Colds, coughs and fevers in children — what parents need to know

About this guide

Children get 6 to 10 colds a year on average — and in those first couple of years in childcare, it can feel endless. Most settle in 7 to 10 days without any treatment beyond paracetamol, fluids, and rest. But children are not small adults, and several medicines that seem helpful for an adult cold can genuinely harm young children.

This is a companion to our adult URTI guide. For the adult principles (timeline, why antibiotics usually don’t help, what green phlegm actually means), see Colds, coughs, sore throats and sinusitis — adult guide. This guide focuses on what’s different when it’s your child.

Why children get URTIs so often

A few reasons:

• Developing immune system — children’s immune systems are still learning. Each virus is a “first encounter” — hence the frequency.
• Close contact in childcare, school, and play — shared toys, shared space, hand-to-face contact many times an hour.
• Anatomy — young children’s airways are narrower, so minor inflammation produces more obvious symptoms.

Getting a lot of colds in early years is actually normal immune development, not weakness or a sign of immunodeficiency. Most children are seen less often in the clinic as they grow through primary school.

A typical childhood URTI

Most follow a similar arc to adults:

• Day 1–3: fever, runny nose, irritability, poor appetite, sometimes a mild cough
• Day 3–7: congestion may feel worse; cough develops or peaks; night waking common
• Day 7–10: most symptoms settle
• Beyond day 10: cough can linger. A lingering cough for up to 3 weeks after a viral URTI is still normal and not a reason for antibiotics on its own.

Fever peaks in the first few days. Persistent fever beyond 3–5 days, or fever that returns after settling, should prompt a visit.

What actually helps a child with a URTI

• Paracetamol or ibuprofen at age-appropriate doses for fever and discomfort. Your doctor or pharmacist will give you the exact mL based on your child’s weight — please don’t use sibling or cousin dosing.
• Fluids — small sips often. Breastfeeding mums should continue on demand.
• Saline nasal drops or sprays — safe at any age, often very effective for a blocked nose. Can be used before feeds in infants.
• Honey — for children over 1 year of age, a teaspoon at bedtime has reasonable evidence for reducing cough. Do not give honey to infants under 12 months because of the risk of infant botulism.
• Rest, cool room, upright feeding — sensible general measures.
• A cool, humidified environment if the air is very dry.

And perhaps the most underrated intervention: time.

What NOT to give young children — and why

Over-the-counter cough and cold medications

International authorities agree that OTC cough and cold medications should not routinely be used in young children. The specific age thresholds differ, but the reasoning is the same:

In practical terms: products like combined “children’s cough-cold-fever” syrups containing antihistamines, decongestants, or cough suppressants should not be given to a child under 2, and are unlikely to be genuinely helpful in children 2–5 either.

The risk-benefit question honestly

A reasonable question parents ask is: “A cough or runny nose doesn’t kill. How serious can medicine for it really be?”

The answer is that the adverse events from cough and cold medications in young children are rare but real — and include convulsions, dangerous heart rhythms, respiratory depression, and in a small number of reported cases worldwide, death. In contrast, the symptoms of an uncomplicated viral URTI in an otherwise healthy child are uncomfortable but not dangerous.

So we’re comparing:

• A rare but catastrophic risk from a medication with only modest-at-best evidence of symptomatic benefit, against
• A nearly zero risk from the underlying cough or runny nose, which will settle on its own.

That asymmetry is why major authorities — US, European, Singapore — have converged on essentially the same advice: don’t use these products in very young children. The HSA’s “unless a doctor has weighed benefits against risks” wording makes it slightly more permissive than the AAP’s blanket under-4 position, but the practical caution is the same.

Singapore-specific data on adverse events from cough and cold medications in children is limited, which is itself part of the reason HSA largely defers to international pharmacovigilance signals when setting policy. The absence of local data doesn’t mean absence of risk — it means that when in doubt, the more cautious position is the reasonable one.

Codeine-containing cough syrups

Historically, some children’s cough syrups contained codeine or pholcodine. Since 2016, the HSA has restricted codeine-containing cough medicines in children under 12. FDA (2018) went further — restricting all codeine and hydrocodone cough medicines for children under 18.

Why the restriction:

• Codeine is converted to morphine in the liver by an enzyme called CYP2D6.
• A meaningful minority of people (including children) are ultra-rapid metabolisers who convert codeine to morphine much faster than normal, producing dangerously high morphine levels even at standard doses.
• Deaths from respiratory depression have been reported, particularly in children given codeine after tonsillectomy or adenoidectomy.
• You can’t easily predict which child is an ultra-rapid metaboliser without genetic testing that isn’t part of routine care.

