Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – reassurance and supportive care

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1st line – 

reassurance and supportive care

Reassure patients about the self-limiting nature of the condition, and that symptoms usually clear within 7 to 10 days.

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. The implications of increased fluid intake in acute respiratory infections have not been studied in any trials to date.[35]

Antibiotics are not recommended for the common cold.[7]​​[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]

Consider – analgesic/antipyretic

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Consider – 

analgesic/antipyretic

Additional treatment recommended for SOME patients in selected patient group

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] [ Cochrane Clinical Answers logo ]

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.

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]

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

Primary options

paracetamol: children: 15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children ≥6 months of age: 5-10 mg/kg orally every 4-6 hours when required, maximum 30 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

naproxen: adults: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

aspirin: adults: 300-600 mg orally every 4 hours when required, maximum 4000 mg/day

Consider – decongestant and/or antihistamine

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Consider – 

decongestant and/or antihistamine

Additional treatment recommended for SOME patients in selected patient group

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 safe and effective in young children.[36]​

There are many formulations available aimed at treating rhinorrhoea, nasal congestion, or sneezing, including single-agent and combination formulations. Decongestants are available as oral or intranasal formulations. A few examples are provided; however, this list is not exhaustive and a local formulary should be consulted.

Decongestants and/or antihistamines are the best option for adults with bothersome nasal symptoms; however, the effect is considered small, and use should be limited to 3 to 7 days.[36]​​

Decongestants and/or antihistamines are not recommended in children <6 years of age, and caution is recommended in children aged 6 to 12 years. There is no evidence that they 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).[36]​​

The US Food and Drug Administration does not recommend cold products in children under 4 years of age.[52]​ In the UK and Canada, cold products are not recommended in children under 6 years of age. FDA: use caution when giving cough and cold products to kids Opens in new window

Intranasal decongestants should be used for a maximum of 3 to 7 days due to the risk of chronic/rebound nasal congestion (rhinitis medicamentosa).

Ipratropium nasal spray is an effective treatment for rhinorrhoea, 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]

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]

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

Primary options

oxymetazoline nasal: (0.05%) children ≥6 years of age and adults: 1-2 drops/sprays in each nostril two to four times daily when required

OR

ipratropium nasal: (0.06%) children 6-11 years of age: 2 sprays in each nostril three times daily when required; children ≥12 years of age and adults: 2 sprays in each nostril three to four times daily when required

OR

cetirizine/pseudoephedrine: children ≥12 years of age and adults: 5 mg/120 mg (1 tablet) orally (extended-release) twice daily when required

Consider – antitussive

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Consider – 

antitussive

Additional treatment recommended for SOME patients in selected patient group

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, mucolytic agents, or antihistamines (including combinations of these agents) to reduce the incidence of cough in adults or children, particularly young children.[54][55]​ 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]

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][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]

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

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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