BMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

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Research

Duration of symptoms of respiratory tract infections
in children: systematic review
OPEN ACCESS
1Matthew Thompson Helen D Cohen endowed professor of family medicine , Talley A Vodicka
2
3
2
consultant , Peter S Blair senior research fellow , David I Buckley assistant professor , Carl4
5
Heneghan professor , Alastair D Hay professor of primary care and NIHR research professor , onbehalf of the TARGET Programme Team
Department of Family Medicine, Box 354696, University of Washington, Seattle, WA 98195-4696, USA; 2Department of Primary Care Health
Sciences, University of Oxford, Oxford, UK; 3School of Social and Community Medicine, Level D, St Michael’s Hospital, University of Bristol, Bristol,
UK; 4Departments of Family Medicine, Medical Informatics and Clinical Epidemiology, Public Health and Preventive Medicine, Oregon Health andScience University, Portland, OR, USA; 5Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol,UK
1

Abstract
Objective To determine the expected duration of symptoms of common
respiratory tract infections in children in primary and emergency care.
Design Systematic review of existing literature to determine durationsof symptoms of earache, sore throat, cough (including acute cough,bronchiolitis, and croup), and common cold in children.
Data sources PubMed, DARE, and CINAHL (all to July 2012).
Eligibility criteria for selecting studies Randomised controlled trials
or observational studies of children with acute respiratory tract infectionsin primary care or emergency settings in high income countries who
received either a control treatment or a placebo or over-the-counter
treatment. Study quality was assessed with the Cochrane risk of bias
framework for randomised controlled trials, and the critical appraisal
skills programme framework for observational studies.
Main outcome measures Individual study data and, when possible,
pooled daily mean proportions and 95% confidence intervals for symptom
duration. Symptom duration (in days) at which each symptom had
resolved in 50% and 90% of children.
Results Of 22 182 identified references, 23 trials and 25 observational
studies met inclusion criteria. Study populations varied in age andduration of symptoms before study onset. In 90% of children, earache
was resolved by seven to eight days, sore throat between two and sevendays, croup by two days, bronchiolitis by 21 days, acute cough by 25days, common cold by 15 days, and non-specific respiratory tract
infections symptoms by 16 days.

Conclusions The durations of earache and common colds are
considerably longer than current guidance given to parents in the United
Kingdom and the United States; for other symptoms such as sore throat,
acute cough, bronchiolitis, and croup the current guidance is consistent
with our findings. Updating current guidelines with new evidence will
help support parents and clinicians in evidence based decision making
for children with respiratory tract infections.

Introduction
Respiratory tract infections are particularly common in children;
most are self limiting and the risk of complications is small.
Recommended management therefore typically involves selfcare and treatment of symptoms. Nevertheless, such infections
still account for over a third of paediatric consultations toprimary care in the United Kingdom and the United States,1 2
and antibiotics are commonly prescribed in many countries
despite limited evidence of effectiveness.

One of the most common questions that parents ask when
consulting healthcare services is “how long will my child’s
symptoms last?” Accurate information about the expected courseof respiratory tract infections in children is essential for bothclinicians and parents, as it sets expectations and lets them know
when the illness is deviating from the expected.3 4 This directly
informs parents’ decisions to seek medical attention, whether
to re-consult, and when to use delayed prescriptions ofantibiotics, as well as clinicians’ decisions on when to prescribe
antibiotics or consider other treatments.3 5-7

Correspondence to: M Thompson mjt@uw.edu
Extra material supplied by the author (see http://www.bmj.com/content/347/bmj.f7027?tab=related#webextra)
Appendix 1: Search strategies
Appendix 2: Characteristics of included studies
Appendix 3: Quality assessment
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RESEARCH

BMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

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RESEARCH

Methods
Selection

Studies were eligible for inclusion if they recruited otherwise
healthy children (birth to 18 years) with acute respiratory
infections presenting to primary care or emergency department
settings; were conducted in high income countries, as definedby the Organisation for Economic Co-operation andDevelopment10; provided data on time to resolution of symptoms
or complete duration of symptoms; involved placebo or notreatment arms of controlled non-surgical treatment trials orprospective observational studies; and reported in English.
Although respiratory tract infections can include a cluster ofvarious symptoms, certain symptoms (such as cough)predominate in clinical experience and in published trials,
depending on a child’s illness, ability to describe his or her
symptoms, and/or parental recognition and interpretation ofsymptoms.11 Given this, we chose to not only include studies
of children presenting with clustered symptoms (such ascommon cold or undifferentiated respiratory tract infections)but also those of individual symptoms (such as sore throat). We
included studies of children presenting with primary complaintsof earache (acute otitis media), sore throat (or pharyngitis or
tonsillitis), cough (or acute bronchitis, bronchiolitis, or croup),and common cold (or upper respiratory tract infection).
We excluded studies of children with chronic, recurrent, orcomplicated infections; experimentally induced infection; ormedical conditions associated with a high risk of serious
infections (such as cystic fibrosis, immunodeficiency). We also
excluded studies conducted in inpatient settings or in low or
middle income countries as defined by the Organisation for
Economic Co-operation and Development, where the risk ofcomplications from infection might be higher. Studies thatreported data on both children and adults were included only ifdata were presented separately by age. We excluded trials
comparing two active treatments, those of prophylactic or
adjuvant treatments, and retrospective studies; studies withfollow-up of 24 hours or less; and studies that presented
symptom duration only before consultation, assessed only
incidence or prevalence, or presented duration of symptoms bysymptom score or individual pathogen.

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Search
We identified relevant intervention trials and observational
studies using two search strategies (appendix 1). Firstly, we
conducted searches in PubMed, DARE, and CINAHL (alldatabases searched through July 2012) to identify randomised
controlled trials and systematic reviews of trials for each of thefour symptoms of respiratory tract infection (sore throat, cough,common cold, and earache). Search terms included clinicalsyndromes and symptoms, study design, and paediatricpopulation with both MeSH and free text terms. We also handsearched the Cochrane Acute Respiratory Infections and Ear,
Nose and Throat Groups for systematic reviews of randomised
controlled trials. Secondly, we searched PubMed (1966-July2012) for observational studies of children with acute sore throat,
cough, common cold, or earache using terms for clinicalsyndromes and symptoms, child, and limited by publication
type (that is, excluding clinical trials and systematic reviews ofclinical trials). We reviewed reference lists of selected studies
identified using both of these strategies and searched related
citations to identify additional references. One author (TAV)
screened titles and abstracts using the inclusion and exclusion
criteria. Two authors (TAV and MT) reviewed the full text ofall potentially relevant studies to determine final inclusion.

