Does my child really need an antibiotic for a cold, cough or fever?

Most of the time, no. Nearly all coughs, colds, runny noses and sore throats in young children are caused by viruses, and antibiotics do nothing to viruses. They help when a bacterial infection is likely, such as strep throat, some ear infections, pneumonia or a urine infection. Below are the questions parents ask Dr Dutta most often, with straight answers.

Do antibiotics work for a cold or cough in a child?

No. Colds are caused by viruses, and antibiotics only work against bacteria.¹

A Cochrane review pooled the trials. People given antibiotics for a cold did no better than people given a dummy tablet.² UK family doctors do not recommend them for colds, because they do not ease symptoms or speed up recovery.¹

What does help a child with a cold:

• Rest and plenty of fluids. Breast milk counts for babies.
• Saline (salt water) nose drops before feeds and sleep.
• Paracetamol if your child is miserable with fever or aches.
• A smoke-free home. No cigarettes, mosquito coils or agarbatti near the child.

How many colds does a child get in a year?

A lot more than most parents expect. The American Academy of Pediatrics says most children have about 8 to 10 colds in their first two years alone.³

Children in a creche or day care, or with school-age children at home, may catch even more.³ In a Kolkata joint family, the monsoon and winter months can feel like one long cold.

This is not a sign of weak immunity. Each cold teaches the immune system something new. A child who is growing well, playing between illnesses and eating reasonably does not need tonics, immunity boosters or antibiotics to "prevent" the next one.

How long does a cold last in a toddler?

Often two weeks, and the cough can last longer. A large review found that cold symptoms had settled in 9 out of 10 children by about 15 days, and a short-term cough by about 25 days.⁴

So a child who is still coughing on day 10 or 12 is usually following the normal course. A long cough alone is not a reason for an antibiotic.

What matters more is the direction. A child who is slowly getting better is fine. A child who gets worse, breathes fast, or develops a new high fever after starting to improve needs to be seen.

Does green or yellow snot mean my child needs antibiotics?

No. Thick yellow or green mucus is common in an ordinary viral cold.

The colour comes from the body's own white blood cells, which gather to fight the virus. Mucus often goes from clear, to thick and coloured, and back to clear over a week or so.

The Cochrane review also looked at this exact situation: thick, coloured nasal discharge for under 10 days. Antibiotics did not clear it any faster than placebo, and they caused more side effects.² Colour alone tells us very little.

When is a runny nose a sinus infection that needs antibiotics?

Only in a few specific patterns. The American Academy of Pediatrics describes three.⁵

• A runny nose or daytime cough lasting more than 10 days with no improvement at all.
• A child who starts to improve and then gets worse again, with new fever or more discharge.
• A severe start: fever of 39 degrees C or more with thick nasal discharge for at least 3 days in a row.

For the first pattern, the doctor may start an antibiotic or watch for 3 more days first.⁵ For the second and third, an antibiotic is advised.⁵ X-rays and scans are not needed to make this diagnosis.⁵

What can I give my child for a cough instead of antibiotics?

For a child over one year, a little honey is a reasonable choice. A Cochrane review found honey probably eases cough better than no treatment or a placebo, though most trials gave it for just one night.⁶

Never give honey to a baby under 12 months.¹

Other things that help:

• Warm fluids, such as warm water or thin soup.
• Saline nose drops, because a blocked nose makes the cough worse at night.
• Raising the head end of an older child's bed slightly.
• Patience. The cough fades on its own over a few weeks.

Is my child's sore throat strep throat?

Usually not. Sore throats are often triggered by viruses, and most people get better within about a week without antibiotics, whatever the cause.⁷

A viral sore throat often comes with a runny nose, cough, hoarse voice or red eyes. Strep throat (a bacterial infection caused by group A streptococcus) is more likely when a child has fever, painful swollen glands in the front of the neck and white patches on the tonsils, without a cold or cough.

These signs overlap a lot, so doctors use simple scoring systems, such as FeverPAIN or Centor, to judge who is likely to benefit from an antibiotic.⁷ A throat swab can help where it is available.

Why do Indian doctors take strep throat more seriously?

Because rheumatic fever still happens in India. Untreated strep throat can set off rheumatic fever, which can scar the heart valves for life.⁸

The WHO says rheumatic fever mostly affects children and teenagers in low and middle income countries, and that treating strep throat with the right antibiotic prevents it.⁸ The Indian Academy of Pediatrics calls rheumatic fever and rheumatic heart disease an important preventable cause of illness and death in smaller towns and villages in India.⁹

So in India the goal is not to avoid antibiotics for sore throats. It is to give them to the right throats, and to finish the course.

