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Ear, nose and throat Infections and infestations Respiratory

Common cold

Last revised in February 2022

The common cold is the conventional term used to describe a mild, self-limiting, viral, upper respiratory tract infection

Common cold: Summary

  • The common cold is the conventional term used to describe a mild, self-limiting, viral, upper respiratory tract infection characterized by nasal stuffiness and discharge, sneezing, sore throat, and cough. No known treatment improves the time course of infection.
  • Rhinovirus is the most common cause of the common cold.
  • The mechanism of transmission of the common cold is usually by either direct contact or aerosol transmission. People can remain infectious (shedding the virus) for several weeks.
  • Adults experience an average of 2–3 colds a year. Young children attending primary school or preschool have an average of 5–8 colds a year.
  • The most common complications are sinusitis, lower respiratory tract infections, and acute otitis media.
  • The onset of symptoms after infection is sudden, reaching a peak at day 2–3, then decreasing in intensity. In adults and older children, symptoms tend to last about a week, although cough can persist for up to 3 weeks. In younger children, symptoms typically last 10–14 days.
  • Smokers tend to have more severe respiratory symptoms (including cough), and the infection is more prolonged.
  • Diagnosis is based on clinical features.
  • Common symptoms or signs in adults and older children include:
    • Sore or irritated throat.
    • Nasal irritation, congestion, nasal discharge (rhinorrhoea), and sneezing. Nasal discharge is often profuse and clear at first but becomes thicker and darker as the infection progresses.
    • Cough, which typically develops after nasal symptoms clear.
    • Hoarse voice caused by associated laryngitis.
    • General malaise.
  • Less common symptoms include fever, headache, myalgia, loss of taste and smell, eye irritability, and a feeling of pressure in the ears or sinuses.
  • Parents may report a child as having the following symptoms:
    • 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.
  • Where appropriate, the person should be examined to exclude a complication or alternative diagnosis.
  • The person or carer should be reassured that although symptoms may be distressing, the common cold is self-limiting and complications are rare.
  • Symptom relief and rest are the most appropriate management. People should be advised that:
    • Antibiotics and antihistamines are ineffective and may cause adverse effects.
    • Adequate rest is advised. Normal activity will not prolong the illness.
  • The person or carer should be advised to use paracetamol or ibuprofen if needed. For children aged under 5 years, this should only be if the child has a fever and appears distressed. 
  • Additional self-care measures and various over-the-counter products may help to relieve symptoms in some people.
  • People should be advised to arrange a follow-up appointment if symptoms are worsening or persisting. An earlier review should be considered for people with risk factors for complications.  

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the management of the common cold.

This CKS topic does not cover the management of influenza, sore throat, or complications of the common cold.

There are separate CKS topics on Allergic rhinitis, Chest infections - adult, Cough, Cough - acute with chest signs in children, Influenza - seasonal, Otitis media - acute, Sinusitis, and Sore throat - acute. 

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

February 2022 — minor update. Removed mention of delta variant COVID-19 symptoms in the differential diagnosis section, as this has now been broadened to include other variants. 

Previous changes

June to September 2021 — reviewed. A literature search was conducted in June 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.

July to August 2016 — reviewed. A literature search was conducted in July 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made, although minor restructuring of the topic has been undertaken.

July 2015 — minor update. Links to the topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues have been added to the sections on Drug treatment and Prescribing information.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic in line with the National Institute for Health and Care Excellence (NICE) guidelines on Key therapeutic topics - medicines management, 2015.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic in line with the National Institute for Health and Care Excellence (NICE) guidelines on Key therapeutic topics - medicines management, 2012.

October 2011 — reviewed. A literature search was conducted in October 2011 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made. Issued in November 2011.

July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency. Prescriptions have been updated to reflect the revised dosing. Issued in July 2011.

May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic in line with the National Institute for Health and Care Excellence (NICE) guidelines on Key therapeutic topics - medicines management, 2011. Issued in June 2011.

October 2010 — technical update. The management section of this topic has been simplified to improve clarity and navigation. There have been no changes to the clinical content or meaning of the recommendations.

