bubble_chart Overview

Acute upper respiratory infections (acute upper respiratory infections) are the most common diseases in children, primarily affecting the nose, nasopharynx, and throat. Therefore, diagnostic terms such as "acute nasopharyngitis" (common cold), "acute pharyngitis," and "acute tonsillitis" are often used. They can also be collectively referred to as upper respiratory infections, abbreviated as "URI." Nasopharyngeal infections often lead to complications involving adjacent organs such as the larynx, trachea, lungs, oral cavity, nasal sinuses, middle ear, eyes, and cervical lymph nodes. Sometimes, the symptoms of the primary nasopharyngeal infection may improve or disappear, while the complications can persist or worsen. Therefore, it is essential to conduct a comprehensive observation and analysis of the clinical characteristics of upper respiratory infections and their complications to enable early diagnosis and treatment, thereby improving efficacy. These infections must not be dismissed as minor everyday illnesses and treated lightly.

bubble_chart Epidemiology

Acute upper respiratory infections can occur throughout the year, with higher incidence in winter and spring. They are most common in early childhood, with individuals experiencing several episodes annually; the frequency gradually decreases in school-aged children. The causative viruses are typically transmitted through droplets, pestilence, and direct contact, and occasionally via the intestinal tract. These infections can manifest as epidemics or sporadic cases. The pestilence period is limited to the first few days in mild cases but lasts longer in severe cases and is further prolonged with secondary bacterial infections. Immunity to these viruses is generally short-lived, lasting only 1–2 months or slightly longer, though it can extend to several years in some cases.

bubble_chart Etiology

It consists of two parts:

1. Pathogens (see Etiology)
2. Predisposing factors: Malnutrition and lack of exercise, as well as children with allergic constitutions, are prone to upper respiratory tract infections due to reduced body defense capabilities, especially in cases of indigestion, rickets, etc. Additionally, children with primary immunodeficiency diseases or acquired immunodeficiency often exhibit severe symptoms when complicated by such infections. These infections are more likely to become epidemic during the winter and spring seasons when climate changes are more frequent.

It must be emphasized that the occurrence and progression of upper respiratory tract infections depend not only on the type, virulence, and quantity of invading pathogens but also on the host's defense capabilities and environmental factors. For example, crowded living conditions, air pollution, passive smoking, and indirect inhalation of smoke can all reduce local respiratory defense capabilities and promote pathogen growth and reproduction. Therefore, strengthening exercise, improving nutritional status, and enhancing environmental hygiene are crucial for preventing upper respiratory tract infections.

bubble_chart Pathogen

Pathogens are mainly viruses, accounting for over 90% of primary upper respiratory infections. Bacteria are less common. After viral infection, the upper respiratory mucosa loses its resistance, allowing bacteria to invade and cause suppurative infections.

I. Common Viruses

Since the advent of tissue culture methods, understanding of viruses has gradually increased. A brief overview is as follows:

1. Rhinovirus: Includes over 100 different serotypes, which can cause upper respiratory infections, bronchitis, and otitis media. Coronavirus is also a common pathogen for upper respiratory infections but requires special methods for isolation.
2. Coxsackie and ECHO viruses: These viruses are very small, belonging to the Picornavirus family, and can all cause respiratory symptoms.
3. Influenza virus: Divided into three serotypes—A, B, and C. Type A can lead to pandemics due to significant antigenic variations, estimated to occur every 10–15 years. Type B outbreaks are smaller and more localized. Type C generally causes sporadic outbreaks with milder symptoms. Among these three types in pediatric respiratory diseases, they primarily cause upper respiratory infections but can also lead to laryngitis, tracheitis, bronchitis, bronchiolitis, and pneumonia.
4. Parainfluenza virus: Divided into four serotypes—1, 2, 3, and 4. Type I is also known as "hemadsorption virus type 2" (HA₂), while type 2 is called "croup-associated virus type I" (HA₁), often causing bronchiolitis and pneumonia, as well as frequent croup. Type 4, also known as M-25, appears to be less common and can cause upper respiratory infections in children and adults.
5. Respiratory syncytial virus (RSV): Only one type exists, with strong pathogenicity for infant respiratory tracts, capable of causing minor outbreaks. About 75% of infants under 1 year old may develop bronchiolitis, and around 30% may experience laryngitis, tracheitis, bronchitis, or pneumonia. After age 2, these diseases become less common, and by age 5, upper respiratory infections significantly decrease, presenting only as mild upper respiratory infections.

