Chapter 6

OTHER COMPLICATIONS OF THE COMMON COLD

THE COMMON cold virus can lead to a host of issues in children. Some of these issues are clogging complications, such as a middle ear infection (discussed in Chapter 5).

Among the other issues are inflammatory complications. The cold virus produces inflammation in different areas of the body, resulting in pain and discomfort.

A cold virus can also trigger an asthma attack in certain genetically predisposed individuals—a situation that may require medication in order to help control symptoms.

This chapter reviews some of the other clogging and inflammatory complications of the common cold not discussed in Chapters 4 and 5, such as a sinus infection, pneumonia, pinkeye, costochondritis, pleurisy, and asthma. Some of these complications require antibiotics (if bacteria are involved); others will resolve on their own with time, needing only supportive care and pain relief.

HOW A BACTERIAL SINUS INFECTION HAPPENS

The sinuses are a system of connected cavities in the skull that help humidify the air we breathe and help enhance our voices.

Sinus infections happen in a similar fashion to a middle ear infection.

1. Each of the sinuses has a drainage pipe. As long as the drainage pipe stays open, an infection should not occur.

2. When a child catches a viral cold infection, the subsequent mucus and inflammation blocks the natural drainage pipe of the sinus.

3. Fluid regularly secreted by the inner skin cells of the sinus then becomes trapped in the sinus area.

4. Bacteria then fester and multiply in the trapped water, leading to a bacterial sinus infection.

SINUSES DEVELOP IN CHILDREN OVER THE FIRST TEN YEARS OF LIFE

Sinuses develop in children during their first nine to 10 years of life. Because children do not have fully developed sinuses like adults, children do not commonly get true bacterial sinus infections. Even in adults, bacterial sinus infections are over-diagnosed. Most sinus infections only involve a virus, and thus do not require antibiotics.

One common misconception is that green mucus indicates a bacterial sinus infection. Green mucus is caused by an enzyme called myeloperoxidase, which is activated in both bacterial and viral infections. The presence of green mucus, in and of itself, is not a reason to start antibiotics. Many viral colds and viral sinus infections will produce green mucus, and do not require antibiotics.

Another misconception is that every cold lasting more than 10 days requires antibiotics. Most colds will last more than 10 days, and adhering to this misconception will lead to overuse of antibiotics. Indicators of a true bacterial sinus infection are: significant sinus pain, headaches, fever, and nasal drainage of thick, foul-smelling mucus. When a true bacterial sinus infection occurs, antibiotics are necessary.

HOW PNEUMONIA HAPPENS

Pneumonias, which are infections of the lungs, also occur in similar fashion to middle ear infections.

The child initially catches a cold, leading to mucus and congestion. The mucus runs down the windpipe and collects in the lung, eventually overwhelming the natural drainage mechanism of the lungs. This leads to fluid getting trapped in the lungs. Eventually, bacteria infect the stagnant fluid and precipitate a bacterial pneumonia.

A bacterial pneumonia is typically preceded by a cold. The child will appear to be slowly recovering from the cold, when there is a sudden and obvious drop in their activity level. Coughing will sharply increase, and their breathing will appear markedly labored (appearing as if they ran a mile). If these changes are observed, a doctor’s visit is warranted— ASAP.

Like a sinus infection, pneumonia can also be triggered by a virus, without any bacterial involvement. There is also a certain atypical bacteria called Mycoplasma that can trigger a condition known as walking pneumonia. Neither of these pneumonias are as serious as a bacterial pneumonia.

Bacterial pneumonias require antibiotics and could also necessitate hospitalization or even surgery. If untreated, a bacterial pneumonia may lead to large amounts of fluid in the lungs or the formation of pockets of pus. If caught in time, a bacterial pneumonia can be handled with close follow-up care in the doctor’s office, and hospitalization and surgery will be avoided. An experienced clinician can diagnose the presence of a bacterial pneumonia without an x-ray, although there are situations when an x-ray is warranted.

Viral pneumonias do not need medication, but may require supportive care (such as oxygen). Walking pneumonias will improve with a certain class of antibiotics known as macrolides.

HOW A BACTERIAL PINKEYE INFECTION HAPPENS

As you might guess, a bacterial pinkeye infection (conjunctivitis) also happens in a similar fashion to a middle ear infection.

