The 2 1/2 Week Cold: Yellow and Green Snot

Leslie asks:

My son has what seems like the longest cold of the decade, ranging from bad feverish days to semi-normal days lasting now for 2 1/2 weeks. 3 days ago I took him to the doc to see if it was an ear infection, it was not. A cough developed later that day and sounds very wet to this day. Lastly, today his snot had what looked like ear wax in it, bright yellow/orange grainy particles in his mucus. Should I be worried?

One Illness or Two?

There are really two likely explanations if ear infection and other common illnesses have been ruled out:

1. Several back-to-back colds
2. Sinusitis

Back-to-Back Colds

Colds are caused by viruses.  Viruses are common and easily transmitted from one person to another.  They are especially easy to transmit from one kid to another in the setting of daycare.  Most kids will have a day or two of mild symptoms before they get the fever, cough, runny nose, etc.  It is during this time that they are probably still in daycare and spreading their cold virus to all the other kids.  Thus kids who spend any time at daycare (including mother’s day out and the church nursery) tend to be sick much more often than other kids.  Most colds last 3-5 days but take 7-10 days for complete resolution of all the symptoms.

The key to this diagnosis is looking back carefully over the last few weeks.  Was there a time when things were better – no fever, eating good, less cough and congestion, etc.?  Then, after a few days did things get worse again?  If this is the case, there is a good chance you are dealing with several back-to-back colds.  On average, kids in the first two years of life will get 10-15 colds per year.  Less if they are not around other kids and more if they spend lots of time in daycare.

Thus many parents feel like their kid is sick for weeks or months at a time.  However, with a little prodding from me and a little honest reflection on their part, a pattern of multiple consecutive minor illnesses emerges.  This is by far the most common reason for kids to be sick for months.

Sinusitis

Most cases of sinusitis start off as a cold.  The congestion in the nose clogs up the sinuses.  This may lead to a bacterial infection in the sinuses.  There is generally a very characteristic story though… a week or so of mild symptoms (from the cold), then an abrupt increase in fever, fussiness, etc.

The diagnosis of sinusitis is a little tricky.  Most people think that the color of the nasal drainage is a good indicator.  However when this has been studied, there is no correlation between the color of the snot coming out of the nose and sinusitis.  The only definitive way to make this diagnosis is to do a CT scan of the sinuses or stick a tiny little camera into the nose and direct it into the sinuses.  Neither of these options is desirable, the CT because of the radiation, and the little camera… well I don’t know many kids interested in that.  Thus in most cases the diagnosis is a “clinical” one, meaning it is made based on the history and physical, not tests or X-rays.

Now the same studies that showed the color of the snot has no bearing on the diagnosis of sinusitis, suggest that the duration of symptoms is a good indicator.  In general if your child has had symptoms for less than 7 days it is probably just a cold.  If the symptoms have lasted more than 7 days, the likelihood of sinusitis increases, becoming more common after 10 days of symptoms.  For this reason the AAP recommends that pediatricians consider sinusitis in kids who have had runny nose, cough, fever, etc. every day for 10 days.  The recommended treatment for uncomplicated sinusitis is 10-14 days of Amoxicillin.

Does This Treatment Protocol Work?

Sadly, the answer is no.  In this article from a 2001 issue of Pediatrics, the authors come to this conclusion:

Neither amoxicillin (Amoxil) nor amoxicillin-clavulanate (Augmentin) offered any clinical benefit compared with placebo (no treatment) for children with clinically diagnosed acute sinusitis.

Now this does not mean that antibiotics are ineffective for sinusitis.  Rather it just means making the “clinical” diagnosis of sinusitis is not very accurate.  Thus a large number of cases diagnosed as “clinical” sinusitis are probably just the back-to-back colds mentioned above, which of course do not benefit from antibiotics.

My Opinion

Be honest with yourself and try to assess if you are dealing with progression of the same illness or several different back-to-back colds.  Remember, in most cases the best thing we can do for our children is to do nothing at all.  That said, a trip to see your pediatrician is warranted.  Initially to rule out more serious illness (like pneumonia) and other common treatable things (like ear infection).  Then a follow-up, to reevaluate and consider things like sinusitis if it is not better by 7 days.

In your case, if you feel that there is NOT a pattern of several back-to-back colds, a trial of antibiotics seems reasonable if you are on day 18 or 19 without any improvement and only progression.  If you and your pediatrician feel like sinusitis is likely, discuss the pros and cons of antibiotic treatment.  In general, I do not recommend antibiotics unless the child is very uncomfortable, is having persistent high fevers (above 102), or the parents insist on a trial of antibiotics.  From what I have read, most kids with a “clinical” diagnosis of sinusitis are better at 14 days regardless of antibiotic treatment.  While antibiotics are overall safe, rare and serious side-effects do occur.  I am of the opinion that unless there is some convincing evidence that a medication is going to help, I am not going to use it.

It is important to note that the above information makes the assumption that your child has been evaluated by your pediatrician and common things like ear infection have been ruled out.  It also assumes that your child is not having any more worrisome symptoms like difficulty breathing, severe pain, lethargy, or rigid (stiff) neck.  If your child has any of these worrisome symptoms you should call your doctor.

Next Post

The Yellow Triaminic???

References

AAP on Sinusitis

This is a parent handout published by the AAP regarding sinusitis and prolonged colds (URI).

Pediatrics (2001)

This is an article from a 2001 issue of Pediatrics comparing the outcome of children aged 1-18 years who had been given a clinical diagnosis of sinusitis.  There was no difference in outcome whether they were given an antibiotic or nothing.  Most kids were better by day 14.  Those who got amoxicillin were almost twice as likely to report adverse reactions like rash or diarrhea.

AAP Policy Statement

This is the Policy Statement published by the AAP on sinusitis.  It is basically the suggested way to practice with respect to diagnosing and treating sinusitis.