nostril. The syringe bulb should be cleaned with
soap and water after each use.
• Encourage older children to blow their nose frequently.
• Apply petroleum jelly to the skin around the nostrils as a protectant.
Source: References 1, 2, 5, 13, and 14.
Symptom-Specific
Symptom-Specific Consid
Considerations
(Table 1). These measures should serve as the mainstay
of treatment for all children with the common cold.7 Considerations in managing nasal symptoms and
cough—typically the most bothersome or prob-
There is no convincing evidence that echinacea, lematic common cold symptoms—in children are
high-dose vitamin C, zinc, or any other herbal prod- discussed below.
ucts or dietary supplements are effective treatments
for the common cold in children.3,15
Nasal Symptoms
Pharmacotherapy Relieving nasal obstruction is especially important in
infants and young children, because this symptom can
Definitive recommendations regarding the use of
impair drinking and lead to dehydration.7 Any of the
nonprescription cough and cold medications in
nondrug measures listed in Table 1 may be considered
children 4 years of age or older are limited by a
for children of all ages. They are the only interventions
lack of conclusive clinical evidence.1,7 Most infor-
recommended for children younger than 4 years of age.
mation comes from small trials with varying inter-
ventions and subjectively reported outcomes.16 If Oral and topical decongestants are an option for
pharmacotherapy is desired, a reasonable option is older children. Strict adherence to the age-specific
to target therapy to specific bothersome symptoms.3 dosing instructions is critical; acute overdose can
Because symptoms appear, peak, and resolve at be life threatening in children.1 Children also are
different times, single-agent products are preferred more likely to experience adverse effects of systemic
over combination products.1,3 Pharmacists should agents, including central nervous system and cardio-
take special care to ensure that caregivers under- vascular stimulation.1 Use of topical decongestants
stand the intended effect of any medications used should be limited to 3 to 5 days to prevent the de-
and can determine the proper age-appropriate or velopment of rhinitis medicamentosa (i.e., rebound
weight-based dosage.1,3 congestion).1,3 However, use of topical decongestants
may be impractical because children may find it dif-
Whenever nonprescription medications are used to
ficult to self-administer these agents properly.7
treat cough and cold symptoms in children, parents
and caregivers need to be reminded of the impor- Oral decongestants often are marketed in combina-
tant points listed in Table 2.17,18 Pharmacists should tion with first-generation antihistamines. The first-
stress these key messages in all interactions with generation antihistamines may reduce rhinorrhea by
parents and caregivers and make a special effort to 25% to 30%, primarily through an anticholinergic
assess parents’ and caregivers’ understanding of the drying action on the mucous membranes.3,7 (Hista-
criticality of following these guidelines. mine is not an inflammatory mediator in the com-
mon cold; thus, second-generation antihistamines
have little or no effect.7) First-generation antihista-
mines typically cause sedation, but they also may
cause paradoxical excitation in children.1
Devices such as nasal dilator strips may help to relieve
nasal congestion by lifting the nares open and enlarg-
ing the anterior nasal passage.1 They are available in
smaller sizes for children 5 to 12 years of age.
Cough
Cough suppression usually is not indicated in patients
with a common cold.3 In fact, if the cough is produc-
tive, suppressing it would be counterproductive.1 None-
theless, relieving cough (especially nocturnal cough) in
children with the common cold may be an important
goal of parents or caregivers if family members lose
sleep because the cough keeps them awake at night.7
Dextromethorphan is the primary nonprescription
cough suppressant.1 It has a wide margin of safety, but
very high doses of dextromethorphan can lead to seri-
ous adverse effects including respiratory depression.1,7
Cough that appears in close proximity to nasal symp-
toms may be caused by irritation associated with
postnasal drip.3 The anticholinergic action of first-
generation antihistamines may help to relieve cough
with this etiology.3 The first-generation antihistamine
diphenhydramine also is approved by the Food and
Drug Administration as an antitussive.1
The efficacy of either dextromethorphan or diphen-
hydramine in treating cough associated with the
common cold in children is questionable, however.
In a study by Paul and colleagues, the parents of
100 children with upper respiratory infections were
asked to rate the frequency, severity, and bothersome
nature of nocturnal cough on 2 consecutive days—
before and after administration of dextromethorphan,
diphenhydramine, or placebo 30 minutes before
bedtime.19 Sleep quality for both the child and the
parent also were assessed for both nights. Neither
diphenhydramine nor dextromethorphan produced
a superior benefit when compared with placebo
for any of the outcomes studied; of note, parents of
children who received medication did not rate their
child’s sleep or their own sleep significantly better
than did parents of children who received placebo.
