How to Minimize Antibiotic Overuse In Kids with Upper Respiratory Illnesses

Infants and children can easily develop up to 10 respiratory illnesses per year. Most of these are viral, and will often run their course with basic supportive measures. Alas, these seemingly ‘basic’ measures seem to have become little known to the majority of parents and caregivers, who are all-too-eager to give children unnecessary antibiotics.

Over the past few decades, there has been a sharp rise in antibiotic over-prescribing in the US and worldwide. When a parent or caregiver brings a child with a respiratory illness to a doctor’s office, it is often expected that a prescription for antibiotics will be given. Many parents will be disappointed, and even question a doctor’s judgment, if no antibiotics are offered. This is especially the case when the child has an ear infection; parents often assume that antibiotics should be administered.

Concerns for potential complications of bacterial infections, fear of losing patients to follow-up, and the increased practice of ‘defensive medicine’ have all contributed to the medical community’s continued overuse of antibiotics for viral illnesses. The result? An inordinate rise in bacterial resistance, a need for stronger antibiotics, and the use of adult dosing to treat bacterial illness in pediatric patients.

Clear Guidelines, Clearly Ignored

In 2004-2005, The American Academy of Otolaryngology-Head and Neck Surgery, together with the American Academy of Pediatrics, published guidelines regarding treatment of children with acute otitis media (ear infections). These guidelines explicitly recommend ‘watchful waiting’, with treatment of pain and fever with analgesics and antipyretics for 24 hours in the majority of children.

As most ear infections are caused by viruses, and will begin to resolve as the pain resolves, antibiotics are seldom necessary. Only in select, higher risk populations, such as children under age six months, children with immunosuppression, or children with other complicating illnesses, should antibiotics be given as a first-line therapy.

A study assessing the impact of these recommendations was published earlier this year in the journal Otolaryngology-Head and Neck Surgery. Unfortunately, there has been little actual change in the management of acute otitis media in this population, despite the fact that these guidelines have been well recognized and well understood by most providers who treat children.

In other words, there has been no decline in the use of antibiotics for uncomplicated ear infections, despite the fact that most of these infections are caused by viruses.

Since the vast majority of respiratory illnesses, including acute otitis media, are viral in origin, physicians and families need to have a clearer understanding of what they can do to minimize the severity and duration of these frequent occurrences. Many of these recommendations may seem obvious, but I am always amazed by how few clinicians and caregivers recognize and implement these simple approaches.

The Saline Solution

The most basic way to both treat and prevent respiratory illnesses, in both children and adults, is nasal saline. Any brand, any time. I personally prefer the saline that comes in a cylindrical bottle, so that the parent can give it a good squeeze each time they use it on their child, as opposed to the flatter bottle, which gives less pressure and less volume.

Parents also need to understand that the nasal airway is angled ‘back’, and not ‘up’, so when they hold the bottle, they should aim ‘back’, and not ‘up’. I find that giving a quick demonstration in the office is quite helpful. I use an empty clean bottle, or even an otoscope speculum to demonstrate the angle and technique.

The infant or child should be in an upright sitting position (not lying on a bed or changing table). Insert the nozzle first, and then squeeze the bottle. Parents should avoid touching the nasal septum, which is quite sensitive; they should place the nozzle in the center of the nostril, not towards the nasal septum.

I explain that most of the saline will drip back out, but some will get into the nose and nasopharynx, and will act as both an irrigant as well as a flush. I recommend two sprays in each nostril, every two hours when the child is awake. I also recommend saline spray every night at bedtime, especially for cold-prone children, throughout the fall and winter months.

Here are a few other effective alternatives for managing upper respiratory infections:

Oxymetazoline: For a child who is especially congested, an under-utilized, although remarkably safe and effective medication is oxymetazoline. This can be used in infants as well. It can be used as a spray or a drop, depending on which is best tolerated by the child.

Like all drugs, oxymetazoline should be used judiciously, in limited quantity and duration. An easy way for families to remember is the ‘rule of 2’s’: two sprays per nostril, two times per day, for no more than two days. While this medication is safe for all ages, rebound response can occur, even after short-term use.

Humidifiers: A humidifier in the child’s bedroom can be a big help during a respiratory illness. Parents often ask about whether or not menthol additives are beneficial. I advise against them, as many young children may have adverse reactions to inhaled menthol. Tap water works best. If the water has a high calcium content, families can purchase a mineral filter to leach out the calcifications which may form during the evaporation process.

Clear Fluids: Infants and children with a respiratory illness need oral hydration. Even if a child is afebrile, nasal congestion with associated mouth breathing can be dehydrating. They need clear fluids!. Water or juices are OK, but children with febrile illnesses often lose electrolytes, so electrolyte replacement may be indicated.