Data extraction
Two authors (TAV and MT) independently extracted data using
a predetermined template. Authors were not blinded to any
aspect of the studies during extraction, and disagreements wereresolved by consensus (TAV, MT, and DIB/CH). We extracted
data on country and setting of study; population; length offollow-up; description of presenting symptom(s) and/or
diagnostic criteria; description of intervention and control;
definition of usual care in placebo arms of trials; specified
outcome(s); outcome assessor (parent, child, clinician, orinvestigator); method of outcome assessment; and data on
adverse events (complications, re-consultations, admission tohospital).
The outcomes of interest were time to resolution of symptoms
or duration of symptoms. These included time taken forprespecified proportions (such as 50%) of children’s symptoms
to have resolved, the study population, proportion of children
with unresolved symptoms at follow-up, or mean or median
duration of symptoms. For studies of common cold or
undefined/non-specific respiratory tract infections, we extracted
data on symptom duration for the cluster of symptoms
comprising a cold as defined in each study (reported in appendix
2). We extracted data from studies that reported proportions ofchildren with symptoms at time points, provided continuous
data from which proportions could be inferred, or presented
mean (and 95% confidence interval) durations of symptoms.
When available we also extracted data on symptom duration
before consultation. We extracted data only from thenon-intervention (that is, placebo) arms of included randomised
controlled trials. Data from line graphs were extracted with
DigitizeIt software (DigitizeIt 2010, version 4.0.2, Carrascal).

Quality assessment
Two authors (TAV and MT) independently assessed quality ofincluded studies using the Cochrane risk of bias framework for
randomised controlled trials12 and the critical appraisal skills
programme13 framework for observational studies.
Disagreements were resolved by consensus (TAV, MT, and
DIB/CH). Judgment regarding risk of bias (“high,” “low,” or“unclear risk of bias”) was made for each criterion.
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Commonly used estimates of the expected time course of
symptoms of common respiratory tract infections are highlyvariable and not always evidence based. For example, the 2008
National Institute for Health and Care Excellence guidelines
for treatment of respiratory tract infections include estimates of
average duration of the illness (before and after seeing a doctor)of four days for acute otitis media, one week for acute sorethroat, one and a half weeks for the common cold, and three
weeks for acute cough or bronchitis.8 By contrast, information
for patients from the US Centers for Disease Control andPrevention describe sore throat as lasting one to two weeks,
common cold lasting up to two weeks, and cough duration
ranging from two to eight weeks.9 The durations quoted in thesesources reflect findings based on expert opinion or fromindividual studies rather than from data synthesis of multiple
studies and are not child specific. We therefore conducted asystematic review of the literature on symptom durations of themost common respiratory tract infections (earache, sore throat,
cough, and common cold) in children presenting to primarycare.

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RESEARCH

Data synthesis

Results
The search for randomised controlled trials identified 10 829
papers; after review of titles and/or abstracts we excluded 10637 (fig 1⇓). Based on full text review of 192 papers, we
excluded a further 169 and included 23 trials in the analysis.
The search for observational studies identified 11 353 papers;
after review of titles and/or abstracts we excluded 11 226 (fig2⇓), and after review of the full text of 127 we excluded 102,
leaving 25 observational studies in the analysis. We present
results separately by type of symptom of respiratory tract
infection.

EaracheWe included data from seven trials with 958 children14-20 andthree observational studies with 451 children21-23 (tables 1⇓ and2⇓). Included trials and studies came from the UK,14 23 USA,16
Netherlands,15 Sweden,19 Denmark,18 Finland,20 Canada,17Poland,22 and Israel21 (appendix 2).
Earache was generally present less than four days before study
entry, and follow-up ranged from eight days to four months inrandomised controlled trials, and 21 days to a year inobservational studies. In most studies, parents assessed symptom
duration14-17 19-23 using daily symptom diaries, telephoneinterviews, or in person questionnaires. Most studies had low
risk of bias, though assessment of bias was difficult because of
unclear methods in two studies18 23 (appendix 3). Risk of bias
was highest in the study by Neumark and colleagues,19 whichused an open trial design with no blinding among parents or
clinicians.

Among the five studies that reported mean duration, symptomsof earache lasted from half a day to nine days14 15 19 21 22 (table1⇓). Based on the pooled results from 10 studies, 50% ofchildren’s symptoms had resolved at day three and 90% by days
seven to eight (fig 3⇓). Damoiseaux and colleagues15 andGreenberg and colleagues21 reported fever (as well as earache)lasting three days (median) and 2.9 days (mean, SD 2.6),
respectively.

Sore throat
We included six trials on 241 children24-29 and one observational
study of 103 infants.22 Most trials took place in North
America,24 26 27 with the remainder from the UK,25 Italy,28 and
the Netherlands.29 The single observational study was conductedin Poland.22
Characteristics of patients varied across studies (appendix 2).
Average duration of illness before entry into the study ranged
from less than one to less than four days. Outcomes were
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Among the four studies that reported mean duration, symptomsof sore throat lasted from two days to 6.7 days22 24 27 29 (table3⇓). Though we could not pool data from the three studies thatreported the proportion of children with symptoms because of
insufficient data at several time points, 33-37% of children still
had sore throat symptoms at day three25 26 28 (fig 4⇓, table 3⇓).
Based on visual inspection of the data, time to complete
resolution did not seem to be related to group A β haemolytic
streptococcal infection or duration of symptoms before
enrolment. The single study that reported on duration of fever
reported that 17% of children had fever for less than a day, 11%
had fever one to two days, 44% had fever for two to three days,and 28% had fever for more than three days.26