A subsequent study by Paul and colleagues suggests
that honey may be an effective treatment for nocturnal
cough in children with the common cold.20 In that
study, 105 children with upper respiratory tract
infections were randomized to (1) treatment with
buckwheat honey, (2) treatment with honey-flavored
dextromethorphan syrup, or (3) no treatment. The
single dose of honey or dextromethorphan was
administered 30 minutes before bedtime. On the day
following treatment, parents rated honey most favor-
ably. In paired comparisons, honey was significantly
better than no treatment, but dextromethorphan was
not. Comparison of honey with dextromethorphan
revealed no significant differences. (Note that honey
should not be administered to children younger than
1 year of age because of the risk of infantile botulism.)
The topical antitussives camphor and menthol are
available in a wide variety of products, ranging from
creams, ointments, and patches that are applied
directly to the chest or throat, to a portable battery-
operated fan that blows the vapors into the room.
The topical creams and ointments are labeled for use
in children as young as 2 years of age. “Baby rub”
products that are labeled for use in infants 3 months
of age and older do not contain camphor or menthol;
instead, they contain other aromatic oils such as
eucalyptus, lavender, rosemary, and peppermint that
are intended to have a soothing effect. Menthol also is
used in medicated lozenges (“cough drops”) that are
labeled for use in children 5 years of age and older.
The expectorant guaifenesin helps to make minimally
productive coughs more productive by thinning and
loosening lower respiratory tract secretions.1 It should
not be used to treat effectively productive coughs.1 Al-
though combination cough products often contain both
dextromethorphan and guaifenesin, this combination
is considered to be irrational—it would be expected to
result in thinned secretions that could not be expelled
easily because the cough reflex would be suppressed.1,7
Prevention
Prevention
Preventing transmission of common cold viruses is
an important goal.1,7 Frequent, careful hand cleansing
and avoidance of manual nose and eye manipula-
tion help to interrupt the chain involved in spreading
viruses by direct contact.3 Because viruses persist
on environmental surfaces, children’s toys and play
areas should be cleaned thoroughly and frequently.2,5
Children with a cold, as well as anyone who comes
into direct contact with the child, should wash their
hands frequently with soap and warm water for 15
to 20 seconds.8 The Centers for Disease Control and
Prevention suggest that this is about the amount of
time it takes to sing the “Happy Birthday” song twice.8
People who do not have ready access to soap and
water may use alcohol-based disposable hand wipes
or gel sanitizers.8 Products containing ethyl alcohol
(62%–95% concentration), benzalkonium chloride,
salicylic acid, pyroglutamic acid, or triclosan have
been proven effective.1 People who use gel sanitizers
should rub their hands together until the gel is dry.8
Whenever possible, patients with the common cold
should cough or sneeze into a tissue, dispose of
the tissue, then wash their hands.8 If a tissue is not
available, patients should cough or sneeze into the
crook of the arm rather than using their hand to
cover their nose or mouth.8,15

Table 2. Recommendations for the Safe Use of Nonprescription Cough and Cold
Medications in Childrena
• Nonprescription cough and cold medications do not cure coughs or colds. They only relieve symptoms and make a child
feel more comfortable; however, they do not treat the cause of the symptoms or shorten the length of time a child is sick.
• Medications should be selected based on a child’s specific symptoms, to avoid administering unneeded active ingredients that
might be present in multisymptom products.
• Parents and caregivers should precisely follow the dosing directions on the “Drug Facts” label, using only the measuring
device that comes with the product.
• Products labeled and intended for adult use should not be given to children.
• Special care should be taken not to use two products at the same time that contain the same or similar active ingredients.
• To prevent unsupervised ingestions, medications should be stored out of the reach and sight of children. Parents and
caregivers should select products with child-resistant safety caps.
• Parents and caregivers should not use nonprescription cough and cold medications to sedate a child or make a child sleepy.
• Aspirin-containing products should not be administered to children with signs or symptoms of a cold or flu unless
otherwise instructed by a health care provider.
• Parents and caregivers should stop giving any medication and contact a health care provider immediately if a child develops
any troubling side effects or reactions.
• Parents and caregivers should talk with a physician, pharmacist, or other health care professional if they have any questions
about using cough and cold medications in children 4 years of age and older.
Nonprescription oral cough and cold medications should not be used in children younger than 4 years of age.
a

Source: References 17 and 18.

What Parents Need to Know About the Common Cold 3

1. How many colds will a young child
typically have during a given year?
a. 2 to 3.
b. 4 to 5.
c. 6 to 8.
d. More than 12.
2. The majority of common colds
in children are caused by:
a. Coronaviruses.
b. Influenza viruses.
c. Respiratory syncytial virus.
d. Rhinoviruses.
3. A caregiver asks for assistance
in selecting a product to treat
nasal congestion in a 3-year-
old child. Which of the following
treatment options is best?
a. A single-agent oral product
containing pseudoephedrine.
b. A combination product
containing a decongestant
and a first-generation
antihistamine.
c. A topical decongestant
containing phenylephrine.
d. Only nondrug measures, such
as saline nasal drops.
References
1. Berardi RR, Ferreri SP, Hume AL, et al., eds.
Handbook of Nonprescription Drugs: An Interactive
Approach to Self-Care. 16th ed. Washington, DC:
American Pharmacists Association; 2009.