   The latter three types of viruses mentioned above all belong to the myxovirus family. Among upper respiratory infections, parainfluenza virus, respiratory syncytial virus, and coronavirus are relatively common.

6. Adenovirus: Over 30 different serotypes exist, causing upper respiratory infections of varying severity, such as nasopharyngitis, pharyngitis, pharyngoconjunctival fever, and follicular conjunctivitis, and can also lead to pneumonia outbreaks. Types 3 and 7 adenovirus can persist in the upper respiratory glands and may cause fatal pneumonia. Type 8 adenovirus easily causes epidemic keratoconjunctivitis in school-aged children. Types 3, 7, and 11 can cause pharyngoconjunctival fever. From 1979 to 1983, swimming in Beijing led to outbreaks of types 3 and 7 adenovirus pharyngoconjunctival fever.
7. Mycoplasma pneumoniae: Also known as pleuropneumonia-like organisms (PPLO), it not only causes pneumonia but also upper respiratory infections. Pneumonia is more common in children aged 5–14.

II. Common Bacteria

Account for only about 10% of primary upper respiratory infections. Secondary bacterial infections invading the upper respiratory tract mostly belong to group A β-hemolytic streptococci, pneumococci, Haemophilus influenzae, and staphylococci. Among these, streptococci often cause primary pharyngitis.

Recent foreign literature mentions that Branhamella catarrhalis, formerly known as Neisseria catarrhalis, is one of the resident bacterial flora in the nasopharynx. It can sometimes develop into a pathogenic infection in the respiratory tract, with an increasing trend, though it is less common than infections caused by pneumococcus and Haemophilus influenzae.

bubble_chart Pathological Changes

In the early stages, there is only edema in the submucosal layer of the respiratory tract, primarily characterized by vascular dilation and mononuclear cell infiltration, which later shifts to neutrophil infiltration. The epithelial cells are damaged and shed, then regenerate during recovery.

bubble_chart Clinical Manifestations

The severity can vary greatly, generally being milder in older children while more severe cases are common in infants and young children.

