This is the second most common reason parents bring their babies in to see me. What’s the MOST common reason, you ask? Cough. Bad cough. UGLY cough, Doc! We’re really going to address both concerns in the same post because they are intimately related. Most of the time, that cough is being caused by mucus draining into the throat from that snotty nose above. Sometimes it’s not and I’m going to go into more detail about how to tell the difference further on. But first, SNOT!
The first thing I want all you moms and dads to understand is that older infants and toddlers are snotty little creatures most of the time. The most common cause of nasal congestion in tiny people is viral upper respiratory infection. The average, normal, HEALTHY child under the age of five years can be expected to catch a new upper respiratory virus about . . . . once a month. And that virus is going to hang around causing cough and congestion for about . . . two to three . . . weeks. Yes, I said weeks. Not days, weeks. Yes, I’m serious. No, I’m not making this up. I know you don’t believe me. Look, there’s a study. It’s my favorite study in the history of studies. Are you ready for this? Let’s look at this glorious study.
“Better Identification of Germs – Longitudinal Viral Epidemiology Study” . . . you guys, Better Identification of Germs, Longitudinal Viral Epidemiology . . . B. I. G. Lo. V. E. IT’S THE BIG LOVE STUDY!!! So, this rad little study was conducted in Utah and it followed twenty-six households (108 individuals) for an entire year. Parents were asked to keep a journal of their children’s respiratory symptoms and all individuals were tested for the presence of an upper respiratory virus every week for an entire year. That’s some serious leg work. What did they find? Little kids are sick all the time. To be more specific, children under the age of five tested positive for at least one virus about two thirds of the time. They have symptoms for about half the time they test positive. Therefore, your average toddler is going to have a snotty nose for literally a third of their life. That’s a normal healthy toddler. These are toddlers who have nothing whatsoever wrong with their immune systems. Now you know.
But how are you supposed to know when to worry and when not to worry? Well, that’s what I’m here to tell you, peeps. Parenting small children is not for the faint of heart, y’all. Even a minor respiratory illness can make your kid completely miserable. They’re up all night coughing, no one is getting any sleep, their cough sounds like they’re dying and it hurts so they cry and you probably cry too because your baby is pathetic and you’re so tired you can’t see straight and WHY WON’T THE DOCTOR JUST MAKE IT STOP???
I’ll tell you why – it’s because we can’t. When it comes to the common cold, we do not have medication that will make the mucus go away or make the cough stop. If I’m being brutally honest, you don’t actually want to make the cough stop. I know you think you do, but you don’t. The cough is what is keeping all that nasty fluid and mucus out of the lungs. It’s triggered by mucus draining down from the upper airway and trying to drain down into the lower airway because gravity. Your kid’s lungs know this is not good, so the gag reflex and their trusty cilia are working overtime to expel said mucus right back up where it came from. (From whence it came? I know I just ended a sentence in a preposition and for that I offer my most sincere apologies to all the English teachers in my life. Mia culpa.) Even if I had a medication that would stop the cough, I wouldn’t give it to you, because it wouldn’t actually do your kid any favors. It would probably increase the likelihood that your child WOULD end up with a serious secondary lung complication like bacterial pneumonia. You know why kids with cystic fibrosis get so seriously ill? Their expulsion mechanisms don’t work. They can’t get the mucus up. That’s why they get into trouble when they catch a virus. Your regular healthy kid? They need to keep coughing. I know there are a bazillion cough suppressants on the shelf at Walgreen’s. I know your internet mommy groups have lots of suggestions for home remedies to stop the cough. None of these are better than placebo. For reals, they’re not. Cough suppressants just don’t seem to work in kids under six. I don’t know why, but they don’t. Furthermore, they can have some seriously nasty side effects like respiratory suppression (that’s fancy doctor talk for suppressing breathing – it’s bad), hallucination, seizures, etc. So don’t give them to your toddlers, OK? Your best bet is going to be physical removal of the snot. That means nasal saline and suction. There have been a couple of studies showing some improvement with aromatherapy (so go get your Vicks’ just like Grandma told you, but put it on the chest, not the feet, also not safe in kiddos under 24 months, OK?) A spoonful of honey can be helpful in kids over 12 months (not safe for infants because botulism). A humidifier may help, but make sure its squeaky clean so you’re not just aerosolizing mildew and other nasty water crud like legionella or something. Sleeping on an incline can allow gravity to help a bit. But the thing that’s really going to cure that head cold is time. Two to three weeks’ worth of time. And getting older and building immunity to their community’s viruses.
If you want to know more about how to tell a head cold from something else, go read my post on bacteria vs. viruses and how to decide when to seek emergent care, see your regular doctor etc. I’ll link that right here. Spoilers – I don’t care what color the snot is. GASP! No really, I don’t. OK OK, I care if it’s bloody or like, purple. Any shades of yellow or green do not change my level of concern because snot the color of Mountain Dew does not mean bacteria, it’s usually still viral. https://dockatevaccineblog.wordpress.com/2017/03/26/virus-vs-bacteria/
Parents often tell me that they become concerned about lung infection (i.e. pneumonia) when they can feel the chest vibrate when their child breathes. Honestly, this doesn’t actually mean the infection is down in the lungs. When there is congestion in the upper airway, the whole baby will vibrate, and the cough can sound very juicy and deep (low-pitched). I get concerned about lower respiratory tract involvement when there is wheezing (squeaky, high-pitched sound breathing out), fever beyond about day 3 of illness, increased breathing rate, retractions, nasal flaring or grunting. I’m also worried about a kid with significantly decreased energy or who can’t drink enough fluids to stay well hydrated. If you don’t know what these look or sound like, YouTube can be a great resource for that. Look up stridor, while you’re at it. If you hear stridor, that kid needs to be seen right away, although stridor is an upper airway sound, not a lower airway sound.
OH, and one more thing – what about allergies? Can toddlers even have seasonal allergies? An immune system must be exposed to potential allergens over time to develop a sensitivity. No one is BORN allergic to ragweed. Thus, it’s very very rare for a human under the age of about 12 months to have true allergies. However, they can have some upper airway irritation and congestion due to environmental irritants like smoke, heavy pollen, etc. For any given 15-month-old, their snotty nose is MUCH more likely to be caused by a viral infection, but could it have something to do with the fact that they were outside while Dad was mowing the grass yesterday? Totally. Does it really matter? No. Because is there anything I can do about it? No.
I lied, two more things. I have seen exactly two cases of cystic fibrosis in my career that presented with chronic nasal congestion. These kids had perpetual disgusting purulent snot from early infancy and it literally never ever went away. This was not for a third to a half the time, it was literally all the time. BUT, they also had other signs and symptoms. They weren’t gaining weight very well, they were constipated, etc.. So yes, perpetual snot can occasionally be associated with something serious, but there should be more than that going on. This post pertains to normal, healthy toddlers. If a toddler is not a normal healthy toddler, we should be picking up on that with our regular check-up visits. So do please take your kids in for their routine check-ups with their board-certified pediatrician or family physician. If your parental instincts tell you your kid just ain’t right, TELL ME and give me lots of details about why. Thank you. OK, Doctor Kate over and out. Happy bulb sucking! It will get better! I promise!!
Wanna read some more? Cool, here ya go:
 Carrie L. Byington, Krow Ampofo, […], and Andrew T. Pavia. “Community Surveillance of Respiratory Viruses Among Families in the Utah Better Identification of Germs-Longitudinal Viral Epidemiology (BIG-LoVE) Study”. Clin Infect Dis. 2015 Oct 15; 61(8): 1217–1224. Published online 2015 Aug 4. doi: 10.1093/cid/civ486