Cough (acute cough, bronchiolitis, and croup)
We included six trials of acute cough,30 croup,31-33 orbronchiolitis,34 35 providing data on 700 children. Five trials took
place in North America30-32 34 35 and one in Australia.33 We
included six observational studies of 1063 children withcough3 22 36 37 or bronchiolitis,38 39 from the UK,3 36 Poland,22
Australia,37 USA,38 and Canada39 (appendix 2).
Cough was present five to 14 days before study entry amongchildren with acute cough, four days among children withbronchiolitis, and one day among children with croup. In moststudies follow-up lasted two to three weeks or until symptoms
resolved (range one to four weeks). Parents assessed outcomesin all trials and studies that used symptom scales orscores,30-32 34 39 symptom diaries,3 36-38 standardised
questionnaire,22 or interview.39 Studies had either a low ormoderate risk of bias; those with moderate risk of bias generally
lacked details of randomisation or sequence allocation30 33(appendix 3).
Among the five studies that reported mean duration of illness,
the time to resolution of cough ranged from one to 25
days3 22 30 36 37 (table 4⇓). Based on the pooled results from fivestudies that reported proportions of children with symptoms,
cough had resolved in 50% of children at 10 days, and 90% by
25 days (table 5⇓, fig 5⇓). Symptom duration was relatively
shorter in two studies,22 30 of which one30 was small (n=23) andenrolled children with symptoms lasting up to 14 days before
recruitment, and the other22 recruited only infants.

The mean duration of croup was two and three days in the twostudies that reported this information32 33 (table 4⇓), and, basedon the pooled data from two studies,31 32 symptoms of croup
resolved in 50% of children at day one and 80% by two days
(table 5, fig 6⇓).

Finally, the mean time to resolution of cough for bronchiolitis
ranged from eight34 to 1538 days (table 4, fig 7⇓). Based onpooled data from four studies that reported proportions ofchildren with symptoms,34 35 38 39 50% of children improved byday 13 (table 5⇓). Though we were unable to determine the time
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We report data on duration of symptoms for each symptom
category from each study. When possible (that is, at time points
included in two or more studies) we calculated the pooled dailymean proportions and 95% confidence intervals for symptom
duration and presented summary data visually. Given theheterogeneity in study populations and inconsistent methods ofassessment, we have also presented the individual study datain addition to pooled means to display the variation in symptom
durations. We identified the mean time point (as number ofwhole days) at which the symptom was resolved in 50% and in
90% of children with that particular symptom. Though we hadplanned to carry out subgroup analyses based on age andsymptom duration before enrolment, we were unable to do so
because of insufficient data.

assessed by parents in all studies,22 24-29 clinicians in two
studies,26 28 and children in three studies,25 27 28 with length offollow-up ranging from two days to a week or, in two studies,22 27
until symptoms resolved. Most studies had a low risk of bias,
except one in which blinding of outcome assessors was
impossible because of the mode of intervention delivery(intramuscular penicillin v oral placebo)26 (appendix 3).
Measurement of outcomes varied considerably across studies,
involving different methods, assessors, and lengths of follow-up.
Outcome measurement was based on standardised scales in only
two studies24 27; the remainder22 25 29 used parental assessment(by questionnaire, symptom diary, or overall parental
assessment), or clinician assessment.28

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RESEARCH

Common cold; undefined or non-specificrespiratory tract infections
We included four trials involving 457 children40-43 and 15
observational studies involving 4870 children.7 22 37 44-55 Included
trials and studies were from the US,40 42 43 49 50-52 55 the UK,7 44 53
Finland,41 48 Canada,45 47 Poland,22 Australia,37 Denmark,54 andGermany46 (appendix 2).

Follow-up ranged from two to 21 days in randomised controlled
trials; in observational studies, follow-up generally lasted twoto three weeks. The mean duration of symptoms before trial
entry ranged from up to one day43 to 8.7 (SD 5.1) days.41
Outcome assessment was performed by parents (using interviews
or symptom diaries) in three trials40 41 43 and by both parents andchildren (symptom diary) in one.42 Overall, included studies had
low to moderate risk of bias (appendix 3). Treatment andplacebo lozenges were dissimilar in appearance in one
randomised controlled trial, which raised the risk of bias frominadequate blinding.42 Several studies failed to report
randomisation,40 cohort selection,49 52 or inclusion criteria.7 44 46

Among the four studies that reported mean duration, common
cold symptoms lasted from seven to 15 days22 42 46 51 (fig 8⇓,
table 6⇓). Based on the pooled data from five studies,22 40 42 49 51
by day 10 about 50% of children had improved. We did nothave sufficient data to determine the time at which 90%
improved, but based on visual inspection from figure 8 weestimated this as about 15 days. The largest study (n=1314)
reported common cold symptoms lasting 1.8 weeks (SD 1.3)
for children aged 7 or younger.46

The mean duration of non-specific respiratory symptoms ranged
from four to 16 days7 43 45 47 48 50 53-55 (table 6⇓). Data on the
proportion of children with symptoms was obtained from 11
studies7 37 41 43-45 47 48 50 53 54 and was highly variable acrossindividual studies: 50% of children had improved by day sevento eight and 80% by day 14; we could not identify the time for
90% resolution, although a projected estimate would be aroundday 16 (table 7⇓, fig 9⇓). The studies that reported symptoms
at day 14, however, showed an extremely wide range in the
proportion still symptomatic, from 6%44 to 60%.48 The shorter
length of symptom duration reported by both Butler andcolleagues44 and Jacobs and colleagues47 could be explained byslightly longer average duration of symptoms before study entry.
Taylor and colleagues reported duration of fever of 0.64 meandays (SD 1.16).43

