Common cold

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Reassure patients about the self-limiting nature of the condition, and that symptoms usually clear within 7 to 10 days. The severity and duration of symptoms appear to be related to what the patient believes and feels about the treatment received, and empathetic treatment, as perceived by the patient, is associated with improvement in symptoms and biochemical markers.[32][33][34]

Advise patients about hygiene measures and limiting the spread to others, as well as the importance of rest and maintaining fluid intake to stay hydrated.[7] The implications of increased fluid intake in acute respiratory infections have not been studied in any trials to date.[35]

Symptomatic relief is the mainstay of treatment. Many over-the-counter medications claim to alleviate symptoms of the common cold; however, quality evidence to support the use of these medications is limited.[36]

The BMJ: what treatments are effective for common cold in adults and children? Opens in new window

The BMJ: treatments for cough and common cold in children - practice pointer Opens in new window

Fever and pain

Paracetamol is recommended for pain and/or fever. Evidence suggests that it may also help with nasal congestion and rhinorrhoea, but not sore throat, malaise, sneezing, or cough.[37] Despite this, it is still one of the most widely used analgesic/antipyretic agents, and is a first choice for many clinicians for the management of pain and fever in both adults and children.[38]

A review of non-steroidal anti-inflammatory drugs (NSAIDs) found benefit for reducing discomfort, but found no benefit in terms of easing respiratory symptoms. Possible adverse effects need to be considered (e.g., gastrointestinal adverse effects, rash).[39] [ ] Studies of aspirin have found it to be effective for pain and fever, without serious gastrointestinal adverse effects with short-term use, although a small increased risk of dyspepsia has been reported.[40][41] Aspirin should be avoided in children and adolescents under 18 years of age because of the risk of Reye's syndrome.

Analgesics are available as single-agent or combination (with decongestants and/or antihistamines) formulations.

There is some evidence that over-the-counter medicated lozenges (containing a local anaesthetic, antiseptic, or NSAID) can help reduce pain associated with sore throat in adults. However, they may only reduce pain by a small amount. There is no evidence for non-medicated lozenges, mouthwashes, or local anaesthetic sprays.[42] Lozenges should not be given to children aged <4 years.[43]

Nasal symptoms

Using a humidifier, vaporiser, or breathing in steam from a bowl of hot water or shower may help. Saline nasal drops or sprays may be used. A rubber suction bulb can be used in young children to clear mucus.[43] There is low-quality evidence that saline drops or sprays may be effective and safe in younger children. They improve nasal congestion in older children, and possibly reduce rhinorrhoea severity.[44] There are many different formulations of decongestants and/or antihistamines available over-the-counter for the treatment of nasal symptoms (i.e., congestion, rhinorrhoea, sneezing), including single-agent and combination formulations.

In adults, decongestants and/or antihistamines are the best option for patients with bothersome nasal symptoms; however, the effect is considered small.[36]

Decongestant monotherapy

Sympathomimetic decongestants are available in oral (e.g., pseudoephedrine) or intranasal (e.g., oxymetazoline) formulations. There is no evidence to support the use of one route of administration over another.[36] A Cochrane review found a small subjective decrease in nasal congestion from multiple doses of nasal decongestants (3 to 4 doses per day over 5 to 10 days), but it was unclear whether this was beneficial for patients.[45]
Oxymetazoline nasal spray has been shown to have an effect in reducing airway resistance, but there is limited evidence on patient-oriented benefits.[46][47] Intranasal decongestants should be used for a maximum of 3 to 7 days due to the risk of chronic/rebound nasal congestion (rhinitis medicamentosa).
Pseudoephedrine-containing medications are associated with a risk of posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS). These are rare conditions with potentially serious and life-threatening complications. Pseudoephedrine-containing medications should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[48]

Antihistamine monotherapy

A Cochrane review found that first-generation (sedating) antihistamines are associated with relief of sneezing and rhinorrhoea, but not nasal congestion; sedation is commonly reported. Studies evaluating second-generation (non-sedating) antihistamines show an unclear effect on nasal congestion, with no effect on sneezing or rhinorrhoea.[49]