March 2009 — minor update. New advice from the Medicines and Healthcare products Regulatory Agency (MHRA) regarding over-the-counter cough and cold medicines for children has been added, specifically that certain antitussives, expectorants, nasal decongestants, and antihistamines should not be used in children under 6 years of age. Issued in April 2009.

January to May 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations for management of the common cold. More detail has been added about the diagnosis of the common cold, the differential diagnosis, complications that may occur, and the use of common remedies.

October 2006 — minor update. Analgesia prescriptions updated because new doses of ibuprofen for children are recommend by the British National Formulary. Issued in October 2006.

October 2005 — minor technical update. Issued in November 2005.

January 2004 — written. Validated in March 2004 and issued in June 2004.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 September 2021.

HTAs (Health Technology Assessments)

No new HTAs since 1 September 2021.

Economic appraisals

No new economic appraisals relevant to England since 1 September 2021.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 September 2021.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 September 2021.

New policies

No new national policies or guidelines since 1 September 2021.

New safety alerts

No new safety alerts since 1 September 2021.

Changes in product availability

No changes in product availability since 1 September 2021.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of common cold.
  • Give self-care advice on the management of cold symptoms.
  • Rule out alternative serious diagnoses.
  • Arrange follow up in primary care as appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

  • Non-steroidal anti-inflammatory drugs (NSAIDs)
    • Review the appropriateness of non-steroidal anti-inflammatory drug (NSAID) prescribing widely and on a routine basis, especially in people who are at higher risk of gastrointestinal, renal and cardiovascular morbidity and mortality (for example, older people).
    • If an NSAID is needed, use ibuprofen (1,200 mg a day or less) or naproxen (1,000 mg a day or less). Use the lowest effective dose and the shortest duration of treatment necessary to control symptoms.
    • Co-prescribe a proton pump inhibitor with NSAIDs for people who have osteoarthritis or rheumatoid arthritis, and think about the use of gastroprotective treatment when prescribing NSAIDs for low back pain, axial spondyloarthritis, psoriatic arthritis and other peripheral spondyloarthritides.

[NICE, 2018]

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • The common cold is the conventional term used to describe a mild, self-limiting, upper respiratory tract infection characterized 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.

[Arroll, 2011; Li, 2013; BMJ Best Practice, 2020]

How is it transmitted?

  • The mechanism of transmission of the common cold varies depending on which virus is implicated, but three routes are usually responsible [Heikkinen, 2003; Arroll, 2011; Allan, 2014]:
    • 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 [Tolan, 2007].
  • People with a cold can remain infectious (shedding the virus) for several weeks.
  • Children are especially important in the transmission of the common cold [Tolan, 2007; Thompson et al, 2014; BMJ Best Practice, 2020].
    • They act as reservoirs of infection, as they have fewer antibodies and therefore are more susceptible to the common cold.
    • They tend to have a greater concentration of virions in secretions, and they shed viruses for longer.
    • They often have close contact with each other and adults.

Which viruses cause the common cold?

  • At least seven different families of viruses are implicated in the common cold (see Table 1) [Heikkinen, 2003]:
    • Rhinovirus is the most common cause of cold.
      • About 50% of all colds are associated with this virus; although this proportion can increase to 80% in autumn months.
      • There are over 100 subtypes of rhinovirus.
    • About 25% of colds have no identifiable cause.
    • It is thought that infection with two or more viruses occurs in 5% of colds.

Table 1. Viruses implicated in the common cold.

 Virus family*Estimated annual proportion of cases (%)
Rhinoviruses30–50
Coronaviruses$10–15
Influenza viruses†5–15
Respiratory syncytial virus5
Parainfluenza viruses5
AdenovirusesLess than 5
EnterovirusesLess than 5
MetapneumovirusUnknown
Unknown20–30

*Some episodes of streptococcal pharyngitis may be misclassified as colds.

$Not including COVID-19.

†Influenza sometimes causes milder symptoms which overlap with those normally associated with the common cold.

