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Sinusitis - Diagnosis and Treatment in Children

Is it a sinus infection? Or does your child just have a cold?

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Updated July 16, 2014

Caucasian girl laying on couch blowing her nose
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Sinusitis is often overdiagnosed in children. Many parents (and doctors) think that a child has a sinus infection at the first sign of a green or yellow runny nose. Instead, these children often just have a viral upper respiratory tract infection (URI), like the common cold, and do not require treatment. In fact, URIs are reported to be 20-200 times more common than a true bacterial sinus infection.

Symptoms of a URI usually begin with a clear runny nose, which may become green or yellow after 2-3 days. Other symptoms can include a fever, cough, headache and decreased activity, although facial pain and facial swelling is not always present in children. These symptoms usually worsen over 5-7 days and then gradually get better. Because they are caused by viruses, URIs do not respond to antibiotics. Antibiotics won't help your child with a cold get better any faster, and when used unnecessarily, being on antibiotics make it more likely that you will get a secondary infection with a bacteria that has become resistant to antibiotics, maker it much more difficult to treat.

The American Academy of Pediatrics recently released a clinical practice guideline on the Management of Sinusitis that should make it easier to diagnose and treat sinus infections in children.

The AAP recommends that the diagnosis of sinusitis be made when children have a runny nose, postnasal drip, and/or a daytime cough, which may worsen at night, and that these symptoms have lasted for more than 10 to 14 days. Children with a shorter duration of symptoms might still have a sinus infection if the symptoms are severe, including 3-4 days of fever (over 102 degrees F) in a child that appears ill.

It is important to keep in mind that having persistent symptoms, which are lasting 10-14 days, doesn't necessarily always mean a sinus infections though. If the symptoms are slowly improving, then even if they are lasting more than 2 weeks, it is probably still just a viral URI.

When considering if a child has a sinus infection, the AAP recommends that the diagnosis be made clinically, which means that it should be based on the symptoms that the child is having. It is not necessary to get a sinus x-ray, especially in children under six years of age. The need or benefit of x-rays or a CT in older children is controversial, unless the child has persistent or recurrent symptoms.

Because there are now bacteria that are resistant to antibiotics, so that the antibiotic may not be able to fight the infection, the AAP guidelines also make recommendations on which antibiotics are most likely to be effective to treat children with sinusitis.

For children who are not at risk of having an infection caused by a resistant bacteria, for example, kids who are not in daycare or who have not been on antibiotics recently, they may be treated with a regular dose of amoxicillin, which can now be given just twice a day. If the child is not improving with amoxicillin, or is at risk of having a resistant bacterial infection, then high dose amoxicillin, with a dose about twice as high as the usual dose, or high dose amoxicillin-clavulanate (Augmentin ES) should be used. Alternatives can include cefdinir (Omnicef), cefuroxime (Ceftin), cefpodoxime (Vantin), or a shot of ceftriaxone (Rocephin) if the child is vomiting. For children with a serious allergy to penicillin, clarithromycin (Biaxin), azithromycin (Zithromax) or clindamycin (Cleocin) may be used.

Antibiotics that are unlikely to be effective in children who do not improve with amoxicillin include trimethoprim-sulfamethoxazole (Bactrim) and erythromycin-sulfisoxazole (Pediazole), as many bacteria are resistant to these older antibiotics.

Children that fail to respond to two antibiotics may be treated with intravenous cefotaxime or ceftriaxone and/or a referral to an ENT specialist.

How long should your child be on antibiotics? Although doctors often prescribe a standard 7, 10, 14, 21, or 28 days of antibiotics, the AAP states that it might be best to treat the child until he has been free of symptoms for at least 7 days. Since most children show improvement in 3 days, this usually results in 10 days of antibiotics. But if it takes 5-7 or 10 days for your child to get better, then 10 days of antibiotics might not be enough, especially if your child has recurrent or chronic sinus infections.

The main lesson to be learned is that a green or yellow runny nose does not mean that your child has a sinus infection. The diagnosis of a sinus infection is made more by how long your child has had symptoms and how bad they are.

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