Combination formulations of decongestants and antihistamines

Antihistamines and decongestants are often formulated together, with or without an analgesic. Certain combinations of these agents may improve congestion, rhinorrhoea, and sneezing. A Cochrane review found that there is limited data on the effectiveness of these combinations for the common cold; however, there appears to be some general benefit in adults and older children, which must be weighed against the risk of adverse effects. The effect on individual symptoms is probably too small to be clinically relevant. Adverse effects include headache, sedation, and insomnia.[50]

Ipratropium

A systematic review found low-quality evidence to suggest ipratropium nasal spray is effective for rhinorrhoea compared with placebo, but not for nasal congestion. Adverse effects (e.g., dry mouth, nose bleeds, nasal dryness) were more frequent compared with placebo or no treatment.[51]

In children, the evidence for these treatments is more limited. There is no evidence that decongestants alleviate nasal symptoms in children, and they are known to cause adverse effects (e.g., drowsiness, gastrointestinal upset, more serious harms such as convulsions and rapid heart rate, and death). Therefore, decongestants are not recommended in children <6 years of age, and caution is recommended in children aged 6 to 12 years.[36]

The US Food and Drug Administration does not recommend cold products that contain a decongestant and/or antihistamine in children under 4 years of age due to possible serious and life-threatening adverse effects.[52]
FDA: use caution when giving cough and cold products to kids Opens in new window
The advice differs in other countries. For example, in the UK and Canada, over-the-counter cold treatments are not recommended at all in children under 6 years of age.

Despite these warnings, data from the Pediatric Cough and Cold Safety Surveillance System indicate that the overall rate of adverse effects related to over-the-counter cough and cold medications in children <12 years of age is relatively low (1 adverse effect per 1.75 million dose units sold), with 67% of adverse effects being related to accidental unsupervised ingestion. Fatalities were extremely rare (0.6% of patients) and not associated with therapeutic doses.[53]

Cough

Many different cough suppressants or expectorants are available over-the-counter, including single-agent and combination formulations (often combined with decongestants and/or antihistamines), and people may wish to try these.

There is no evidence to support or refute the use of over-the-counter antitussive agents, expectorants (e.g., guaifenesin), or mucolytic agents to reduce the incidence of cough in adults or children, particularly young children.[54][55]
However, the American College of Chest Physicians recommends against the use of over-the-counter cough and cold medicines for the treatment of cough.[56][Evidence C]What are the effects of over-the-counter (OTC) medications compared with placebo in reducing the duration of cough associated with the common cold in children and adults in community settings?[56]

Cough and cold medications that contain opioids, such as codeine or hydrocodone, should not be used in children aged 18 years or younger as the risks (slowed or difficult breathing, misuse, abuse, addiction, overdose, and death) outweigh the benefits when used for cough in these patients.[57]

Pholcodine-containing medications have been withdrawn from the market in a number of countries, including Europe and the UK, due to a very rare risk of anaphylaxis to neuromuscular blocking agents (used in general anaesthesia) in patients taking pholcodine-containing medications in the previous 12 months.[58][59]
Results from the ALPHO study show that pholcodine use during the 12 months preceding anaesthesia with neuromuscular blocking agents is linked to a higher risk of perianaesthetic anaphylaxis.[60] The risk has been estimated to be 1 case per 10,000 procedures.[61] The very small risk may persist for up to 3 years.[62]
Advise patients to stop taking pholcodine-containing medications and consider appropriate alternatives. Patients who are scheduled to undergo general anaesthesia with neuromuscular blocking agents should be reviewed for pholcodine use in the previous 12 months.[63]

Honey may be used to relieve cough in children aged ≥1 year and adults.[43] Honey has been shown to offer more relief of cough symptoms compared to no treatment, placebo, and diphenhydramine in children aged 1 to 18 years, but is not better than dextromethorphan.[56][64][Evidence C]What are the effects of honey in reducing the duration of cough associated with the common cold in children?[56]