Data from: [Heikkinen, 2003; Arroll, 2011; Passioti, 2014; BMJ Best Practice, 2020]

What are the 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 [Heikkinen, 2003] [Allan, 2014] [BMJ Best Practice, 2020].
  • Common complications in adults include:
    • Sinusitis — characterized by prolonged nasal congestion and facial pain, which has been estimated to follow on from the common cold in 0.5–2.0% of cases. Occurs more commonly in smokers, people with asthma, and people who are immunocompromised. 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 Chronic obstructive pulmonary disease 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 [Allan, 2014; BMJ Best Practice, 2020].
  • Complications in very young children and babies (particularly following preterm delivery) include bronchiolitis, pneumonia, and croup [Dolin, 2001; Thompson et al, 2014].
  • 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 [Short, 2017].

How common is it?

  • The common cold can affect all population groups. It is most common in children and is especially common in younger children [Tolan, 2007; Arroll, 2011; Allan, 2014; BMJ Best Practice, 2020].
    • Adults experience an average of 2–3 colds per year.
    • Children experience an average of 5–8 colds per year.
  • Adults who are in contact with children tend to get more colds than those who are not regularly in contact with children [BMJ Best Practice, 2020].
  • The common cold is much more frequent in winter months, a trend observed in all northern hemisphere countries.
  • Rhinovirus, the most common cause, shows peaks of activity in late autumn and early spring. Colds caught in the summer months are more likely to be caused by other viruses, such as coronavirus or parainfluenza virus. So far there is no generally accepted explanation for the seasonality of the common cold [Tolan, 2007; Eccles, 2015; BMJ Best Practice, 2020].

What is the 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. Studies using artificial inoculation with rhinovirus indicate that the incubation period may be as short as 10–12 hours, although it may be longer in normal settings.
  • 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 in smokers than in 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.

[Heikkinen, 2003; Arroll, 2011; Allan, 2014; Thompson et al, 2014; Short, 2017; BMJ Best Practice, 2020]

Diagnosis of common cold

How should I diagnose the common cold 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, chronic obstructive pulmonary disease, sickle-cell disease, and diabetes.
  • Investigations (such as nasal and throat swabs) are not necessary to diagnose the common cold.

Basis for recommendation

The recommendations on the diagnosis of the common cold in adults and older children are based on expert opinion in the Institute for Clinical Systems Improvement (ICSI) guideline Diagnosis and treatment of respiratory illness in children and adults [Short, 2017] and the BMJ Best guideline Common cold [BMJ Best Practice, 2020], in addition to review articles on the common cold [Heikkinen, 2003; Tolan, 2007; Worrall, 2011; Allan, 2014; Passioti, 2014].

How should I diagnose the common cold 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 preschool 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 topic on Feverish children - risk assessment and 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.

Basis for recommendation

The recommendations on the diagnosis of the common cold in younger children and infants are based on expert opinion in the National Institute for Health and Care Excellence (NICE) guideline Fever in under 5s: assessment and initial management [NICE, 2019], the Institute for Clinical Systems Improvement (ICSI) guideline Diagnosis and treatment of respiratory illness in children and adults [Short, 2017], the British Medical Journal (BMJ) Best practice guideline Common cold [BMJ Best Practice, 2020], and a number of review articles on the common cold [Tolan, 2007; Heikkinen, 2003; Worrall, 2011; Allan, 2014; Passioti, 2014].

What else might it be?

  • The symptoms of the common cold can be non-specific and may need to be differentiated from other conditions, such as:
    • Meningitis — for more detailed information, see the CKS topic on Meningitis - bacterial meningitis and meningococcal disease.
      • In infants and babies it may be characterized by a high fever; drowsiness; blank, staring expression; vomiting and loss of appetite; high-pitched screaming; floppiness; a tense or bulging fontanelle; or a non-blanching rash.   
      • In older children and adults it may be characterized by fever, vomiting, stiff neck, photophobia, severe headache, muscular pains, fits, abdominal cramps, and/or confusion.
    • Upper airway obstruction — may be characterized by stridor, drooling, or an inability to swallow. It may indicate peritonsillar or retropharyngeal abscesses, or epiglottitis. See the CKS topic on Sore throat - acute for more information.
    • 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. Symptoms can include fever, a new and continuous cough, shortness of breath, fatigue, loss of appetite, anosmia (loss of smell) and ageusia (loss of taste). See the CKS topic on Coronavirus - COVID 19 for more information.
    • Influenza — a viral infection where severity can range from asymptomatic carriage to severe, life-threatening infection. If symptoms of myalgia or fever are prominent, suspect influenza. See the CKS topic on Influenza - seasonal for more information.
    • Streptococcal pharyngitis — a bacterial infection which causes a sore throat. Usually pain is more severe if there is infection with Streptococcus pyogenesis, and cough, sneeze, and nasal congestion are absent. See the CKS topic on Sore throat - acute for more information.
    • Allergic rhinitis — occurs in response to exposure to specific allergens. Nasal symptoms similar to those of the common cold may have been present for up to 2 weeks or more. See the CKS topic on Allergic rhinitis for more information.
    • Glandular fever (infectious mononucleosis) — is prevalent in adolescents and young adults. It is caused by Epstein-Barr virus and is characterized by prolonged fever, a severe sore throat, fatigue, and cervical lymphadenopathy. See the CKS topic on Glandular fever (infectious mononucleosis) for more information.
    • Whooping cough (pertussis) — a highly infectious condition caused by the bacterium Bordetella pertussis. It may cause prodromal symptoms similar to those of the common cold, but it should be distinguishable once the characteristic severe cough develops. See the CKS topic on Whooping cough for more information.