The child initially catches a cold, leading to mucus and congestion. The mucus blocks the tear ducts that normally drain the eye. Mucus and tears then get backed up in the eye. Eventually, bacteria infect the mucus and backed-up water, leading to a bacterial pinkeye.

Bacterial pinkeye can become serious quickly and should be treated with antibiotic eye drops. Newer, expensive eye drops are rolled out regularly by pharmaceutical companies, but the older, cheaper antibiotic eye drops generally work well.

HOW TO DIFFERENTIATE BETWEEN THE DIFFERENT TYPES OF PINKEYE (BACTERIAL, VIRAL, AND ALLERGIC)

Like a sinus infection or pneumonia, some types of pinkeye are triggered by a virus, with no bacterial involvement.

In fact, viral pinkeye is far more common than bacterial pinkeye, and does not require antibiotic drops. Like a cold, it will improve over the course of seven to 10 days with no medications.

Allergic pinkeye is also fairly common, but it generally occurs in children older than 2 years of age. Allergic pinkeye can be treated with over-the-counter antihistamine eye drops.

For viral and allergic pinkeye, many doctors will prescribe antibiotic eye drops either unwittingly or prophylactically, to prevent it from evolving into a bacterial infection.

Schools often require children with any version of pinkeye to be on antibiotic eye drops, and do not distinguish between a bacterial, viral, or allergic cause. This can lead to unnecessary prescriptions and purchases of expensive medications.

Bacterial pinkeye should be treated when present. What separates a bacterial pinkeye from the other two is the presence of copious discharge that must be wiped away on an hourly basis. Both viral and allergic pinkeye will present with goop in the eye, but this is largely present first thing in the morning; and unlike a bacterial pinkeye, little will accumulate throughout the rest of the day.

Another sign of bacterial pinkeye is swelling and redness of the skin around the eye, which, if left untreated, will worsen with each passing day. Any worsening of symptoms should be seen by a doctor as soon as possible.

COSTOCHONDRITIS

A common inflammatory complication of the cold that causes chest pain is costochondritis, or inflammation of the joint space between the ribs and the breastplate (sternum).

Costochondritis, unlike previously mentioned clogging complications, is not a secondary effect of mucus clogging a drainage pipe. It is simply triggered by a cold virus migrating to a joint space and causing inflammation, or from inflammation of the joint space as a result of severe bouts of coughing.

Chest pain will occur with any movement of the upper body, or pressure being placed on the joint space. Like the common cold, this will resolve with time and rest. Pain relievers such as ibuprofen and acetaminophen can be taken to alleviate pain and discomfort.

PLEURISY

Another inflammatory complication that causes chest pain is known as pleurisy, which is the inflammation of the double pleural membranes surrounding your lungs. The pleural membranes are like a sort of plastic wrap surrounding your lungs, which helps to keep them well lubricated and moving easily.

Normally, the double membranes move smoothly against each other as the lung inhales and exhales. However, when a cold virus invades the pleural membrane, it becomes rough like sandpaper. As the lung inhales and exhales, a sharp pain is felt, almost as if being poked with a sharp object.

Like the common cold, this will resolve with time and rest. Pain relievers such as ibuprofen and acetaminophen can be taken to alleviate pain and discomfort.

HOW ASTHMA AFFECTS YOUR LUNGS

In genetically predisposed individuals, asthma can be a serious complication when triggered by a cold virus. Asthma is a complex disease—one which would require several chapters to explain adequately—but a short summary here can help parents know what to look for. Like bronchitis and bronchiolitis (described in Chapter 4), asthma is essentially an airway issue.

When triggered by a cold virus (which is the most likely scenario, amidst the many other triggers for asthma), the asthmatic airway will become inflamed and filled with mucus, leading to some combination of wheezing, shortness of breath, labored breathing, flaring of the nostrils, and retractions of the chest muscles.

Unlike bronchitis and bronchiolitis, which can affect any individual, asthma issues usually only affect those people with a genetic predisposition. There is usually a family history of asthma, typically found in mom and/or dad. Both asthma and bronchitis/bronchiolitis create a narrowing of the airway, and thus appear similarly; as such, it is difficult even for an experienced doctor to tell them apart.

Asthma medications can help control asthma, but will not make much of a difference in a child with bronchitis or bronchiolitis. Asthma medications are typically safe, so it is reasonable to attempt a trial of these medications to see if a child responds.

