Common Cold

Overview

This Guidelines summary of NICE's Clinical Knowledge Summary (CKS) on the common cold has been developed for use by community pharmacists and therefore only covers the information relevant to this setting. Areas covered include diagnosis, management, and prescribing information for adults, children, and young people. For further information, refer to the full guideline.

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Definition

• The common cold is the conventional term used to describe a mild, self-limiting, upper respiratory tract infection characterised by nasal stuffiness and discharge, sneezing, sore throat, and cough
• The common cold can be caused by a wide range of viruses from several different families. This has prevented the development of preventative/curative treatments for the common cold.

Transmission

• The mechanism of transmission of the common cold varies depending on which virus is implicated, but three routes are usually responsible:
  • direct contact—the virus is passed directly by skin contact or hand contact with a shared object. Once the hand is contaminated, autoinoculation may occur through contact with the nose or eyes
  • small-particle aerosols—these linger in the air and can be highly infectious. This is the most important route of transmission of the influenza virus, although rhinoviruses can also be transmitted by this route
  • large-particle aerosols—these can be formed when sneezing or coughing, but their importance in common cold transmission is less well documented. As many as one million virions may be present in 1 ml of nasal wash
• People with a cold can remain infectious (shedding the virus) for several weeks
• Children are especially important in the transmission of the common cold.

Complications

• The main complications of the common cold are a consequence of viral spread to adjacent organs, or bacterial superinfection occurring after the viral infection
• Common complications in adults include:
  • sinusitis—characterised by prolonged nasal congestion and facial pain. See the CKS topic on sinusitis for more information
  • lower respiratory tract infections—including acute bronchitis, acute exacerbation of asthma or chronic obstructive pulmonary disease (COPD), and community-acquired pneumonia. See the CKS topics on chest infections—adult, cough—acute with chest signs in children, asthma, and COPD for more information
  • acute otitis media—the most common complication in younger children, where it follows about 20% of common colds. See the CKS topic on otitis media—acute for more information
• Complications in very young children and babies (particularly following preterm delivery) include bronchiolitis, pneumonia, and croup
• Complications are more common in people who are immunocompromised, who smoke, and with comorbidities such as diabetes mellitus, congestive heart failure, asthma, chronic obstructive pulmonary disease, cystic fibrosis, and sickle-cell disease.

Prognosis

• The common cold is a self-limiting illness, and no known treatment improves the time course of infection
• The onset of symptoms after infection is sudden
• Symptoms tend to peak within 2–3 days, then decrease in intensity. Symptoms usually last around 1 week in adults and older children, although they may last longer. In particular, cough can last for up to 3 weeks
• In younger children, symptoms typically last 10–14 days
• Smokers tend to have more severe respiratory symptoms such as cough, and infection is more likely to be prolonged compared with non-smokers. In addition, smokers have double the risk of developing a lower respiratory tract infection compared with non-smokers
• Symptom recurrence is common, although it is not clear whether the causative pathogen is the same virus, a subtype, or a different pathogen.

Diagnosis in Adults and Older Children

• Most adults and older children reliably self-diagnose the common cold within a day of developing symptoms. The diagnosis is clinical based on history
• Common symptoms include:
  • sore or irritated throat—often the first symptom, typically has a sudden onset and resolves rapidly
  • nasal irritation, congestion, nasal discharge (rhinorrhoea), and sneezing—nasal discharge is often profuse and clear, but may become thicker and darker as the infection progresses (although this does not usually indicate that bacterial infection is present)
  • cough develops in about 30% of people, typically after nasal symptoms have cleared
  • hoarse voice caused by associated laryngitis
  • general malaise
• The onset of symptoms is usually rapid, over 1–2 days
• Other symptoms are less common and may include:
  • fever—this is unusual in adults and is typically low grade
  • headache and myalgia—more often associated with influenza rather than the common cold
  • loss of taste and smell, eye irritability, and a feeling of pressure in the ears or sinuses (due to obstruction or mucosal swelling)
• Consider the person’s previous medical history, relevant comorbidities, and smoking status
• Examine the person to exclude a complication or alternative diagnosis, and manage appropriately
  • be aware that complications may be more common in people with comorbidities including congestive heart failure, asthma, COPD, sickle-cell disease, and diabetes
• Investigations (such as nasal and throat swabs) are not necessary to diagnose the common cold.