Basis for recommendation

The information on differential diagnoses of the common cold is based on expert opinion in the BMJ Best practice guideline Common cold [BMJ Best Practice, 2020] and in review articles on the common cold [Heikkinen, 2003; Worrall, 2011; Allan, 2014; DeGeorge, 2019].

Management

Scenario: Management

From age 1 month onwards.

How should I manage a person with the common cold initially?

  • 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.
  • For all other people:
    • If the person is at risk of complications because of pre-existing comorbidity or other risk factors arrange follow up at an interval according to clinical judgement.  
    • Reassure the person or carer that although symptoms may be distressing, the common cold is self-limiting and complications are rare.
      • The natural history of the common cold is rapid onset, with symptoms peaking after 2–3 days, and typically resolving after 7 days in adults and 14 days in younger children, although a mild cough may persist for 3 weeks.
      • No treatments are available that can cure the common cold and most treatments are not effective at relieving symptoms.
    • 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.
      • For detailed prescribing information on paracetamol and ibuprofen, see the CKS topics on Analgesia - mild-to-moderate pain, NSAIDs - prescribing issues, and Feverish children - risk assessment and management.
    • Advise about additional self-care measures that may help to relieve symptoms in some people.
    • 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. Good hygiene measures include:
      • Washing hands frequently with soap and hot water when the person has symptoms of the common cold, or comes into contact with someone who has symptoms. 
      • Avoiding the sharing of towels.
      • For children, discouraging the sharing of toys with an infected child.
    • Offer the patient information leaflets Common cold and Treating coughs and colds in children available at www.bmj.com.

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. Care should be taken to avoid scalding. Sitting in the bathroom with a running hot shower is a safe option.
    • 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. One or two drops applied to the nostrils of infants has also been reported to help feeding.
  • For adults and children over 6 years of age, various products are available that combine analgesics with other drugs, such as decongestants. Although some over-the-counter treatments may relieve some symptoms, people should be aware of their limited benefit and potential for adverse effects before using them. For example:
    • Intranasal decongestants can improve breathing and help promote sleep (they have fewer stimulatory adverse effects than oral decongestants). However, prolonged use of topical decongestants may cause rebound congestion, and in severe cases, rhinitis medicamentosa.
    • Oral decongestants are commonly combined with an analgesic in over-the-counter preparations. Decongestants may relieve nasal congestion in the short term, but this effect does not extend past a few days, and the benefit is relatively small.
    • Cough medicines have limited benefit on cold symptoms in general, but may be useful for a cough in children over 6 years of age and adults, and are usually safe.
    • People should be advised to follow use instructions carefully and not to use multiple products, particularly those containing paracetamol, because of the risk of overdose.
  • For children aged 6 years and under, over-the-counter cough and cold products should not be used because the overall balance of benefits versus risks have not been shown to demonstrate a clear advantage.
    • Ingredients which should be avoided in children aged 6 years and under are:
      • Antitussives (dextromethorphan and pholcodine).
      • Expectorants (guaifenesin and ipecacuanha).
      • Topical and oral decongestants (ephedrine, oxymetazoline, phenylephrine, pseudoephedrine, and xylometazoline).
      • Antihistamines (brompheniramine, chlorphenamine, diphenhydramine, doxylamine, promethazine, and triprolidine).
    • 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.

