The Chronic Runny Nose

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by Len Leshin, MD, FAAP

Copyright 1996, All rights reserved
So your child has had a runny nose for more than a week....or maybe more than a month. When should a parent get concerned? When are antibiotics called for? When should tests be done, and what kind?

The easiest diagnosis comes when the mucus from the nose ("rhinorrhea") is clear. That represents allergy more than 90% of the time, and the rest of the time it represents something called "vasomotor rhinitis," which means a non-allergic irritant is irritating the nose, and regular medications aren't going to help much. Chronic allergic rhinitis ("rhinitis" = inflammation of the nose) can usually be controlled (notice I didn't say "treated") through oral and/or nasal medications; when it can't, then allergy testing can help identify the offending agents so avoidance measures can be started.

The fun starts when the mucus isn't clear. Almost all doctors agree that cloudy or white nasal mucus indicates a head cold, caused by those nasty viruses that linger in schools, daycare centers and Sesame Street concerts. (Please note that wind, cold weather and running outside with wet hair and bare feet do not by themselves make a child sick.) Head colds may last 5 to 7 days, and typically cause some mild chest congestion before disappearing completely.

What about the yellow or green stuff? Actually, most doctors call this "purulent drainage" but it doesn't necessarily mean anything more than infection. Viruses can cause the mucus to be green or yellow. After a certain amount of days, then doctors might call it "sinusitis" or "upper respiratory infection" and prescribe antibiotics. How long is that time frame? It depends on the doctor, and that depends on the last thing they've read or how sick the child is. Without fever or any other problems, most doctors tell parents to wait 3 to 7 days after the emergence of the yellow/green mucus before prescribing antibiotics. One thing to keep in mind, by the way, is that nasal mucus typically looks dark when dried or in the first 2 hours of the morning, so that doesn't count. And mucus that changes from clear to discolored and back is most likely a virus.

If the color isn't that helpful, how else can sinusitis be diagnosed? Again, colds last only about 5 to 7 days; anything more than that is usually a sinusitis. Also, colds rarely cause a body temperature of over 101 F, so fever is a good sign of sinusitis (though sinusitis doesn't always cause fever). Sinus infections also tend to cause more sinus pressure than colds: that feeling of pain over the cheeks or above the eyes, especially when the head is rapidly moved or the face is tapped. Some doctors will take a sample of the mucus and look at it under a microscope for the white blood cells that signify infection.

Sinus Xrays can be helpful in most children, though there are false-negatives (Xrays that look normal even when sinusitis exists). Some doctors have taken to doing limited CAT scans of the sinuses instead, as they are much better as finding sinusitis as well as determining sinus anatomy than conventional sinus Xrays, and usually about the same price.

While most sinus infections can be treated with 10 days of antibiotics, some infections that are long-standing may require 20 to 30 days. Nasal decongestants may help the sinuses drain; but antihistamines may actually make the sinus infection worse, as they sometimes make the mucus thicker and harder to drain. Topical decongestants (the nose drops and sprays) make the child feel better but at a terrible price: overuse of these products actually make the lining of the nose addicted to them, so that the child can't breathe well without using them. So stay away form these as much as possible. A better treatment is salt water (saline) nose drops followed by suction....if your child is of a mind to let you, that is.

What is contagious and what isn't? This is simple: allergies are not contagious; sinus infections are slightly contagious; head colds are very contagious. However, since the majority of children with sinus infections started out having a head cold, we still consider the children contagious as long as there is fever or other signs of active infection. If you have a child with a runny nose for more than a couple of weeks, clear or slightly discolored, and without fever or signs of infection, then that's most likely allergic and not contagious.

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