1. Incubation period: Mostly 2 to 3 days or slightly longer.
2. Mild cases: Only nasal symptoms, such as runny nose, stuffy nose, sneezing, etc., may also include tearing, mild coughing, or throat discomfort, and can resolve naturally within 3 to 4 days. If the infection involves the nasopharynx and throat, fever, sore throat, tonsillitis, and hyperemia and hyperplasia of the lymphoid tissue on the posterior pharyngeal wall are common, and sometimes lymph nodes may be slightly swollen. Fever can last for 2 to 3 days or up to about a week. In infants and young children, vomiting and diarrhea are easily triggered.
3. Severe cases: Body temperature can reach 39–40°C or higher, accompanied by chills, headache, general weakness, sharp loss of appetite, and restlessness. Soon after, the throat becomes slightly red, and herpes and ulcers develop, known as herpetic pharyngitis. Sometimes the redness and swelling are pronounced, affecting the tonsils, with follicular purulent exudate appearing, worsening the sore throat and systemic symptoms. Nasopharyngeal secretions change from thin to thick. Submandibular lymph nodes become significantly enlarged and tender. If the inflammation spreads to the sinuses, middle ear, or trachea, other symptoms arise, and systemic symptoms become more severe. In more severe cases, attention should be paid to febrile seizures and acute abdominal pain, and differential diagnosis with other diseases is necessary.
   1. Febrile seizures caused by acute upper respiratory infections are mostly seen in infants and young children, occurring several times within 1 to 2 days after onset.
   2. Acute abdominal pain can sometimes be very intense, mostly around the navel, without tenderness, often appearing early and usually temporary, possibly related to increased intestinal peristalsis. However, it may persist, sometimes resembling symptoms of appendicitis, mostly due to concurrent acute mesenteric lymphadenitis.
4. Acute tonsillitis: Part of acute pharyngitis, its course and complications are not entirely the same as acute pharyngitis, so it can be considered a separate condition or grouped with pharyngitis.
   1. In cases caused by viruses, white spotty exudate may sometimes be seen on the tonsil surface, along with small ulcers on the soft palate and posterior pharyngeal wall. The bilateral buccal mucosa is congested with scattered bleeding points, but the mucosal surface remains smooth, distinguishing it from measles.
   2. In cases caused by streptococci, generally seen in children over 2 years old, systemic symptoms are more prominent at onset, including high fever, chills, vomiting, headache, abdominal pain, etc. Later, sore throat may vary in severity, with difficulty swallowing. The tonsils are mostly diffusely red and swollen, or show follicular purulent exudate. The patient's tongue is red or coated. If treatment is inadequate, complications such as sinusitis, otitis media, and lymphadenitis are likely to occur.
5. Blood test results:
   1. In viral infections, white blood cell counts are generally low or within the normal range, but in the early stages, total white blood cell count and neutrophil percentage may be higher.
   2. In bacterial infections, the total white blood cell count is mostly elevated, though it may decrease in severe cases, but the neutrophil percentage remains high.
6. Course of illness: In milder cases, fever lasts from 1 to 2 days up to 5 to 6 days, but in more severe cases, high fever can persist for 1 to 2 weeks. Occasionally, prolonged low-grade fever may last for weeks, requiring a longer recovery period if the infection site is not cleared.

bubble_chart Diagnosis

The following aspects should be noted:

1. Epidemic situation: Understanding the local prevalence of diseases is helpful for both diagnosis and differential diagnosis. When suffering from certain acute upper respiratory infections, not only are the symptoms of patients similar, but their complications are also roughly the same. Some common acute pestilence diseases, such as roseola infantum, measles, scarlet fever, epidemic cerebrospinal membraneitis, etc., have symptoms similar to upper respiratory infections at the onset, so attention should be paid to the local epidemic situation for differentiation.
2. Physical examination: A thorough physical examination should be conducted carefully to rule out other diseases. Observe the entire pharynx, including the tonsils, soft palate, and posterior pharyngeal wall. If the tonsils and pharyngeal membrane are severely red and swollen, both bacterial and viral infections are possible; when there is purulent discharge on the tonsils, streptococcal infection should be considered. If there is a large membrane-like exudate on the tonsils or extending beyond the tonsillar area, diphtheria must be carefully ruled out. Generally, a throat swab is used to examine for bacteria, and culture may be performed if necessary. If acute pharyngitis is accompanied by hemorrhagic rash, sepsis and membraneitis must be excluded.

bubble_chart Treatment Measures

The main focus is on adequate rest, releasing the exterior, clearing heat, and preventing complications, with emphasis on general care and supportive therapy.

1. Drug Therapy

It can be divided into etiological treatment and supportive therapy. For viral infections, Chinese medicinals are often used in etiological treatment. Some have extracted secretory IgA from colostrum for nasal drops, administering 0.3–0.5 mg/kg per day in 6–8 divided doses for 2–3 days, with satisfactory results. For bacterial infections, penicillin or other antibiotics are used. Most acute upper respiratory infections are viral, and antibiotics are not only ineffective but can also disrupt the body’s microbial balance, promoting viral replication. Therefore, misuse must be avoided. When bacterial infections occur, such as pharyngitis or tonsillitis caused by group A β-hemolytic streptococci, penicillin is effective. If no improvement is seen after 2–3 days, other pathogens should be considered. For high fever, applying a cold towel to the forehead or entire head and changing it every 10 minutes can often control febrile convulsions. Additionally, general antipyretics such as appropriate doses of aspirin or acetaminophen can be used, repeated every 4–6 hours as needed. However, excessive doses should be avoided to prevent sudden drops in body temperature, profuse sweating, or even collapse. For mild cough in children, especially infants, large doses of cough suppressants (whether Chinese or Western) should not be administered.