[Taverner, 2007; MHRA, 2009; Arroll, 2011; Fashner et al, 2012; Allan, 2014; Short, 2017; BMJ Best Practice, 2020]

Basis for recommendation

The recommendations on the initial management of the common cold are largely based on expert opinion in the Institute for Clinical Systems Improvement (ICSI) guideline Diagnosis and treatment of respiratory illness in children and adults [Short, 2017], the BMJ Best practice guideline Common cold [BMJ Best Practice, 2020], and in review articles on the management of the common cold [Arroll, 2011; Fashner et al, 2012; Allan, 2014; Passioti, 2014; Van Driel, 2018; DeGeorge, 2019].   

Serious illness
  • The ICSI guideline Diagnosis and treatment of respiratory illness in children and adults advises that where there is suspicion of upper-airway obstruction, lower-airway obstruction, or the person reports severe headache or other symptoms of serious illness they should be assessed urgently and managed as appropriate [Short, 2017].
Antihistamines
  • A large systematic review of 18 randomized controlled trials (RCTs; n = 4342) has shown that antihistamines used alone have a limited short-term (days one and two of treatment) beneficial effect on severity of overall symptoms but not in the mid to long term. However, the authors concluded that overall, antihistamines used alone have no clinically significant effect on symptoms of the common cold such as nasal obstruction, rhinorrhoea, or sneezing [Sutter, 2015].
Increased fluid intake
  • Despite being almost universally recommended, very little evidence supports increased fluid intake in the management of common cold. A Cochrane review concluded that there is currently no evidence from RCTs for or against the recommendation to increase fluids in acute respiratory infections [Guppy, 2011].
  • It is important to maintain normal hydration as fluid loss is likely to be greater when fever and nasal discharge are present. CKS therefore pragmatically recommends that people should drink enough fluid to compensate for this increased fluid loss.
Diet
  • There is no evidence that specific diets are beneficial in people with the common cold. Furthermore, the available evidence does not support the use of high doses of vitamin or mineral supplements [Hemila, 2013; Science, 2012]. The recommendation to advise a healthy diet is therefore pragmatic, based on what CKS considers to be good medical practice.
Antipyretics and analgesics
  • The recommendation that paracetamol or ibuprofen should be used to treat headache, muscle pain, or fever is based on expert opinion in guidelines and review articles [Arroll, 2011; Allan, 2014; Short, 2017; DeGeorge, 2019; NICE, 2019], as well as being pragmatic, based on what CKS considers to be good medical practice.
    • Despite their wide use and therefore strong anecdotal evidence that use of paracetamol and ibuprofen subjectively improves symptoms of common cold, very few studies have formally assessed this.
    • One systematic review of four randomized controlled trials (n = 758) found that paracetamol may help relieve nasal obstruction and rhinorrhoea, but does not appear to improve other cold symptoms in adults (including sore throat, malaise, sneezing, and cough) [Li, 2013]. 
    • One systematic review (n = 1069) of children and adults from the USA, Japan, Belgium, and Denmark found that nonsteroidal anti-inflammatory drugs (NSAIDs) may improve headache, ear pain, and muscle and joint pain, but there is no clear evidence that NSAIDs are effective in improving cough and rhinorrhoea [Kim, 2013].
Preventing spread of infection
  • The recommendation on preventing spread of infection is based on expert opinion in the ICSI guideline Diagnosis and treatment of respiratory illness in children and adults [Short, 2017], the BMJ Best practice guideline Common cold [BMJ Best Practice, 2020], and in review articles on the management of the common cold [Turner, 2005; Fashner et al, 2012; Allan, 2014; Passioti, 2014; DeGeorge, 2019].
    • A major route of transmission of viruses involved in the common cold is direct bodily contact. Hand washing is thought to reduce transmission of the common cold [Turner, 2005], but definitive evidence of clinical benefit from controlled trials is still lacking. Trials have investigated the role of specialized hand washes in preventing the cold.
Symptomatic remedies
  • There is limited evidence to support the use of symptomatic remedies from some studies and anecdotal reports.
    • Steam inhalation may theoretically help congested mucus drain better and heat may destroy the cold virus as it does in vitro. A Cochrane systematic review identified six randomized controlled trials (n = 394) and found that steam inhalation led to symptom relief in the common cold. However, the authors concluded that steam inhalation has not shown enough consistent benefit to make a clear recommendation for its use in treating the common cold, and they warned of the dangers of steam inhalation, in particular scalding in young children [Singh, 2017].
    • Vapour rubs. Evidence for their efficacy in the common cold is lacking, although parent surveys have rated vapour rub favourably when compared to petrolatum and no treatment for the symptomatic relief of their child's nocturnal cough, congestion, and sleep difficulty caused by upper respiratory tract infection (URTI) [Paul et al, 2010].
    • Gargling with salt water has not been shown to be effective in any study, but there are anecdotal reports that it may soothe a sore throat, and it is unlikely to be harmful.
    • Menthol lozenges have little effect on nasal congestion using objective measurements, but they may create the sensation of improved airflow and therefore create a subjective improvement [Eccles, 1990].
    • Saline nasal drops are thought to facilitate mucus drainage from the nose [MHRA, 2009]. A Cochrane systematic review identified five RCTs that randomized 544 children (three studies) and 205 adults (exclusively from two studies). One of the larger trials of children showed a significant reduction in nasal secretion and nasal breathing (obstruction) in the saline group. The authors concluded that nasal saline irrigation possibly has benefits for relieving the symptoms of acute URTIs, although the included trials were generally small with a risk of bias [King, 2015].