One option is a drink that can easily be prepared at home by mixing warm tap water, a squeezed lemon (pits removed), and a bit of table salt and brown or raw sugar (or an organic sugar alternative) to taste. This will provide a bit of sweetness from the sugar, electrolytes from the salt, vitamin C from the lemon and hydration from the water. Parents can titrate the amount of sugar, depending on what the child is willing to drink, and either heat it a bit or add ice, depending on the child’s preference for a warm or cool drink.

Parents can also make “sorbet” by blending the same ingredients and adding ice chips to the mix. Children can eat this right from the blender, or the mixture can be frozen in ice cube trays to be eaten later as ice pops.

Fevers Without Fear

Another seemingly obvious recommendation is that a family should have at least one (ideally several) functional digital thermometer. These do not need to be the high-end pricey kind, but there have been so many instances when I’ve asked a family what the child’s temperature was, and they state that they do not own a thermometer, but that the child ‘felt warm’.

Once a family has a thermometer, I advise parents to keep very careful notes when it comes to a child’s fever: these should include the time the temperature was taken, what the temperature was, and what medication/therapy was given. For high fevers, children over six months can tolerate an alternating regimen of acetaminophen and ibuprofen up to every three hours. Children under age six months should get acetaminophen only, up to every four hours.

Many parents are quite concerned about fevers, and rightly so. However, a fever in a child is a symptom, not an illness. Medications can reduce (though not necessarily eliminate) a fever, but it is very important to try and address the cause of the fever. Is it an ear infection? A sinus infection? Just another cold?

In any event, a child with a fever is usually uncomfortable. One thing that can help is to place a cool, wet washcloth on the child’s forehead and/or the back of the neck. Somewhat paradoxically, a warm (not cold) bath can also help, as can frequent oral hydration. If the child is sweaty, it’s a good idea to change his/her clothes frequently.

If a very young child (under age six weeks) has a temperature over 100.4° F, he or she needs immediate medical attention. This is a helpful guideline to give to parents, who need to understand that low-grade fever does not equal “urgent need for antibiotics.”

Easing the Pain

Fortunately, most respiratory illnesses are not especially painful. One exception, of course, is acute ear infection, which can be excruciating. Any adult who has suffered from an episode of acute otitis media will likely discover new-found empathy for these children! The pain can be stabbing and relentless. Systemic analgesics (acetaminophen or ibuprofen). can help ease the discomfort.

Topical anesthetics, such as Auralgan® drops can also be helpful, but be careful with these drugs: In the setting of an acute tympanic membrane perforation during an ear infection, Auralgan® can enter the middle ear, leading to acute vertigo and temporary hearing loss.

Another respiratory infection that causes severe pain is that caused by Coxsackie virus. This is often referred to as ‘herpangina,’ if it involves the throat alone, or ‘hand-foot-and-mouth’ disease if there are viral ulcers on the hands and feet. Children with severely painful oral ulcers are at risk for dehydration because they don’t want to drink. In these cases, pain control is crucial in order to minimize the need for intravenous fluids.

Have a pharmacist prepare an oral solution of one part Lidocaine 2%, one part Kaopectate® and one part Benadryl® (The ‘One to One to One’ solution). Provided they are old enough, children with painful mouth ulcers can swish and spit 15 to 30cc of this solution every four to six hours for pain control. For younger children, the solution can be ‘painted’ onto the upper palate with an unused paintbrush or a cotton-tipped applicator.

Acute tonsillitis is most often viral, but can also be quite painful. “One-to-One-to-One” solution can sometimes help, though is not as helpful for young children, as the tonsillar areas are very sensitive to touch, and a child will gag if the solution is painted on to the area. It can be swished-and-spit, but it is not as effective for pain control as it is for coxsackie lesions.

Warm saline mouth rinses (warm tap water with table salt) may alleviate some tonsillitis pain, especially if associated with multiple crypt abscesses. The warm saline will loosen the debris from the crypts, hastening the healing process. For painful cervical adenopathy associated with tonsillitis (or other viral illnesses such as adenovirus), an ice pack to the upper neck area (just under the jaw line) or, even better, an un-opened bag of frozen peas, can help reduce the inflammatory nodes and alleviate some of the pain.

The vast majority of respiratory illnesses in young children can be managed without antibiotic therapy. As we have become an overly prescribing society, the basic care measures have fallen by the wayside. Rediscovery of the simple, inexpensive and safe treatments described above will hopefully lead us back to more targeted and judicious use of antibiotics when they are genuinely necessary.


Dr. Nina Shapiro is the Director of Pediatric Ear, Nose, and Throat at the Mattel Children’s Hospital UCLA, and Associate Professor of Surgery at the David Geffen School of Medicine at UCLA. She is a regular guest on CBS’ The Doctors and has also appeared on Extra TV LifeChangers,, NBC News, and NPR. She is the author of Take A Deep Breath: Clear the Air for the Health of Your Child and editor of the Handbook of Pediatric Otolaryngology: A Practical Guide for the Evaluation and Management of Ear, Nose, and Throat Disorders in Children.

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