Sinusitis in Children

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

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 a yellow runny nose. Instead, these children often just have a viral upper respiratory tract infection (URI), like the common cold, and do not actually have a sinus infection.

In fact, URIs are reported to be 20-200 times more common than true bacterial sinus infections.

Symptoms of Common Colds

Symptoms of the common cold or a non-specific URI usually begin with a clear runny nose, which may become green or yellow after 2-3 days. Other symptoms can include:

  • Fever
  • Congestion
  • Cough
  • Headache
  • Bad breath (halitosis)
  • Decreased activity

These symptoms usually worsen over 5 to 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, making it much more difficult to treat.

Symptoms of Sinus Infections

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 and that these symptoms have lasted for more than 10 days without any improvement. Children with a shorter duration of symptoms might still have a sinus infection if the symptoms are severe, including 3 days of fever (over 102 F) in a child that appears ill, or if they start to get worse after some initial improvement.

It is important to keep in mind that having persistent symptoms, which are lasting 10 days, doesn't necessarily always mean 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.

So symptoms of a sinus infection might include:

  • Persistent cold symptoms
  • Worsening cold symptoms
  • Severe cold symptoms

When considering if a child has a sinus infection, the AAP recommends that the diagnosis is 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.

Treating Sinus Infections

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 sinus infections.

For children with persistent symptoms, though, instead of antibiotics, like the latest ear infection guidelines, a period of observation without antibiotics might be a better idea.

If after three days of waiting, these children still don't get better, or they get worse, then they may start their antibiotics.

Other children with sinus infections might start their antibiotics right away, without waiting.

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 to 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.

What To Know About Sinusitis in Kids

Other things to know about kids with sinusitis include that:

  • It is usually best to treat children with antibiotics until they have been symptom-free for at least 7 days.
  • Doing cultures from a child's nose to try and figure out what bacteria is causing a child's sinus infection typically shouldn't be done, as it may not detect what is causing the infection. Even healthy children have bacteria in their nose.
  • Kids should typically improve within about 72 hours after starting an antibiotic. If there is no improvement or any worsening after a child has been taking an antibiotic for 72 hours, then it might be time to change the antibiotic.
  • Other treatments for sinus infections, including nasal steroids, decongestants, and saline nasal irrigation are not recommended for children.
  • Sinus infections are much less common than most people believe them to be.

The main lesson to be learned is that a green or a 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.


American Academy of Pediatrics Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics 2013;132:e262–e280.

Chow AW, Benninger MS, Brook I, et al; Infectious Diseases Society of America. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72–e112