Discussion
Our review provides parents, clinicians, and policy makers with
up-to-date evidence based estimates of the expected length ofsymptoms for children presenting with the most common
respiratory tract infections in primary care and emergency
department settings in high income countries: earache, sorethroat, cough, and non-specific cold symptoms. These infections
were selected because they are common and drive most primarycare consultations and antibiotic prescribing for children in highincome countries. We used data from systematic searches forboth randomised controlled trials (placebo arms) andobservational studies conducted in high income countries. For
many symptoms of respiratory tract infection the data werehighly heterogeneous in terms of age, definition of infection,
outcome assessment, and duration of illness before study entry;
however, our data provide the most robust estimates available.
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For some symptoms of respiratory tract infections our estimatesof duration are much longer than those currently used (table8⇓). For example, for earache (otitis media) we found that 90%
of children are better by seven to eight days, which isconsiderably longer than the average duration of four days citedby the UK National Institute for Health and Care Excellence
and two days cited by the US Centers for Disease Control andPrevention. In contrast, for some symptoms current estimates
seem to overestimate the expected duration. We found that acutecough symptoms are better in 50% of children by 10 days, incontrast with the longer average duration of 21 days cited by
National Institute for Health and Care Excellence. Finally, forother symptoms, the currently cited estimates of symptom
duration match closely (or are slightly longer) with ourfinding—for example, for sore throat/tonsillitis we found that90% are better by two to seven days, whereas National Institutefor Health and Care Excellence and the Centers for Disease
Control and Prevention cite average durations of seven days
and seven to 14 days, respectively. Similarly, the common cold
seems to last from 10 (50% better) to 15 days (90% better),similar to advice from both National Institute for Health andCare Excellence (10-11 days) and the Centers for Disease
Control and Prevention (<14 days).

Strengths and limitations
We believe this is the first systematic review of the duration ofillness for common respiratory tract infections in children. Our
strategy of including data from placebo arms of randomised
controlled trials and from observational studies not only
increases the available data but also provides more generalisable
populations of children. This approach inevitably included
children who might have been given over-the-counter treatments
for symptoms and, in a few cases, antibiotics. We consider that
it would be unrealistic to restrict our review to children withrespiratory tract infections who were not given any symptomatic
treatment. While symptomatic treatments might reduce symptom
severity, however, they are unlikely to influence the overall
duration of illness. It is possible that excluding studies ofexperimentally induced infection might have reduced eligible
studies, though we do not consider that these types of usually
single pathogen infections reflect the reality of clinical practice,where patients typically present with clinical syndromes rather
than pathogen specific infections. In synthesising our results,
we opted to present the number of days when 50% and 90% ofchildren were reported to be asymptomatic. Although the data
were not available for all the respiratory tract infections, we
believe that this additional information avoids the ambiguity ofterms such as “average duration” for parents and clinicians. Ourestimates of duration also apply to children who are given(usually symptomatic) drugs rather than those given nothing at
all, thereby providing more valuable information for how mostchildren are managed in the community. As many trials andstudies will have excluded children with severe symptoms, ourfindings might not be generalisable to such children or those in
low or middle income countries where risks of complications
are higher. While we included data from both randomised
controlled trials and prospective observational studies, we
excluded retrospective studies, which could be subject to recall
or recording bias.
As with any systematic review, our findings and complexity ofsynthesis are limited by the number and quality of included
studies and the data these provided. The included studies were
inevitably clinically heterogeneous in many aspects. The
definition of the respiratory tract infection syndromes differed(or were poorly defined) in some studies, which could affectSubscribe: http://www.bmj.com/subscribe

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for 90% to improve, based on the data presented in figure 7 thiswas estimated at 21 days.

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RESEARCH

Implications for clinicians, policy, andresearch
Our review provides evidence that can be put to daily use byclinicians and parents caring for children with respiratory tract
infections, as well as informing health policy and evidence based
treatment guidelines. We provide data as far as possible fornumber of days for 50% and 90% of children’s symptoms tohave improved; we anticipate that clinicians and parents could
interpret these values into absolute terms as the “time for halfof children” to get better, and “time for 9 out of 10 children” toget better (table 8⇓). There are two key clinical decisions thesedata could inform. First is the parents’ decision to consult
primary care, with its attendant implications for appropriate useof healthcare resources. Here, the data could inform algorithms
used by healthcare providers (in writing, by telephone, or inperson) to give parents information about expected length oftime that symptoms might last, helping to reassure parents andtrigger consultations more appropriately when the illness seems
to deviate from course. Second is the clinician’s decision toprescribe antibiotics. Once again, these data could help reassureclinicians regarding the “normality” of some respiratory
symptoms lasting for longer than previously appreciated andnot necessarily requiring antimicrobial intervention.
We found limited data for the duration of illness for several
respiratory tract infections (such as croup), which suggests thatobservational studies would be helpful to increase certainty of
our estimates of duration of symptoms. What parents andclinicians still need are better ways of predicting which children
will have an adverse or prolonged illness and need additional
treatment (such as antibiotics) or more intensive monitoring(such as repeated visits). Results of ongoing research efforts
such as the TARGET study (www.targetstudy.org.uk/) will help
to provide these prediction tools. Future research should also
focus the evaluation of new and existing interventions inchildren with the most severe illness trajectories.
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Conclusions
Parents, clinicians, and policymakers should use these evidence
based estimates of symptom duration when making decision
regarding healthcare seeking and prescribing, and also whendeveloping clinical guidelines for respiratory tract infections inchildren. Widespread dissemination of these data will improveparental and clinician awareness of how long symptoms last inchildren with respiratory tract infections.
TARGET team: Alastair D Hay, Andrew Lovering, Brendan Delaney,
Christie Cabral, Hannah Christensen, Hannah Thornton, Jenny Ingram,Jeremy Horwood, John Leeming, Margaret Fletcher, Matthew Thompson,
Niamh Redmond, Patricia J Lucas, Paul Little, Peter S Blair, Peter
Brindle, Peter Muir, Sandra Hollinghurst, Sue Mulvenna, Talley A
Vodicka, and Tim Peters.
c Crown Copyright 2013
Contributors: MT and ADH were responsible for the concept of thisresearch study. MT, ADH, CH, DIB, and PSB were responsible for the
methods used for the systematic review. MT, TAV, DIB, and CH were
responsible for the searches and identification of included studies, forassessing quality, and extracting data from included studies. TAV, MT,
and PSB were responsible for data analyses and presentation of results.
All authors were involved in reviewing, commenting, and editing draftsof the manuscript and all approved of the final manuscript. MT isguarantor.
Funding: This study was funded by the National Institute for HealthResearch (NIHR) under its programme grants for applied researchfunding scheme (RP-PG-0608-10018) and from a career development
fellowship (for MT) supported by the National Institute for HealthResearch. The views expressed in this publication are those of theauthor(s) and not necessarily those of the NHS, the NIHR or the
Department of Health. The funding agency had no involvement in the
study design, data collection, analysis, writing of the manuscript, ordecision to submit it for publication.
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf and declare: nosupport from any organisation for the submitted work; no financial
relationships with any organisations that might have an interest in thesubmitted work in the previous three years; no other relationships oractivities that could appear to have influenced the submitted work.
Ethical approval: Not required.
Data sharing: No additional data available.
Transparency: MT affirms that the manuscript is an honest, accurate,
and transparent account of the study being reported; that no important
aspects of the study have been omitted; and that any discrepancies
from the study as planned (and, if relevant, registered) have been
explained.
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less discrete conditions (such as the common cold) more thanothers (such as croup); though this is a problem with muchresearch in this area. Secondly, the duration of illness before
study entry varied and was not consistently recorded, which
prevented us from calculating what would have been potentiallymore useful for parents—namely, the duration of illness frominitial onset rather than presentation. However, this mirrors thesituation in primary care where patients present in exactly thisway. Thirdly, the lack of sufficient data on age in included
studies meant that we were not able to conduct age specificanalyses. For some infections, however, the age ranges ofchildren in included studies were relatively narrow (such as forbronchiolitis and croup) as would be predicted clinically, so
subgroup analysis might not have contributed much to theirinterpretation. For other infections, such as sore throat or cough,the age ranges were much broader and subgroup analysis basedon age would have been useful clinically. Fourthly, the methods
used in individual studies to measure and report symptoms werehighly variable, and the absence of consistent (daily) reportingfor similar durations of follow-up for each respiratory tract
infection meant that we were not able to pool data for all
infections studied. When possible, we attempted to pool resultsby calculating mean proportions and 95% confidence intervals,
but this does not take account of the lack of homogeneity
between studies. We attempted to mitigate this by including theindividual study data in all our figures to give some idea of thevariability in symptom projection. Thus, pooled means need to
be interpreted cautiously.

BMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 6 of 19

RESEARCH

Respiratory tract infections in children are responsible for more primary care consultations that any other group of illnesses
Parents need to know how long symptoms will last to guide help seeking behaviour and use of antibiotics
The scientific basis for current estimates of duration of illness of common respiratory tract infections is not clear and differs between
international bodies such as the UK National Institute for Health and Care Excellence and the US Centers for Disease Control andPrevention

What this study adds
This systematic review provides new evidence based estimates of the expected duration of the most common respiratory symptoms ofchildhood respiratory tract infections, including earache, sore throat, cough, and common cold
There are clinically important differences between the duration estimates we found and those previously published. In most (90%)
children earache was resolved by seven to eight days, sore throat by two to seven days, croup by two days, bronchiolitis by 21 days,
acute cough by 25 days, common cold by 15 days, and non-specific respiratory tract infections symptoms by 16 days
Accurate estimates of duration will help to direct more appropriate help seeking behaviours by parents and use of antibiotics. Results
will help clinicians and parents distinguish normal from abnormal respiratory tract infections
10
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Accepted: 08 November 2013
Cite this as: BMJ 2013;347:f7027
This is an Open Access article distributed in accordance with the Creative Commons
Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute,
remix, adapt, build upon this work non-commercially, and license their derivative works
on different terms, provided the original work is properly cited and the use isnon-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/.

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What is already known on this topic

BMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 7 of 19

RESEARCH

Table 1| Duration of earache in children in seven randomised controlled trials and three observation studies

Study

No in
sampleFollow-up

Mean or range
age

Concurrent
treatment

Mean (SD)symptom
duration
before study
entry
30.1 hours

Mean (SD)time tosymptom
resolution(days)
3.34

Proportion of children with symptoms
remaining at follow-up:
3 days6 days8 days

46%

18%

13%

—

72% (89/123)—

Randomised controlled trials
Burke, 1991*

113

3 months

3-10 years

AB (14%); S

Damoiseaux,
2000

105

6 weeks

13.3 months

S

Hoberman,
2011†

139

21 days6-23 months

S<2 days

—

70%

52%

47%

Le Saux, 2005‡

246

4 months

2.87 years

S<4 days—78%(193/246)——

Mygind, 198177

3 months

4.1 years

S≤24 hours

—

38%

—

—

Neumark, 2007

87

3 months

5.9 years

S<4 days

0.5 (0-5)§

56%

25%

17%

Tahtinen, 2011158

8 days

16 months

S

NR

—

45%

4%

0

54% had9 (mediansymptoms
duration of pain
lasting >3 days
and crying)

Observational studies
Greenberg, 2003

150

21 days14.8 (SD 8.3)
monthsAB (% NR); SNR

6.5 (5.2)———

Jedrychowski,
2005

45

Until symptom
resolution<1 yearNR<48 hours

8.6

—

—

—

Smith, 2010256

3 months

Median 3 (IQR
1-5) years

AB: 92% (eardischarge),
44% (no ear
discharge)

NR

—

—

—

34% (13/38) withear discharge;
20% (44/218)
with no ear
discharge

AB=antibiotics; NR=not reported; S=symptomatic treatment; IQR=interquartile range.

14*Outcome presented is proportion of children with “whose initial episode had persisted up to or beyond that time.”†Outcome presented corresponds to the second recording of AOM-SOS of 0 or 1.
‡Outcome presented is proportion of children with ear pain.