Which antibiotic is used for strep throat, and do I need to finish it?

Penicillin or amoxicillin is the usual first choice, according to US infectious disease guidance.¹⁰ Indian guidance lists a single benzathine penicillin injection, oral penicillin V, or azithromycin to clear the strep germ.⁹

Antibiotics shorten a sore throat a little. In trials, fewer people still had a sore throat on day 3 if they took them.¹¹ But 82 percent of those who took no antibiotic were free of symptoms by one week anyway.¹¹ The main reason we treat strep in India is protection of the heart, not speed.

Give the full course your doctor prescribes, even if your child feels better in two or three days. Do not save the leftover syrup for "next time".

Does an ear infection always need antibiotics?

No. Most children with an ear infection get better within 3 days without antibiotics, though symptoms can last up to a week.¹²

A Cochrane review found that antibiotics did not reduce ear pain at 24 hours.¹³ They helped a little with pain on days 2 to 3. But for every 14 children treated, one had vomiting, diarrhoea or a rash caused by the medicine.¹³

The most useful first step is pain relief. NICE advises regular paracetamol or ibuprofen at the right dose for the child's age or weight.¹² Please do not put oil, garlic or any home drops into the ear, especially if there is discharge.

When does an ear infection need antibiotics straight away?

When a child is very unwell, has signs of a more serious illness, or is at high risk of complications. NICE advises an immediate antibiotic for these children.¹²

Two other groups are more likely to benefit from antibiotics: a child of any age with discharge coming out of the ear, and a child under 2 with infection in both ears.¹² For them, the doctor may start the antibiotic, give a back-up prescription, or wait and watch.¹²

A back-up prescription means you have the medicine in hand, but you only start it if your child is not improving within 3 days or gets worse quickly.¹² Many families find this a sensible middle path.

Is it safer to give an antibiotic just in case?

No. An antibiotic course has real side effects, and the benefit for a viral illness is zero.

In ear infection trials, antibiotics raised the chance of vomiting, diarrhoea or rash.¹³ In the cold trials, antibiotics for thick coloured mucus also caused more side effects than placebo.² Allergic reactions can happen too.

There is also a hidden cost. Each course gives resistant germs in your child's gut and nose an advantage. The next time your child truly needs an antibiotic, for pneumonia or a kidney infection, the usual one may not work.

What is antibiotic resistance and why does it matter in India?

Resistance means bacteria stop responding to drugs that used to kill them. A global study estimated that in 2019 about 1.27 million deaths were directly caused by drug-resistant bacterial infections.¹⁴

The burden was highest in low-resource settings.¹⁴ In neonatal units in India, including where Dr Dutta trained, doctors see newborn babies with infections that respond to very few antibiotics. Those babies never bought an antibiotic. They picked up resistant germs from the world around them.

Every unnecessary course for a cold adds a little to that problem. Using antibiotics well is something each family can do for everyone's children.

What does the red line on an antibiotic strip mean?

It means the medicine should be taken only on the advice of a qualified doctor. India started putting a red line on antibiotic and some other prescription-only strips in 2016.¹⁵

Very few people know this. In a hospital study in Kerala, only 6 percent of doctors could explain the red line, and none of the patients could.¹⁵ People in the same study felt the rules on selling antibiotics are poorly enforced.¹⁵

So:

• Do not buy an antibiotic over the counter for your child.
• Do not use leftovers from an earlier illness, or a sibling's medicine.
• Ask your doctor: "Do you think this is bacterial? What happens if we wait?" A good doctor will welcome the question.

How can I lower my child's need for antibiotics?

Prevent infections in the first place. Vaccines, handwashing and a smoke-free home all cut down illness.

Keep your child up to date with the IAP or government schedule, including the vaccines that protect against pneumococcus, Hib and typhoid. Wash hands with soap after nose-wiping and before meals. Breastfeed if you can. Keep babies under 3 months away from people with colds where possible.³

When should I take my child to a doctor for a cold or cough?

Most colds can be cared for at home, but some signs mean your child should be seen. For a baby 3 months or younger, call the doctor at the first sign of illness.³

For older children, see a doctor if:³

• Breathing is fast or hard, the nostrils flare, or the skin between the ribs sucks in.
• The lips or nails look blue.
• The temperature is over 38.9 degrees C.
• There is ear pain, or crying and fussiness that does not settle.
• Your child is unusually sleepy or very cranky.
• Nasal mucus lasts more than 10 to 14 days, or a daytime cough more than 10 days.

Also come in the same day for a stiff neck, a rash that does not fade when pressed, poor drinking with very little urine, or swelling behind the ear. Sometimes the best care is a careful examination and no antibiotic. That is not being sent home with nothing.