A review of inhaled corticosteroids for acute and sub-acute cough found insufficient evidence to recommend their routine use for acute respiratory tract infections in adults. However, some trials have shown benefits, suggesting the need for further high-quality, adequately powered trials.[65]

Antibiotic therapy

Antibiotics are not effective for symptoms of the common cold and are known to cause adverse effects.[66] The US Centers for Disease Control and Prevention, and the American College of Physicians do not recommend antibiotic treatment.[7][43]

Recommendations in other countries may vary, and you should consult your local guidance. In the UK, the National Institute for Health and Care Excellence (NICE) recommends:

Only offering an antibiotic to treat acute cough associated with an upper respiratory tract infection in patients who are systemically very unwell (offer an immediate antibiotic) or at higher risk of complications (offer an immediate antibiotic or a delayed prescription).[67]
Considering an immediate antibiotic (or delayed prescription) for patients with acute sore throat and a FeverPAIN score of 4 or 5 (or a Centor score of 3 or 4). Immediate antibiotics should be offered to patients who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or have a high risk of complications. A delayed prescription may be considered in patients with a FeverPAIN score of 2 or 3.[42] NICE: FeverPAIN and Centor criteria Opens in new window

Antibiotics are often requested by patients at consultation, but there is increasing evidence that this encourages resistant strains of bacteria and causes unnecessary harm. There is limited evidence that purulent nasal discharge (interpreted by many clinicians and patients as suggestive of bacterial infection) will not respond to antibiotics.[66] A delayed prescription for antibiotics, alongside advice on the natural history of the illness and symptomatic treatments, has been found to reduce the rate of antibiotic use (31%) compared with immediate antibiotics (93%) with similar rates of patient satisfaction.[68] Providing written information about the use of antibiotics to parents of children with upper respiratory tract infections can also reduce the number of antibiotics used without affecting parental satisfaction.[69]

Other interventions that may have an effect on reducing antibiotic prescribing in acute respiratory tract infections in a primary care setting include C-reactive protein testing, procalcitonin-guided management of infections, and shared decision making between doctors and their patients; however, there is only moderate quality evidence for these interventions.[70] [ ]

Other treatments with limited or no evidence of efficacy

No other treatments are supported by adequate evidence. Interventions such as echinacea and humidified air have been studied in placebo-controlled trials.[26][71][72] Overall, they have shown minimal evidence of effectiveness.

Vitamin C supplementation has been found to have no benefit on the incidence of colds.[19][20] While one study found that vitamin C may reduce the duration of colds, systematic reviews (that included seven randomised controlled trials) found that vitamin C had minimal or no impact on the duration of the common cold in terms of the number of days at home or out of work.[19][73] However, administration of extra therapeutic doses of vitamin C at the onset of a cold, in addition to routine supplementation, has been found to reduce the duration of colds, shorten the time of indoor confinement, and provides symptomatic relief of chest pain, fever, and chills.[74]

Oral zinc lozenges have been found to reduce the duration of the common cold by 2.25 days compared to placebo in healthy adults, although the quality of evidence was low.[24]

Commercial inhalant products are popular, although evidence from clinical trial data to support efficacy is limited. Studies evaluating a combination of intranasal and inhaled sodium cromoglicate found inconclusive evidence of effectiveness.[75][76] There is some evidence for the effectiveness of vapour rubs in providing symptomatic relief.[77] Based on current evidence, there is no role for intranasal corticosteroids in the treatment of common cold.[78]

Treatments for which there is evidence of benefit from a single trial or from poor-quality trials include green tea, garlic, various Chinese herbal medicines, African geranium, and Pelargonium sidoides (also known as umckaloabo).[79][80][81][82][83][84][85][86][87] There is limited evidence that sea buckthorn has no effect.[88] A systematic review found evidence to support the use of black elderberry (Sambucus nigra) to reduce upper respiratory symptoms.[89] A Cochrane review found that homeopathic products did not show any benefit in terms of cure rates or prevention of acute respiratory infections in children compared to placebo.[90] [ ] [ ]

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