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TablesBMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 8 of 19

RESEARCH

Table 2| Proportion of children with earache on days one to eight in seven randomised controlled trials and three observation studies

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

13 (15/118)

13 (15/118)

Randomised controlled trials
Burke, 1991*

67 (79/118)

67 (79/118)——

Damoiseaux, 2000

46 (54/118) 31 (37/118) 23 (27/118) 18 (21/118)—

72 (89/123)——

Hoberman, 2011† 100 (147/147) 86 (126/147) 70 (103/147) 64 (94/147) 55 (81/147) 52 (76/147)——

47 (69/147)—

Le Saux, 2005‡

42 (106/254)

33 (83/250)

22 (53/246)

—

—

—

—

—

Mygind, 1981

—

—

38

—

—

—

—

—

Neumark, 2007

95 (83/87)

75 (65/87)

56 (49/87)

44 (38/87)

30 (26/87)

25 (22/87)

17 (15/87)—

100 (160/160) 63 (101/160) 45 (72/160) 25 (40/160) 17 (27/160)

4 (6/160)

4 (6/160)

0 (0/0)—34 (13/38)§; 20 (44/218)¶—

Tahtinen, 2011

Observational studies
Smith, 2010

—

—

—

—

—

14

*Outcome presented is proportion of children with “whose initial episode had persisted up to or beyond that time.”†Outcome presented corresponds to second recording of AOM-SOS of 0 or 1.
‡Outcome presented is proportion of children with ear pain.
§Children with ear discharge.
¶Children without ear discharge.

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Proportion of children (numbers) with symptoms remaining at follow-up
StudyBMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 9 of 19

RESEARCH

Table 3| Duration of sore throat in children in six randomised controlled trials and one observation study

Follow-up(days)*
2

Age (years)

Concurrent
treatment

Symptom
duration before
study entry

10.1 (3)†S<48 hours

Time to symptom
resolution

Proportion of children with sore throat
remaining at follow-up
Day 1

Day 2

≥Day 3———

Randomised controlled trials
Bulloch, 2003

51

48 hours (95% CI
38.0 to 58.0)

Chapple, 1956

57

3

2-9

S

<48 hours———

33% (57/174)

Nelson, 1984

17

3

5-11

N

24 hours(median)—

53% (9/17)

35% (6/17)—

Olympia, 2005

25

Until
resolution

11.3

S

NR

70.8 (49.6)† hours‡

—

—

—

Ruperto, 201132

4

8.1 (1.7)†

NR<1 week———

37% (12/32)

Zwart, 2003

56

7

10.1 (3.9)†S

3.8 days (mean)

3.5 days (95% CI
2.9 to 4.1)§; 4.7
days (84 to 141.6)‡

—

—

—

103

Until
resolution

0-1

NR

<48 hours¶

6.7 days———

Observational study
Jedrychowski,
2005

NR=not reported; S=symptomatic.
*Follow-up for outcome of symptom duration.
†Mean (SD)
‡Children without group A streptococcal infection or other culture.
§Children with group A streptococcal infection.
¶To be counted as episode, child must show symptoms for at least one day.

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Study

No in
sampleBMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 10 of 19

RESEARCH

Table 4| Duration of cough in children in six randomised controlled trials and six observational studies

No insampleAgeConcurrent
treatment

7 days1-10 years

AB (38%); S

1-14 days

Follow-up

Time tosymptom
resolution

Proportion of children with cough remaining
at follow-up
Day 3

Day 6

Day 10Weeks 2-4

—

58%

18%

13%

—

Acute coughRandomised controlled trials:
Bernard, 1999

23

Observational studies:
Hay, 2003

228

Until symptom
resolution

Median 21 (IQR
8.6-35) months

AB (18%); S

Median 5 (IQR
3-14) days

—

93%

75%

50%

10% (day25)

Hay, 2007

154

Until symptom
resolution

Median 24 (IQR
12-37) months

AB (24%); S

Median 7 days

—

—

75%

50% (day9)25%

Jedrychowski,
2005

225

Until symptom
resolution<1 yearNR<48 hours

Cough: mean 7.3
days; barking
cough: 5.7 days

—

—

—

—

Kusel, 2007*

198

Until symptom
resolution<5 years

AB (23%); S

NR

—

83%

52% (4-7days)

22% (1-2
weeks)

6% (2-4
weeks)

Croup
Randomised controlled trials:
Bjornson,
2004†

348

21 days

Mean 35 (SD 23) AB (% NR); S
monthsMean 0.8 (SD2.4) days

—

22%

—

—

—

Cruz, 1995

19

7-10 days

Mean 21 (SD 8)
monthsS

Mean 1.04 (SD1.0) days

Median 3 days

58%

—

—

—

Geelhoed,
1996

48

7-10 days

Mean 45 (SD 26)
monthsNR

21 (54) hours

Mean 2 (SD 1.6)
days

—

—

—

—

Bronchiolitis
Randomised controlled trials:
Patel, 2003

61

2 weeks or until
symptom
resolution

Mean 5.1 (SD2.6) months

NR

Median 4 (IQR Median 8.4 (3.7)
3-7) days
days; 8.0 days
(95% CI 7 to 9)

96%

73%

37%

—

Plint, 2009201

22 daysMedian 5 (IQR
3-7) months

NR

Median (IQR) 4(2-6) days

Median 13.3
days (IQR
8.2-19.5)

—

—

—

—

Observational studies:
Petruzella,
2010

95

4 weeks or until
symptom
resolution

Median 4 (IQR
3-7) months

NR

NR

Median 15 (IQR
11-20)

100%

97%

77%

25% (day20)

Plint, 2004

163

2-3 weeks

Median 5 (IQR
2-8) months

S

Median 4 days

Median 12 (IQR
8-20)

—

—

—

—

IQR=interquartile range; NR=not reported; S=symptomatic.
*Outcome is duration of proportion of episodes with cough.
†Outcome is proportion of children with Telephone Outpatient Score of zero.