2. Local Treatment

For rhinitis, nasal drops should be administered before meals and bedtime to ensure respiratory patency and rest, 4–6 times daily, with 2–3 drops per nostril each time. Infants should not be given oily nasal drops to avoid aspiration into the lower respiratory tract, which could lead to lipoid pneumonia. Older children with pharyngitis, laryngitis, or tonsillitis can gargle with mild saline or compound borate solution (Dobell’s solution).

3. Chinese Medicine Treatment

Upper respiratory infections are generally referred to as "common cold" in traditional Chinese medicine (TCM). Based on clinical manifestations, they can be classified into wind-cold common cold and wind-heat common cold. TCM refers to influenza as "influenza," which shares clinical features with wind-heat common cold but has three distinct characteristics:

1. 1. Susceptibility to cold transforming into heat, presenting as high fever;
2. 2. Proneness to convulsions (febrile seizures) during intense heat;
3. 3. Likelihood of gastrointestinal symptoms such as vomiting and diarrhea due to food stagnation. Whether wind-cold or wind-heat, the disease location is superficial, and the treatment principle involves releasing the exterior—using pungent-warm herbs for wind-cold and pungent-cool herbs for wind-heat.

Additionally, tonsillitis is a common condition in upper respiratory infections, and its TCM treatment is described here as well.

1. Common Cold:
   1. Wind-Cold Common Cold: This type is more common in older children during the initial stage, presenting with aversion to cold, fever, absence of sweating, clear nasal discharge, headache and body pain, cough with phlegm, pale-red tongue with thin white coating, and floating-tight pulse. Treatment involves releasing the exterior with pungent-warm herbs.
      Example Prescription: Patchouli 9g, Chrysanthemum Flower 9g, Cultivated Purple Perilla Stem 6g, Fineleaf Nepeta Spike 3g, Forsythia 9g, Raw Gypsum 9g.
   2. Wind-Heat Common Cold: This type is more common in infants and young children, with pronounced fever or persistent fever despite sweating, stuffy nose, yellow nasal discharge, flushed face, red throat, or cough with phlegm. The tongue tip may be slightly red with a thin white or yellow-white coating, and the pulse is floating-rapid or slippery-rapid. Treatment involves releasing the exterior with pungent-cool herbs and clearing heat-toxins.
      Example Prescription 1 (for severe exterior heat): Lonicera 9g, Forsythia 9g, Mentha 6g, Isatis Root 9g, Great Burdock Achene 9g, Raw Gypsum 15g.
      Example Prescription 2 (for severe interior heat): Lonicera 9g, Forsythia 9g, Chrysanthemum Flower 9g, Indigo 3g, Chinese Wolfberry Root-bark 9g, Blackend Swallowwort Root 9g, Unprocessed Rehmannia Root 9g, Isatis Root 9g, Raw Gypsum 15g.
2. Influenza: Onset is abrupt, and the condition is more severe, with pronounced systemic symptoms. Nutrient-aspect pattern manifestations are likely to appear. The treatment approach for wind-heat common cold can be adopted, with modifications based on clinical presentation.
   For the above types of common cold, additional herbs can be selected as needed:
   1. High fever add Skullcap Root 6g; for high fever with dry stool, Infantile Bezoae Powder can be added, 0.3～0.6g each time, taken infused 2～3 times daily.
   2. Summer common cold, high fever with lethargy, nausea, vomiting, greasy tongue coating, can add Patchouli 6g, Fortune Eupatorium 6g.
   3. For severe cough, add Peucedanum 9g, Bitter Apricot Seed 6g.
   4. For high fever with convulsions, optionally add Uncaria 9g, cicada slough 6g, or Nacre 15g.
   5. For accompanying food stagnation, optionally add charred Hawthorn 9g, Jianqu 9g, or radish seed 6g.
   Regarding pediatric infusion granules, the composition and administration methods are detailed in the appendix formula section.
3. Acute tonsillitis: In Chinese medicine, it is referred to as "tonsillitis." Based on clinical manifestations, it can be divided into "red and swollen throat moth" (equivalent to acute tonsillitis) and "lotus seed pot moth" (equivalent to acute crypt tonsillitis). During the acute phase, the main treatments are clearing heat and purging fire, removing toxins, and dispersing swelling, while external treatments may also be applied.
   Example prescription: Lonicera 9g, Forsythia 9g, Puff-Ball 3g, Isatis Root 9g, Belamcanda Rhizome 9g, Scrophularia Root 15g, 地丁 9g, Indigo 3g. The following herbs may be added based on symptoms:
   1. For severe exterior heat, add fresh Reed Rhizome 30g, Chrysanthemum Flower 9g; if without sweating, add Mentha 6g.
   2. For severe interior heat, with high fever, thirst, and sweating, increase Gypsum 15g, Skullcap Root 6g. For high fever with red tongue texture and no sweating, add Moutan Bark 6g.
   3. For dry stool and accumulation, add raw Rhubarb Rhizome 6g, decocted separately and taken mixed; discontinue once bowel movements normalize.
   4. For accompanying submandibular lymph node swelling and pain, add Prunella 9g, Gentian 6g, Red Peony Root 9g.
   Additionally, topical application of Xilei Powder or Borneol and Borax Powder can be used for throat insufflation—apply a small amount to each side 2–3 times daily. For severely ill infants with weakened cough reflexes, use caution during insufflation, applying minimal amounts to avoid inhalation during crying or struggling.