In practice: there is essentially no role for codeine-containing cough medications in children, and at KTMC we don’t prescribe them for this age group. Safer alternatives (paracetamol, rest, honey over age 1) address the underlying discomfort without the unpredictable risk.

Mucolytics — the “phlegmy” cough trap

A common parental question is: “My toddler’s cough sounds so phlegmy — can we give something to loosen the mucus?”

It’s an understandable instinct, but:

• Mucolytics (bromhexine, ambroxol, carbocisteine, acetylcysteine) have poorly established safety in children under 2. The Cochrane review specifically couldn’t draw conclusions for under-2s because data were inadequate.
• In children 2 and older, mucolytics have limited and inconsistent benefit; meta-analyses find modest symptom reduction at best.
• Some regulatory bodies have actively restricted mucolytic use in young children — for example, New Zealand’s Medsafe restricted bromhexine use in children in 2015, and the European Medicines Agency has reviewed ambroxol and bromhexine safety.
• Young children’s airways naturally sound phlegmy for anatomical reasons that aren’t about mucus production. The cartilage in an infant’s trachea is softer and more flexible, which creates a gurgly or “rattly” sound on breathing that often isn’t related to the amount of secretions. Technical term: tracheomalacia or laryngomalacia, usually harmless and growing out of it.

In a healthy child with an uncomplicated URTI and a phlegmy-sounding cough, the best approach is usually saline, fluids, time, and reassurance — not a mucolytic syrup.

Which children are at higher risk

Most children with a URTI can be managed at home. Some are more vulnerable to complications and may need earlier review, rapid testing, and sometimes antiviral treatment:

• Premature babies (especially in their first 1–2 winters)
• Infants under 6 months for RSV and flu
• Children with chronic lung disease (severe asthma, chronic lung disease of prematurity, bronchopulmonary dysplasia, cystic fibrosis)
• Children with significant heart conditions (especially unrepaired congenital heart disease)
• Children who are immunocompromised — by disease or by medication (chemotherapy, long-term steroids, biologics, post-transplant)
• Children with neurological or neuromuscular conditions that affect swallowing or clearing secretions
• Children with Down syndrome (higher rates of respiratory complications)
• Household contacts of high-risk people (e.g. a newborn sibling, a grandparent on chemotherapy)

If your child falls into one of these categories and catches something respiratory, please come in early rather than waiting for a deterioration.

Protecting high-risk children — vaccination

The most important interventions are given before illness, not during it:

• Annual influenza vaccine from age 6 months — inactivated vaccine; different live-attenuated options exist for some age groups internationally. In Singapore, included under the National Childhood Immunisation Programme for high-risk groups and subsidised.
• COVID-19 boosters per current MOH recommendations for children with chronic conditions.
• Pneumococcal vaccination as part of the standard NCIP.
• Pertussis (“whooping cough”) — part of the standard NCIP schedule. Cocooning strategy — vaccinating parents, siblings, and caregivers — helps protect very young infants who haven’t yet received their own doses.
• RSV prevention — for high-risk infants, nirsevimab (a monoclonal antibody) is now available in Singapore (privately) and provides a season’s worth of protection. Maternal RSV vaccination during pregnancy is another evolving option. Ask us which fits your family.

See our Childhood vaccinations (NCIP) guide for the full schedule.

Rapid testing in the clinic — what it can tell us

Paediatric URTI management has been quietly transformed by better point-of-care testing. What we have at KTMC:

Rapid antigen tests (RATs)

Combined panels (commonly called 5-in-1 ART tests) detect COVID-19, Influenza A and B, RSV, and adenovirus from a single nasal swab in about 15 minutes. Sensitivity has improved substantially over the years — these are now genuinely useful in:

• High-risk children where identifying flu (and starting antiviral treatment within 48 hours) changes outcomes
• Household outbreaks where knowing the pathogen informs isolation and whether household contacts need prophylaxis
• Differentiating causes — a child with fever and cough may have any of several pathogens with different implications

Rapid strep antigen testing

For children 3 years and older with a sore throat, a rapid strep swab (15 minutes in clinic) helps decide on antibiotics. Group A streptococcal pharyngitis benefits from antibiotic treatment (shortens illness, reduces spread, prevents rare rheumatic fever), while viral sore throats don’t.