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Study

Symptom
duration
before study
entryBMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 11 of 19

RESEARCH

Table 5| Proportion of children with cough on days 1-7, 10, 15, and 25 in six randomised controlled trials and six observational studies

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 10Day 15

Day 2558% (17/29) 34% (10/29) 27% (8/29)

18% (5/29)

13% (4/29)

—

—

—

Acute coughRandomised controlled trials:
Bernard, 1999 100% (29/29) 83% (24/29)
Observational studies:
Hay, 2003

98%(223/228)96%(218/228)93%(212/228)85%(194/228)80%(182/228)75%(171/228)

67% (153/228)

50%(114/228)

25% (57/228) 10% (22/228)

Hay, 2007

—

—

—

—

75%
(123/164)

—

—

50%
(82/164)(day 9)25% (41/164)—

Kusel, 2007*

—

—

83%
(164/198) (1-3
days)

—

—

—

52% (103/198)(4-7 days)—

22% (44/198)(1-2 weeks)

6% (12/198)(2-4 weeks)

Croup
Randomised controlled trials:
Bjornson,
2004†

70%
(253/361)

47%(170/361)

22% (79/361)

—

—

—

—

—

—

—

Cruz, 1995

58% (11/19)

—

—

—

—

—

—

—

—

—

70% (46/65)

37% (24/65)

25% (16/65)—

50% (at 13.3
days)

25% (at 19.5
days)

Bronchiolitis
Randomised controlled trials:
Patel, 2003

100% (65/65)

100%(65/65)96% (62/65) 91% (61/65) 86% (56/65) 73% (47/65)

Plint 2010

—

—

—

—

—

—

75% (at 8.2
days)

—

Observational studies:
Petruzella,
2010

100%
(112/112)100%(112/112)100%(112/112)100%(112/112)100%(112/112)97%(109/112)95% (106/112)

77%(86/112)Plint, 2004

—

—

—

—

—

—

75% (at 8days)—

50% (56/112) 25% (28/112)
50% (at 12days)

25% (at 20
days)

IQR=interquartile range; NR=not reported; S=symptomatic.
*Outcome is duration of proportion of episodes of cough.
†Outcome is proportion of children with Telephone Outpatient Score of zero.

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Proportion of children with cough remaining at follow-up
StudyBMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 12 of 19

RESEARCH

Study

Concurrent
treatment

Mean
(SD)
symptom
duration
beforestudy
entry

Mean (SD) time tosymptom resolution

Day 3

Mean 25 (SD15.7) months

S†

NR

—

Until symptom Median 13 (IQR
resolution
6-16) years

NR

NR

Until symptom
resolution

NR

NR

SampleFollow-up

Age

Proportion of children with symptoms
remaining at follow-up:

Day 6

Day 10Week 229% (7/24)*

—

—

43%
(13/30)†—Median 9.0 days (95%
CI 8 to 9)

98%

80%

39%

17%

1.8 (1.3) weeks

—

—

—

—

Common cold
Randomised controlled trials:
Hutton, 1991

24*

48 hours

30†
Macknin, 1998

122

—
—

Observational studies:
Grüber,
2007‡

1314

0-7 years
Infants

1.5 (1.6) to 1.8 (2.4)
weeks

3 years

2.1 (3.2) weeks

7 years

1.3 (1.4) weeks

Jedrychowski,
2005

292

Until symptom
resolution<1 yearNR< 48 hours

7.6 days

—

—

—

—

Pappas,2008§

81

10 days

NR

S

NR

—

100

90%

74%

—

Steinweg,
1983

40

Until symptom
resolution

25 months

NR

NR

Clear rhinorrhoea: 13.5
(3.5) days

—

—

—

—

—

—

—

43%
(16/37)

—

—

—

—

Purulent rhinorrhoea:
14.8 (4.2) days
Respiratory tract infection
Randomised controlled trials:
Kristo, 200537

Taylor, 2003244

2 weeks

Mean 6.9 (SD2.0) years

Until symptom Mean 5.4 (SD)resolution (≤21
2.5 years
days)

NR

8.7 (5.1)
days—

AB (7.3%)≤24 hours Median 9 days (95% CI
8 to 10)Observational studies:
Butler,2002/03169

2 weeks

Mean 5.1 (SD3.4) years

Intranasal
sodiumcromoglicate
or saline(100%)

3.3 (2.18)
days

—

71%
(131/184)

32%(57/179)9%(15/171)6%(10/169)

Carabin, 2000

333

10 days

Mean 24.55 (SD6.12) months

NRNR

10.22 days (95% CI
9.14 to 11.29);

—

—

50%

—

Jacobs, 2000

206

2 weeks

Median 3.2
years

AB (24%)<72 hours

Median 4.5 days

75%

50%

10%

5%

Kristo, 200638

3 weeks

Median 9.8(IQR 6-13)
years

AB (6%); S

4 daysMiddle meatal
pathogen: present: 16.7(7.0) days;

100

98%

81%

60%

Middle meatal pathogen
absent: 13.1 (6.0) days

100

90%

67%

43%

median 7.86 days

42
Kusel, 2007¶

236

Until symptom
resolution<5 years

AB (21%); SNR—

91% (1-3days)

59% (4-7
days)—

23% (1-2
wks)

Mitra, 2011

223

Until symptom
resolution (≤21
days)

Mean 8 years

NR

NR

Median 7 days (IQR
5-11)

—

75%

50%

25%

Samet, 19931209

30 days

InfantNR≥ 2 days

Median 6 days

—

50%

—

—

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Table 6| Duration of common cold and non-specific respiratory illness in children in randomised controlled trials and observational studies(studies by Grüber, Taylor, and Wald studies not included in line graphs because outcome reported as a range, not mean)

BMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 13 of 19

RESEARCH

Table 6 (continued)

SampleFollow-up

Age

Taylor,2010**

148

4 daysMean 6 (SD2.7) years

Proportion of children with symptoms
remaining at follow-up:

Concurrent
treatment

Mean (SD) time tosymptom resolution

NR

NR

—

Day 3

Day 6

Day 10Week 2

Sneezing:
66.1%

48.3%

—

—

Runny nose:
41%

50.9%

—

—

Cough:
37.7%

39%

—

—

Nasal
congestion:
59%

44.1%

—

—

Turner Cobb,
1998

116

15 weeks

Mean 9.31 (SD2.4) years

NR≥ 24 hours

8.28 (4) days

—

—

—

von Linstow,
2008

217

Until symptom
resolution<1 yearAB (38%); S

NR

Median 4.7 days; (IQR
2-6) days

—

—

—

—

Wald, 1991

244

Until symptom
resolution<1 yearNR≥ 24 hours

HC: 7.33 (5.54) days;
GC: 8.32 (6.19) days;
DC: 8.87 (6.72) days

—

—

—

—

1-2 years

HC: 6.63 (5.13) days;
GC: 7.98 (6.67) days;
DC: 7.29 (6.54) days

2-3 years

HC: 6.79 (4.96) days;
GC: 7.20 (5.84) days;
DC: 7.82 (6.40) days

AB=antibiotics, HC=home care; GC=group care; DC=day care; NR=not reported; S=symptomatic.
*Placebo.
†No treatment.
‡Outcomes are means (standard deviation).
§Outcome is “proportion of children reporting any symptom by day of illness in 81 common colds.”¶Outcome is duration of proportion of episodes.
**Outcomes are for children with viral RTI.