If there is a good response, the good news is that there are medications that can help. The bad news is that the child may have asthma (or at least a mild form of it). If there is a poor response, the good news is that the child likely does not have asthma. The bad news is that there are likely no medications that will help alleviate their immediate symptoms.

HOW TO PROPERLY USE AN INHALER BY ADDING A SPACER

There are two basic mechanisms by which asthma medications can be delivered: the nebulizer (not shown) and the inhaler with spacer (shown above).

Because of its portability, cost savings, and time efficiency, the inhaler (with spacer) is generally preferred over the nebulizer. However, both are equally effective.

It is important to emphasize that when using an inhaler, a spacer must be used for the medicine to turn into a mist, which can then more easily reach the lungs. Without the spacer, a good portion of the medication will be deposited in the mouth and will be lost.

PREVENTATIVE MEDICATIONS VS. RESCUE MEDICATIONS

There are two basic groups of asthma medications: preventative medicines and rescue medicines.

The rescue medicine that is most widely used is called albuterol, of which there are many brands. A second, less commonly used rescue medicine is called levalbuterol. Both are used to help relax the airway muscles, allowing the airway to open up and make it easier to breathe. The benefits are short-lived, typically lasting four hours or less.

The second group of medications is preventative medicines, of which there are many different forms, inhaled corticosteroids being the principle class. These medications are used on a daily basis to prevent an asthma attack from occurring.

Asthma medications can be thought of like sunburn medicines. Preventative medications, like sun block, are to be used prior to the onset of wheezing and should be used on a daily basis to protect the lungs. However, unlike sun block, should wheezing occur, many doctors will recommend to continue the preventative medicine(s) through the duration of the asthma exacerbation.

Rescue medications, like aloe vera in the case of a sunburn, should be used once the wheezing has set in and relief is needed. Like aloe vera, albuterol should be used as needed until the child is able to breathe normally again, after which the preventative medicine is needed once again to prevent another exacerbation.

Just as sun block cannot prevent every sunburn, preventative asthma medications will not prevent every asthma exacerbation. However, diligent use of preventative medications will significantly reduce the number of asthma episodes and help to prevent serious complications.

A doctor can help manage these medications and determine when they are needed, and when they can be stopped appropriately.

TAKE-HOME POINTS

Sinus infections follow the same pathway as a middle ear infection.

Sinus infections are typically viral; most do not require antibiotics.

Bacterial pneumonias typically follow a cold, and are characterized by decreasing activity, increasing cough, and labored breathing.

Pinkeye is typically viral; most do not require antibiotics.

A bacterial pinkeye will produce discharge hourly and eventually produce redness and swelling of the skin surrounding the eye.

When a bacterial pinkeye is present, cheaper and older antibiotic eye drops will typically work just as well as new, “top-of-the-line” products.

Costochondritis and pleurisy are triggered by inflammation produced by a cold virus; both will improve with time and rest.

In genetically predisposed individuals, asthma can be triggered by a cold virus and may require medications to help control it.

Chapters 4, 5, and 6 explain the various ways in which a cold virus can lead to numerous complications in a child. Remember, there are two types of cold virus complications: inflammatory complications and clogging complications.

Depending on where in the respiratory tract a cold virus invades, it can manifest itself as rhinitis, a viral throat infection, a viral sinus infection, croup, laryngitis, bronchitis, bronchiolitis, or a viral pneumonia. If the cold virus moves outside of the respiratory tract, it can also trigger costochondritis, pleurisy or a viral pinkeye.

If enough mucus is produced by the cold virus and certain drainage pipes are clogged, an ear infection, a bacterial sinus infection, bacterial pneumonia, or bacterial pinkeye can also occur.

At times, several different complications may happen in succession, or even all together at once. Colds are the gateway infection to a host of unwanted conditions. Luckily, many of these conditions do not require antibiotics and will get better with time.

Finally, in those individuals with a genetic predisposition, the cold virus can also trigger an asthma attack. Thankfully, there are medications to help prevent and control asthma exacerbations.

A judicious doctor can help a family know when intervention is needed and when watchful waiting is best. Asthma medicines and antibiotics, when used appropriately, can help keep a child healthy, but it is important to use them only when truly needed.