Diagnosis in Younger Children and Infants 

• Ask about the child’s symptoms. Parents may report the following:
  • restlessness or irritability
  • nasal congestion, nasal discharge (rhinorrhoea), and sneezing—severe nasal congestion may interfere with feeding, breathing, and sleep
  • cough—occasionally, vomiting may follow a bout of coughing
  • fever
• Examine the child to exclude a complication or alternative diagnosis and manage appropriately
  • check the temperature—a fever of 38–39°C is common in pre-school children with a common cold
    • children younger than 3 months with a temperature of 38°C or higher are in a high-risk group, and children aged 3–6 months with a temperature of 39°C or higher are in an intermediate-risk group for serious illness. See the CKS topics on feverish children—risk assessment and feverish children—management for more information
  • examine the:
    • fontanelle—a bulging fontanelle with high-pitched crying may indicate meningism. See the CKS topic on meningitis— bacterial meningitis and meningococcal disease for more information
    • cervical lymph nodes—these may be mildly enlarged but are typically non-tender
    • ears—look for signs of acute otitis media, such as a red, yellow, or cloudy tympanic membrane. See the CKS topic on otitis media—acute for more information
    • throat—there may be a non-specific erythematous inflammation of the pharynx (unusual). An inflamed throat in the absence of nasal symptoms is more likely to indicate a streptococcal infection. See the CKS topic on sore throat—acute for more information
• Investigations (such as nasal and throat swabs) are not necessary to diagnose the common cold.

Differential Diagnosis

• The symptoms of the common cold can be non-specific and may need to be differentiated from other conditions, such as:
  • meningitis
  • upper airway obstruction—may be characterised by stridor, drooling, or an inability to swallow
  • a nasal foreign body should be considered if a child has a persistent, unilateral nasal discharge in the absence of other symptoms
  • COVID-19—symptoms can mimic those of the common cold and include headache, runny nose, sore throat
  • influenza
  • streptococcal pharyngitis—a bacterial infection that causes a sore throat
  • allergic rhinitis
  • glandular fever (infectious mononucleosis)
  • whooping cough (pertussis).

More information on these differential diagnoses can be found in the full CKS topic.

Management

From age 1 month onwards.

Initial Management

• If the person is exhibiting signs and symptoms of a serious complication or alternative diagnosis (particularly possible features of upper or lower airway obstruction, or meningitis) arrange admission or referral as appropriate
• Reassure the person or carer that although symptoms may be distressing, the common cold is self-limiting and complications are rare
• Explain that symptom relief and rest are the most appropriate management. Advise people that:
  • antibiotics and antihistamines are ineffective and may cause adverse effects
  • adequate fluid should be taken during the course of the illness
  • healthy food is recommended, although no specific diet or mineral or vitamin supplementation is necessary—reassure parents that it is common for children to lose their appetite for a few days when they have a cold, and children with colds should eat only when they are hungry
  • adequate rest is advised—although staying off work or school is normally not necessary. Normal activity will not prolong the illness
• Advise the person or carer to use paracetamol or ibuprofen as an antipyretic and/or analgesic if needed for the following:
  • adults and children aged 5 years and over, if the person has a headache, muscle pain, or fever
  • children aged under 5 years, if the child has a fever and appears distressed. When using paracetamol or ibuprofen in children with fever, advise the carer to:
    • continue only as long as the child appears distressed
    • consider changing to the other agent if the child's distress is not alleviated
    • not to give both agents simultaneously
    • only consider alternating these agents if the distress persists or recurs before the next dose is due
• Advise about additional self-care measures that may help to relieve symptoms in some people
  • for detailed prescribing information on paracetamol and ibuprofen, see the CKS topics on analgesia—mild-to-moderate pain, NSAIDs—prescribing issues, and feverish children— management
• Various additional over-the-counter products are available for children over 6 years of age and adults
• Advise the person or carer that transmission of the common cold cannot be completely prevented, but basic good hygiene measures may help to prevent spread
• Offer the patient information leaflets Common cold and Treating coughs and colds in children.

Additional Self-care Measures and Treatments

• The following remedies may help to relieve symptoms of the common cold in some people:
  • steam inhalation may help to relieve congestion
  • vapour rubs may soothe respiratory symptoms in infants and small children when applied to the chest and back (avoid application to the nostril area for safety reasons)
  • gargling with salt water or sucking menthol sweets may help to relieve sore throat or nasal congestion
  • nasal saline drops may help relieve nasal congestion. Sterile sodium chloride 0.9% nasal drops are available on prescription or over the counter
• For adults and children over 6 years of age, various products are available that combine analgesics with other drugs, such as decongestants. For more information, refer to the full guideline
• For children aged 6 years and under, over-the-counter cough and cold products should not be used. For more information, refer to the full guideline
  • simple cough remedies (containing glycerine, honey, or lemon) are still licensed for use. Alternatively, for children over the age of 1 year, a warm drink of honey and lemon could be given.

For recommendations on follow up for people with the common cold, refer to the full CKS topic.

Prescribing Information

• For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Paracetamol

• For detailed prescribing information on paracetamol, see the CKS topic on analgesia—mild-to-moderate pain.

Ibuprofen

• For detailed prescribing information on ibuprofen, see the CKS topic on NSAIDs—prescribing issues.

Latest Guidance Updates January 2023: the Guidelines team removed a section on prevalence from the summary, and added links to other CKS topics and patient information leaflets. February 2022: NICE made minor changes to the COVID-19 recommendation in the differential diagnosis section. June–September 2021: NICE conducted a literature search, and added a recommendation on COVID-19 to the differential diagnosis section.