2. American Academy of Pediatrics. Parenting corner
Q&A: colds. Available at: http://www.aap.org/
publiced/BK0_Colds.htm. Accessed August 4, 2009.
3. Kliegman RM, Behrman RE, Jenson HB, et al., eds.
Nelson Textbook of Pediatrics. 18th ed. Philadelphia,
PA: Saunders Elsevier; 2007.
4. Spector SL. The common cold: current therapy
and natural history. J Allergy Clin Immunol.
1995;95:1133–8.
5. The Children’s Hospital of Philadelphia. Upper
respiratory infection (URI, or common cold).
Available at: http://www.chop.edu/consumer/
your_child/wellness_index.jsp?id=-8011#. Accessed
August 4, 2009.
6. Rosenstein N, Phillips WR, Gerber MA, et al.
The common cold—principles of judicious use of
antimicrobial agents. Pediatrics. 1998;101:181–4.
7. Kelly LF. Pediatric cough and cold preparations.
Pediatr Rev. 2004;25:115–23.
8. Centers for Disease Control and Prevention. Stopping
germs at home, work, and school. Available at: http://
www.cdc.gov/germstopper/home_work_school.htm.
Accessed August 4, 2009.
9. Butler CC, Kinnersley P, Hood K, et al. Clinical course
of acute infection of the upper respiratory tract in
children: cohort study. BMJ. 2003;327:1088–9.
4 American Pharmacists Association
CPE EXAM
What Parents Need to Know About
the Common Cold
Instructions: The assessment questions printed below allow you to preview the online
CPE exam. Please review all of your answers to be sure you have marked the proper
letter on the online CPE exam. There is only one correct answer to each question.
4. Which of the following nondrug
measures may be effective for
treating cough associated with
the common cold?
a. Echinacea.
b. Honey.
c. Vitamin C.
d. Zinc.
5. To help prevent transmission of
common cold viruses, patients
and susceptible contacts are
advised to wash their hands as
long as it takes to sing which of
the following songs twice?
a. “Happy Birthday.”
b. “Stayin’ Alive.”
c. “The Alphabet Song.”
d. “Twinkle Twinkle Little Star.”
10. Vernacchio L, Kelly JP, Kaufman DW, et al. Cough
and cold medication use by US children, 1999-
2006: results from the Slone Survey. Pediatrics.
2008;122:e323–9.
11. Makers of OTC cough and cold medicines
announce voluntary withdrawal of oral infant
medicines [press release]. Washington, DC:
Consumer Healthcare Products Association;
October 11, 2007. Available at: http://www.chpa-
info.org/10_11_07_OralInfantMedicines.aspx.
Accessed August 4, 2009.
12. Statement from CHPA on the voluntary label
updates to oral OTC children’s cough and cold
medicines [press release]. Washington, DC:
Consumer Healthcare Products Association;
October 7, 2008. Available at: http://www.chpa-
info.org/10_07_08_PedCC.aspx. Accessed August
4, 2009.
13. Bond A. Home remedies to soothe your child’s cold
symptoms. AAP News. 2007;28(12):25. Available
at: http://aapnews.aappublications.org/cgi/content/
full/28/12/25-e. Accessed August 4, 2009.
14. MayoClinic.com. Common cold in babies. Available
at: http://www.mayoclinic.com/health/common-
cold-in-babies/DS01106. Accessed August 4, 2009.
15. National Institute of Allergy and Infectious Diseases,
National Institutes of Health. Common cold
prevention. Available at: http://www3.niaid.nih.
gov/topics/commonCold/prevention.htm. Accessed
August 4, 2009.
CPE Instructions
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e-mail InfoCenter@pharmacist.com.
16. Ryan T, Brewer M, Small L. Over-the-counter cough
and cold medication use in young children. Pediatr
Nurs. 2008;34:174–80, 184.
17. FDA statement following CHPA’s announcement on
nonprescription over-the-counter cough and cold
medicines in children [press release]. Rockville,
MD: Food and Drug Administration; October 8,
2008. Available at: http://www.fda.gov/NewsEvents/
Newsroom/PressAnnouncements/2008/ucm116964.
htm. Accessed August 11, 2009.
18. Consumer Healthcare Products Association
Educational Foundation. Tip sheet for giving
oral OTC cough and cold medicines to
children. Available at: http://otcsafety.org/
Media/128702165117015854.pdf. Accessed
August 11, 2009.
19. Paul IM, Yoder KE, Crowell KR, et al. Effect
of dextromethorphan, diphenhydramine, and
placebo on nocturnal cough and sleep quality for
coughing children and their parents. Pediatrics.
2004;114:e85–90.
20. Paul IM, Beiler J, McMonagle A, et al. Effect of
honey, dextromethorphan, and no treatment on
nocturnal cough and sleep quality for coughing
children and their parents. Arch Pediatr Adolesc
Med. 2007;161:1140–6.
09-008