IV. Treatment of Complications

Treating common complications is a crucial aspect of managing acute upper respiratory infections, requiring appropriate measures based on severity and urgency.

V. General Care

Ensure rest and proper care. During fever, provide liquid or soft foods; reduce milk intake for breastfeeding infants to avoid digestive symptoms like vomiting or diarrhea. Maintain a stable room temperature and humidity, especially with laryngitis. Older children may use cold or ice compresses to relieve sore throat or neck lymph node pain. For excessive nasopharyngeal secretions, a prone position may help.

bubble_chart Prognosis

General symptoms such as mental state and appetite are often more important than fever and white blood cell count. If diet and mental state are normal, the prognosis is usually good; if there is lethargy, excessive sleepiness, dysphoria, or pale complexion, caution should be exercised.

bubble_chart Prevention

1. Active Exercise: It is very important to utilize natural factors to strengthen physical fitness, such as frequently sleeping with windows open, outdoor activities, and sports. These are all effective methods. As long as they are consistently and regularly practiced, they can enhance constitution and prevent upper respiratory infections.
2. Maintain Hygiene and Avoid Triggers: Wearing too much or too little clothing, excessively high or low room temperatures, sudden weather changes, environmental pollution, and passive smoking are all triggers for upper respiratory infections and should be guarded against.
3. Avoid Cross-Infection: Wash hands after contact with sick children, and wear isolation gowns when necessary. Isolation not only protects nearby children but also reduces complications in the sick child. This can be implemented in general childcare facilities and hospitals. At home, adult patients should avoid contact with healthy children. Wards should be ventilated, maintained at appropriate temperatures, and the beds of discharged patients should be disinfected, with clean beds kept ready for new patients. If possible, ultraviolet light can be used to disinfect wards and contaminated areas to prevent the spread of pathogens.
4. Medication Prevention: - **Kaman Shu**: 5ml for infants, 10ml for children, taken orally three times a day for 3–6 months as a course. - **Levamisole**: 2.5mg/(kg·d), taken two days a week for three months as a course. - **Chinese Medicinal Astragalus Root**: 6–9g daily for 2–3 months. These medications can enhance the body's cellular and humoral immune functions. Children with recurrent upper respiratory infections may experience fewer relapses after use. The Pediatrics Department of Beijing Friendship Hospital once used a modified **Jade Screen Powder** (formula: 9g raw Astragalus Root, 6g White Atractylodes Rhizome, 3g Saposhnikovia Root, 9g raw oyster shell, 6g Dried Tangerine Peel, 9g Chinese Yam, ground into fine powder), taken orally twice daily, 3g each time. After three years of observation, it was found that this formula may improve immunity in frail children and reduce the incidence of recurrent respiratory infections.