When should I follow up people with the common cold?

  • Advise that the person should seek medical advice if:
    • Fever persists for more than 3 days.
    • Symptoms are worsening after 5 days.
    • Symptoms have not improved after 10 days (note: it is normal for mild cough and congestion to persist for up to several weeks).
    • Concerning symptoms emerge (such as increasing symptoms of illness, lethargy, decreased responsiveness, or difficulty breathing).
  • Consider advising an earlier review for:

Basis for recommendation

These recommendations on when to follow up a person with the common cold are based on expert opinion in the Institute for Clinical Systems Improvement (ICSI) guideline Diagnosis and treatment of respiratory illness in children and adults [Short, 2017] and the BMJ Best Practice Guideline Common cold [BMJ Best Practice, 2020].

  • The natural history of the common cold is for symptoms to peak around 3 days and start improving after 5 days.
  • Symptoms lasting longer than 7–14 days (with the exception of mild cough) are unusual and suggest that complications of the common cold may have developed or an alternative diagnosis may be present.

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Paracetamol

Ibuprofen

Supporting evidence

This CKS topic is largely based on the Institute for Clinical Systems Improvement (ICSI) guideline Diagnosis and treatment of respiratory illness in children and adults [Short, 2017] and the BMJ Best practice guideline Common cold [BMJ Best Practice, 2020], in addition to a number of review articles on the management of the common cold. The rationale for individual recommendations is outlined in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of common cold.

Search dates

June 2016 - June 2021

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • Common Cold* / prevention & control
  • Common Cold* / therapy
  • Common Cold* / virology
  • Common Cold* /diagnosis

