When your child's sniffles last longer than a week, a trip to the pediatrician may be in order. Bacterial sinus infections are common in children, and new treatment guidelines give pediatricians and parents more leeway in how to treat them.
The American Academy of Pediatrics recently published a set of new clinical guidelines for pediatricians for the treatment of acute bacterial sinusitis. One of the recommendations encourages shared decision-making between the doctor and the parent.
Acute bacterial sinusitis is a sinus infection caused by bacteria. This kind of infection is responsible for about 5 to 10 percent of upper respiratory infections that children develop.
These clinical guidelines were authored by a committee led by Ellen R. Wald, MD, of the University of Wisconsin School of Medicine and Public Health. They were published in the journal Pediatrics to update the previous guidelines, which were published in 2001. They include four major changes to the old guidelines.
Shared Decision-Making with Parents
The most significant change in the new guidelines is that doctors are now given the option to delay treating a child with antibiotics if the parent and doctor decide together to do so.
In the past, after a child had symptoms of bacterial sinusitis for more than 10 days, a doctor would usually prescribe the antibiotic amoxicillin. Symptoms include a runny nose, a cough and/or a fever that lasts 10 days or longer.
"Now, there is an option to observe children for a few days before treating the sinusitis, if it's not severe," Dr. Wald told dailyRx.
This new option means the doctor and parent can decide together whether to wait up to three more days to see if a child gets better on their own before giving the child antibiotics.
"Taking care of a child should always be a joint decision between the parent, the child (if capable) and the physician," said Thomas Seman, MD, a pediatrician at North Shore Pediatrics in Danvers, Mass. and a dailyRx expert.
"The goal of therapy is to improve the child's status with the least side effects from the treatment. Most sinus infections are usually fairly mild," Dr. Seman said. "Thus we allow the body to continue to drain the infected mucus, and then the body should be able to handle the residual material by itself."
Communication between the parents and the child's doctor is key, Dr. Seman said.
"Educating the parent and the child as to the reason for the possible treatment plans allows a comfort in the parent to observe and not feel that everything has to be immediately treated to the maximum degree," he said. "This, is turn, helps the child grow up careful about medicines and to focus on strengthening his or her body from within."
Whether to Treat or Wait
Whether to wait or not depends on how bad the symptoms are, the child's quality of life and what the parent feels comfortable doing. Parents may choose to wait if the child is not suffering very much to avoid the possible side effects of antibiotics.
The most common side effect of antibiotics is diarrhea. Some children may also get a rash from the antibiotics. For every three children who take the antibiotics, one will probably experience a mild side effect.
Another reason to wait relates to a public health issue: lower antibiotic usage means less likelihood that antibiotic resistance will increase in the community. The more antibiotics are used by individuals within the population, the more opportunities the bacteria have to adapt to the antibiotics.
If the bacteria adapt to the antibiotics, then the bacteria can become resistant to those antibiotics. This means the antibiotics, over time, may not work as well in treating infections caused by those particular bacteria.
This is not something that happens with individual people after one dose of antibiotics. This is a larger public health issue that can develop in a community over time.
If the parents and doctor decide together to treat the child right away, the doctor will prescribe amoxicillin. If the child does not improve within three days of receiving antibiotics, the parents should contact the doctor for a change in treatment. This change will probably involve a different kind of antibiotic.
Even if the parents and doctor decide together to wait to treat a child, the new guidelines suggest that the child should be prescribed antibiotics if the symptoms do not improve within three days. If they do improve without medication, the body fought off the infection on its own, or it could have been a long cold.
"This is a similar approach to treating ear infections in children 2 years old and older," he said. "Most of the time, the child can handle the amount of infection and within two to three days, there is marked improvement of the symptoms, and when re-examined, the infection is usually gone."
New Way to Describe an Illness
Another change in the guidelines is the addition of a new type of illness description. In the old guidelines, doctors had two ways to describe a child's symptoms. One way is called "presenting with persistent symptoms."
Having persistent symptoms is the most common type of bacterial sinusitis children have. It means the child has had a runny nose, cough and/or mild fever for at least 10 days.
The second type included in both the old and new guidelines is called "severe onset." This means a child has severe symptoms, which include a runny nose with non-clear mucus and a fever of 102.2 degrees Fahrenheit for at least three days. The new guidelines suggest that children with these symptoms should be treated right away.
The new way to describe the illness is called "a worsening course." This means the child's symptoms get better at first and then get worse. The new guidelines suggest that children in this situation should be treated with antibiotics right away as well.
"If the body cannot handle the infection on its own, such that fever starts or symptoms persist or worsen, giving the body a hand by adding oral antibiotics is a sound decision," Dr. Seman said.
No More X-Rays Needed
The third major change in the new guidelines suggest that doctors no longer give children x-rays to confirm whether an infection is sinusitis.
In the past, doctors might x-ray a child's sinuses to see if they are cloudy. Cloudy sinuses were considered confirmation of bacterial sinusitis, Dr. Wald told dailyRx.
However, Dr. Wald said that even children with ordinary colds might have cloudy sinuses. Using x-rays has not been found to be useful in telling the difference between symptoms caused by bacteria and symptoms caused by a virus.
Therefore, doctors are discouraged from using x-rays unless the doctor thinks there is a possibility that the child has a more serious condition.
If the doctor thinks the child may have serious complications from the sinusitis that could affect the eyes or nervous system, then the doctor can give the child a CT (computerized tomography) scan or an MRI (magnetic resonance imaging).
The doctor may suspect complications if the child has a swollen eye. Complications are not very common, but they occur in children younger than 5 years old more often than in older children. Children who have these complications may require surgery, but not always.
If there is no evidence of complications, though, then the guidelines suggest the doctor should not give the child x-rays, CT scans, MRI scans or any other kinds of imaging tests.
New Evidence Guides Pediatricians
The final change to the new clinical guidelines is the inclusion of updated evidence related to treating sinusitis. This evidence is based on the systematic review of research that was published at the same time.
The systematic review was written by Michael J. Smith, MD, from the University of Louisville School of Medicine. Dr. Smith also was a co-author of the clinical guidelines.
In the systematic review, Dr. Smith examined the 17 randomized controlled trials related to treating sinusitis in children that had been published since 2001.
Four of these trials tested the use of antimicrobial therapy on a total of 392 children and found that they were effective in two trials and had no effect in two other trials. Five trials that Dr. Smith reviewed did not include a control group with a placebo (fake medicine) to compare the other therapy to.
Three trials only looked at a different, less severe kind of sinusitis. Six trials tested other therapies besides antimicrobial therapy. Those other studies had mixed results that could not lead to any new suggestions for treatment.
The guidelines and the systematic review were published June 24 in the journal Pediatrics. No external funding was used.
The author of this systematic review, Dr. Smith, has received research funding previously from Sanofi Pasteur and Novartis. One of the authors of the guidelines is employed by McKesson Health Solutions.
Other than some authors' past research related to sinusitis, no other conflicts of interest were reported.