Respiratory PCR panels

More sensitive, broader tests (often 20+ pathogens including bordetella pertussis, parainfluenza, metapneumovirus, mycoplasma, chlamydophila) that are sent to a laboratory and return results in about 24 hours. Available at KTMC at a cost (not subsidised) — usually used when a clearer answer will change management, for example:

• A child with a prolonged cough that might be whooping cough
• A high-risk child where a specific pathogen will guide antivirals
• An unclear severe illness

Your GP’s local view

Because we’re swabbing and seeing children with URTIs every week, we often have a real-time sense of which viruses are circulating in your area — sometimes days or weeks before national surveillance confirms it. If you mention that several kids in the class have the same symptoms, that informs what we look for. This is one of the genuine values of seeing a regular family doctor who knows your neighbourhood’s pattern.

Antivirals for high-risk children

For influenza specifically, oseltamivir (Tamiflu) has a role in higher-risk children:

• Most effective within 48 hours of symptom onset; some modest benefit up to 5 days.
• Who benefits: children in the high-risk groups listed above, children under 2 (flu can be severe in this age), severely unwell children at any age.
• In healthy older children with uncomplicated flu, the benefits of oseltamivir are modest and the trade-off with side effects (nausea, occasional vomiting, rare neuropsychiatric effects) means it’s not always the right call.
• Dosing is weight-based in paediatrics and requires careful calculation.

An under-appreciated benefit — reducing family spread

Oseltamivir does more than shorten the illness — it reduces the amount of virus the child sheds. For households with high-risk contacts (a newborn sibling, a pregnant parent, a grandparent on chemotherapy), treating the index child early meaningfully reduces the chance of those contacts catching the flu. In specific situations we’ll also consider post-exposure prophylaxis with oseltamivir for the high-risk household contact.

Sore throat in children

Strep throat (Group A streptococcal pharyngitis) is most common in the 5 to 15 years age range. Classic features:

• Fever, often above 38°C
• Pus on the tonsils (white or yellow spots)
• Tender lymph nodes in the front of the neck
• Absence of cough or runny nose (pure sore throat rather than the full cold picture)

A rapid strep test in clinic confirms or excludes it. Treatment is a 10-day course of penicillin (or an alternative in penicillin allergy), which:

• Reduces symptom duration by about 1 day
• Reduces the infectious period (child can usually return to school 24 hours after starting antibiotics)
• Reduces the risk of rare but serious complications — rheumatic fever and post-streptococcal glomerulonephritis

Sore throat with an obvious runny nose, cough, or conjunctivitis is almost always viral and does not benefit from antibiotics.

Acute otitis media (ear infection)

Common in young children, particularly after a viral URTI, due to anatomical factors (short, horizontal Eustachian tubes). Signs: ear pain, ear pulling in pre-verbal children, fever, sometimes difficulty hearing.

Management approach:

• Under 2 years, or severe symptoms (high fever, severe pain, bilateral infection) — antibiotics (usually amoxicillin) are typically started.
• Over 2 years with mild to moderate symptoms — watchful waiting for 48–72 hours with paracetamol is often appropriate, with antibiotics if symptoms don’t improve. Many cases resolve without antibiotics.
• Ear drops (analgesic, not antibiotic) can help with pain.

Recurrent otitis media, or otitis with hearing loss or speech delay, warrants referral to an ENT specialist.

RSV and bronchiolitis

Respiratory syncytial virus causes the common cold in older children and adults but can cause bronchiolitis in infants — inflammation of the smallest airways. Presents with wheeze, cough, rapid breathing, and sometimes feeding difficulty.

Severe signs in a baby with RSV (call us, or go to emergency):

• Rapid, laboured breathing — chest pulling in at the ribs, neck muscles working, grunting
• Unable to feed or keep fluids down
• Blue around the lips or fingernails
• Apnoea — pauses in breathing, particularly in young infants

RSV season in Singapore often runs through the wetter months. High-risk infants may be eligible for nirsevimab (a monoclonal antibody given as a single injection for a season’s protection).

Croup

A viral infection (usually parainfluenza) that causes a characteristic barking “seal-like” cough, often at night, sometimes with stridor — a high-pitched noise when breathing in. Commonest age is 6 months to 3 years.

• Mild croup (no stridor at rest) — cool air or steam can help; reassurance and paracetamol.
• Moderate to severe croup (stridor at rest, retractions) — needs urgent review; a single dose of oral dexamethasone is very effective.
• Severe croup (distress, cyanosis, drowsiness) — call 995.

Stridor at rest in a child, particularly if they look unwell, is an urgent situation — please don’t wait.