5. Vaccination: Recent studies suggest that attenuated virus vaccines administered via nasal drops and/or aerosol inhalation can stimulate the production of secretory IgA antibodies in the nasal mucosa and upper respiratory tract, thereby enhancing the respiratory system's defense against infections. Extensive research indicates that secretory IgA is more effective against respiratory infections than any serum antibody. However, due to the vast number of enterovirus and rhinovirus types, vaccine prevention remains challenging.

bubble_chart Complications

Acute upper respiratory tract infections, if left untreated, can lead to many complications, especially in infants and young children. The complications can be divided into three major categories:

1. The infection spreads from the nose and throat to nearby organs. Common examples include acute conjunctivitis, sinusitis, stomatitis, laryngitis, otitis media, and cervical lymphadenitis. Other complications such as retropharyngeal abscess, peritonsillar abscess, maxillary osteomyelitis, bronchitis, and pneumonia are also not uncommon.
2. The pathogen spreads throughout the body via the bloodstream. In cases of bacterial infection complicated by sepsis, it can lead to purulent sexually transmitted disease foci, such as subcutaneous abscesses, empyema, pericarditis, peritonitis, arthritis, osteomyelitis, meningitis, brain abscesses, and urinary tract infections.
3. Due to the influence of allergic reactions caused by the infection, conditions such as wind-dampness fever, nephritis, myocarditis, hepatitis, purpura, Bi disease, and other connective tissue diseases may occur.

bubble_chart Differentiation

1. Differentiation from influenza: Influenza has a clear epidemic history, often accompanied by systemic symptoms such as high fever, limb soreness, headache, etc., and may present with exhaustion. Generally, nasal and pharyngeal symptoms like nasal discharge and cough are milder compared to systemic toxic symptoms.
2. Differentiation from digestive system diseases: Upper respiratory infections in infants and young children often present with digestive symptoms such as vomiting, abdominal pain, diarrhea, etc., which can be misdiagnosed as primary gastrointestinal diseases.
3. Differentiation from allergic rhinitis: Some children with "common cold" may not exhibit severe systemic symptoms but frequently sneeze, have clear nasal discharge, and show pale edema of the nasal mucosa. In such cases, allergic rhinitis should be considered. If eosinophils are found to be increased in nasal swab smears, it can aid in diagnosis. This condition is more common in preschool and school-aged children.
4. Differentiation based on blood tests: When fever is high and white blood cell count is low, common acute viral upper respiratory infections should be considered. Additionally, based on local epidemic conditions and the child's exposure history, influenza, measles, malaria, cold-damage disease, and subcutaneous node disease should be ruled out. When white blood cell count remains persistently elevated, bacterial infection is generally suspected. However, in the early stages of viral infections, it can also reach around 15×10⁹L, but neutrophils rarely exceed 75%. If white blood cell count is exceptionally high, bacterial pneumonia, infectious mononucleosis, and whooping cough should be excluded. Acute pharyngitis accompanied by rash, generalized lymphadenopathy, and hepatosplenomegaly should prompt examination for atypical lymphocytes to rule out infectious mononucleosis.