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Allan, G., M., and Arroll. and B (2014) Prevention and treatment of the common cold: making sense of the evidence. Canadian Medical Association Journal 186(3), 190-199. [Abstract]
  • Arroll, B. (2011) Common cold. Clinical Evidence (BMJ) 3(1510), 1-27. [Free Full-text]
  • BMJ Best Practice (2020) Common cold. London: BMJ Publishing Group.
  • DeGeorge, K.C., Ring, D.J. and Dalrymple, S.N. (2019) Treatment of the common cold. American Family Physician 100(5), 281-289. [Abstract]
  • Dolin, R. (2001) Common viral respiratory infections. In: Braunwald, E., Fauci, A.S., Kasper, D.L., et al. (Eds.) Harrison's principles of internal medicine. 15th edn. New York: McGraw-Hill, 1120-1125.
  • Eccles, R.M.S., Jawad, M.S. and Morris, S. (1990) The effects of oral administration of (-)-menthol on nasal resistance to airflow and nasal sensation of airflow in subjects suffering from nasal congestion associated with the common cold. Journal of Pharmacy and Pharmacology 42(9), 652-654. [Abstract]
  • Eccles, R. and Wilkinson, J.E. (2015) Exposure to cold and acute upper respiratory tract infection. Rhinology 53(2), 99-106. [Abstract]
  • Fashner, J., Ericson, K. and Werner, S. (2012) Treatment of the common cold in children and adults. American Family Physician 86(2), 153-159. [Abstract]
  • Guppy, M., Mickan, S. and Del Mar, C. (2011) Advising patients to increase fluid intake for treating acute respiratory infections. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Heikkinen, T. and Jarvinen, A. (2003) The common cold. Lancet 361(9351), 51-59. [Abstract]
  • Hemilä, H. and Chalker, E. (2013) Vitamin C for preventing and treating the common cold. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Kim, S.Y., Chang, Y.J., Cho, H.M., et al. (2013) Non-steroidal anti-inflammatory drugs for the common cold (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. http://www.thecochranelibrary.com [Free Full-text]
  • King, D., Mitchell, B., Williams, C. and P. (2015) Saline nasal irrigation for acute upper respiratory tract infections. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Li, S., Yue, J. and Dong, B.R. (2013) Acetaminophen (paracetamol) for the common cold in adults (Cochrane Review/Cochrane Intervention Protocol). John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • MHRA (2009) Over-the-counter cough and cold medicines for children. Medicines and Healthcare products Regulatory Agency. http://www.mhra.gov.uk
  • NICE (2018) Non-steroidal anti-inflammatory drugs (KTT13). National Institute for Health and Care Excellence. http://www.nice.org.uk
  • NICE (2019) Fever in under 5s: assessment and initial management. National Institute for Health and Care Excellence. www.nice.org.uk/ [Free Full-text]
  • Passioti, M., Maggina, P. and Megremis S. (2014) The common cold: potential for future prevention or cure. Journal of Current Allergy and Asthma Reports 14(2), 413. [Abstract]
  • Paul, I., M., Beiler, J., et al. (2010) Vapor rub, petrolatum, and no treatment for children with nocturnal cough and cold symptoms. Journal of the Amercian Academy of Pediatrics. 126(6), 1-8. [Free Full-text]
  • Science, M., Johnstone, J. and Roth, D.E. (2012) Zinc for the treatment of the common cold: a systematic review and meta-analysis of randomized controlled trials. Canadian Medical Association Journal 184(10), 551-561. [Abstract]
  • Short, S., Bashir, H., Marshall, P., et al. (2017) Diagnosis and treatment of respiratory illness in children and adults. Updated September 2017. Institute for ClinicalSystems Improvement (ICSI). https://www.icsi.org/wp-content/uploads/2019/01/RespIllness.pdf
  • Singh, M., Singh, M., Jaiswal, N. and Chauhan, A. (2017) Heated, humidified air for the common cold. Cochrane Database of Systematic Reviews 8(8), CD001728. [Abstract]
  • Sutter, D., Saraswat, A. and van Driel, M.L. (2015) Antihistamines for the common cold (Cochrane review). John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Taverner, D. and Latte, J. (2007) Nasal decongestants for the common cold (Cochrane Review) [Withdrawn]. The Cochrane Library. John Wiley & Sons, Ltd. http://www.thecochranelibrary.com
  • Thompson, M., Vodicka, T.,A., Blair, P., et al. (2014) Duration of symptoms of respiratory tract infections in children: systematic review. British Medical Journal. 11, 347-347.
  • Tolan, R.W. and Nguyen, M.N. (2007) Rhinovirus infection. eMedicine. WebMD. http://www.emedicine.com [Free Full-text]
  • Turner, R.B. and Hendley, J.O. (2005) Virucidal hand treatments for prevention of rhinovirus infection. Journal of Antimicrobial Chemotherapy 56(5), 805-807. [Abstract]
  • van Driel, M.L., Scheire, S., Deckx, L., et al. (2018) What treatments are effective for common cold in adults and children? BMJ 363, k3786. [Abstract]
  • Worrall, G. (2011) Common cold. Canadian Family Physician 57(11), 1289-1290. [Abstract]
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