When to come in

Book an appointment if:

• Your child is in a high-risk group (as above) and has caught something respiratory
• Fever above 38°C persisting more than 3 days, or returning after settling
• Cough lasting more than 3 weeks
• Not improving after 7–10 days, or worsening after initial improvement
• Severe sore throat, particularly with fever and no cough — possible strep
• Ear pain, particularly with fever or in a young child
• Feeding poorly for more than 24 hours in an infant
• You’re simply worried and want the child seen

Come urgently (or go to A&E / call 995) for:

• Rapid or laboured breathing — retractions at the ribs/neck, grunting
• Blue around lips or fingernails
• Stridor at rest (harsh noise on breathing in)
• Severe lethargy or drowsiness — a child who is unusually quiet, hard to rouse, or floppy
• Seizures
• Refusing fluids completely for more than a few hours, or signs of dehydration (dry mouth, no wet nappies for 6–8 hours, sunken eyes)
• A high fever (above 38°C) in an infant under 3 months — always warrants same-day assessment
• Any sudden severe symptom your parent instinct says is serious

Protecting the household when a child is sick

Same principles as the adult guide, adapted:

• Hand hygiene — wash hands often, especially before feeding or touching other children
• Avoid kissing babies when you have symptoms; anyone with a cough/cold should wear a mask around newborns
• Don’t share utensils, bottles, or pacifiers
• Ventilate indoor spaces
• Postpone contact with high-risk family members (newborns, elderly with chronic disease, anyone on immunosuppressive treatment) while the child is feverish or coughing heavily
• Clean high-touch surfaces — toy surfaces, changing table, car seat handles
• Consider prophylactic antivirals for high-risk household contacts in specific situations (confirmed flu in the household, a pregnant mother, a grandparent on chemotherapy) — talk to us

Return to school or childcare

As a general rule, children can return to school or childcare when they are fever-free for 24 hours without paracetamol and are eating, drinking, and playing close to normally. Specific conditions have their own rules:

• Strep throat — 24 hours after starting antibiotics
• Conjunctivitis — varies by school; usually once discharge has settled
• Hand, foot and mouth disease — usually until blisters have crusted / dried, plus being fever-free
• COVID-19 — per current MOH guidance, typically once symptoms resolve; your child’s school may have specific policies
• Influenza confirmed by test — typically 5–7 days from symptom onset, or once fever-free for 24 hours without medication

A cough or mild runny nose on its own usually doesn’t require time off school once the child is otherwise well.

Cross-links

• Colds, coughs, sore throats and sinusitis — adult guide — the adult companion, including cough medications explained
• Beyond the Jab: Navigating Flu Season in Singapore — flu-specific content
• Asthma in children — what parents need to know — if your child’s recurring cough is more than URTI
• Childhood vaccinations (NCIP)

Get in touch

Joo Chiat — 172 Joo Chiat Road, #01-01, Singapore 427443 · Tel 6920 1952

Punggol — 658 Punggol East, #01-04, Singapore 820658 · Tel 6312 4589

Email — admin@ktmc.sg

References

Guidelines and authority positions

• Agency for Care Effectiveness (ACE). Upper respiratory tract infection. ACE Clinical Guidance (draft for professional bodies review). ace-hta.gov.sg
• Health Sciences Authority Singapore (HSA). Cough and cold medicines for children — what you should know. hsa.gov.sg
• HSA. Restrictions on the use of codeine-containing products in children and adolescents. 2016. hsa.gov.sg
• US Food and Drug Administration (FDA). Use Caution When Giving Cough and Cold Products to Kids. fda.gov
• American Academy of Pediatrics (AAP). Position on OTC cough and cold medications in children under 4.
• FDA. Restricts use of cough and cold medicines with codeine or hydrocodone for kids (2018).

Specific evidence

• Chalumeau M, Duijvestijn YCM. Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease. Cochrane Database Syst Rev. 2013;(5):CD003124 — limited efficacy; safety not established under 2.
• Medsafe New Zealand. Changes to the use of bromhexine or codeine-containing cough and cold medicines in children. 2015.
• European Medicines Agency. Ambroxol and bromhexine — Article 31 referral. Safety review of paediatric use.
• Oduwole O, Udoh EE, Oyo-Ita A, Meremikwu MM. Honey for acute cough in children. Cochrane Database Syst Rev. 2018;(4):CD007094.
• Jefferson T, Jones M, Doshi P, et al. Neuraminidase inhibitors (oseltamivir) for preventing and treating influenza in adults and children. Cochrane Database Syst Rev. 2014;(4):CD008965.
• Centor RM, et al. Centor criteria for streptococcal pharyngitis.

This information is for general education only and is not a substitute for medical advice. Paediatric management must be individualised by age, weight, and specific clinical situation — please speak with our team. v1.0 · April 2026 · Review due April 2028.