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Study

Mean
(SD)
symptom
duration
beforestudy
entry

BMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 14 of 19

RESEARCH

Table 7| Proportion of children with common cold and non-specific respiratory illness on days 1-14

1

2

3

4

5

6

7

8

9

10

11

12

13

14

—

—

—

—

—

—

—

—

—

—

—

—

80%
(99/124)68%(84/124)60%(74/124)

51%
39%
28%
25%
23%
17%
(63/124) (48/124) (34/124) (31/124) (29/124) (21/124)

Common cold
Randomised controlled trials
Hutton,1991

Macknin,
1998

—

71%
(17/24)*;57%(17/30)†

100%
100%
98%
98%
88%
(124/124) (124/124) (122/124) (122/124) (109/124)

Observational studies
Pappas,2008‡

100%(81/81)100%(81/81)100%(81/81)

97%(79/81)

97%(79/81)90%(73/81)88%(71/81)

82%(66/81)80%(64/81)74%(60/81)

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

43%
(16/37)32%(57/179)26%(49/189)16%(28/175)

Respiratory tract infection
Randomised controlled trials
Kristo,2005——

Observational studies
Butler,2002/03

96%
91%
71%
56%
39%
(185/193) (171/188) (131/184) (101/181) (71/181)

11%
9%
8%
7%
6%
6% (10/(19/175) (15/171) (14/169) (12/169) (10/169) 169)

Carabin,
2000

—

—

—

—

—

—

—

50%
(167/333)

—

—

—

—

—

—

Jacobs,
2000

—

—

75%
(165/220)—50%(110/220)—25%(55/220)——10%(22/220)

—

—

—

5%
(11/220)

Middlemeatalpathogen100%(38/38)100%(38/38)100%(38/38)100%(38/38)100%(38/38)98%(37/38)97%(37/38)95%(36/38)90%(34/38)81%(31/38)79%(30/38)69%(26/38)63%(24/38)60%(23/38)

No middle
meatalpathogen100%(42/42)100%(42/42)100%(42/42)100%(42/42)99%(41/42)90%(38/42)

86%(36/42)

81%(34/42)79%(33/42)

67%(28/42)

63%(26/42)

61%(25/42)52%(22/42)43%(18/42)

Kusel,
2007§——

91% (1-3
days)(180/198)———

59% (4-7
days)(117/198)

—

—

—

—

—

—

23%
(1-2
wks)
(46/198)

Mitra, 2011

—

—

—

—

75%
(428/570)—

50%(285/570)

—

—

—

25%
(143/570)———

Samet,
1993

—

—

—

—

—

50%
(658/1315)

—

—

—

—

—

—

—

—

Taylor,
2003

—

—

—

—

—

—

—

—

—

—

—

Sneezing: 66.1%(99/150)

—

—

48.3%
(72/150)

—

—

—

—

—

—

—

—

—

—

Runny
nose

: 38.7%(58/150)47.5%(71/150)41%(62/150)50.9%(76/150)

—

—

—

—

—

—

—

—

—

—

Cough:

30.7%(46/150)41%(62/150)37.7%(57/150)39%(59/150)

—

—

—

—

—

—

—

—

—

—

Nasal
congestion

—

—

59%
(89/150)44.1%(66/150)

—

—

—

—

—

—

—

—

—

—

Kristo, 2006:

75%
50%
25%
(196/261) (131/261) (65/261)

Taylor, 2010:*Placebo.
†No treatment‡Outcome presented is “proportion of children reporting any symptom by day of illness in 81 common colds.”§Outcome presented is duration of proportion of episodes.

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Proportion of children with symptoms remaining at follow-up:
StudyBMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 15 of 19

RESEARCH

Time (days, unless otherwise stated) for symptoms toresolve
Croup

Average illness duration(days)

In 50% of children

In 90% of children

NICE8

CDC

1

2*

—

—

Earache/otitis media

3

7-8

4

2-3†

Sore throat/tonsillitis

—

2-7‡

7

7-14§

Non-specific respiratory tract
infection

7

16¶

—

—

Common cold

10

15**

10-11

14††

Acute cough

10

25

21

10-14‡‡

Bronchiolitis

13

21§§

—

—

*No of days to 80% resolution.
†Data from www.cdc.gov/getsmart/campaign-materials/info-sheets/child-otitismedia.pdf‡Data not sufficient to calculate pooled proportions or time to 50% or 90% resolution; figures shown are ranges from included studies for days to complete resolution.
§Data from www.cdc.gov/getsmart/antibiotic-use/URI/sore-throat.html¶Data from pooled proportions did not extend beyond time to 80% resolution (14 days), data presented is estimate for time to 90% resolution from fig 9.
**Data from pooled proportions did not extend beyond time to 60% resolution (10 days), figure shown is estimate for time to 90% resolution from fig 8.
††Data from www.cdc.gov/getsmart/campaign-materials/info-sheets/child-rhin-vs-sinus.pdf‡‡Data from www.cdc.gov/getsmart/campaign-materials/info-sheets/child-cough-illness.pdf§§No of days estimated from fig 7. Time to 60% resolution was 16 days.

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Table 8| Duration of common respiratory tract infections in children in current systematic review compared with current advice from UK
National Institute for Health and Care Excellence (NICE) and the US Centers for Disease Control and Prevention (CDC)

BMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

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RESEARCH

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FiguresFig 1 Flow of included randomised controlled trials of respiratory tract infections in children

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RESEARCH

Fig 3 Proportion of children with symptoms of earache. Symptom duration before study onset was less than four days infive studies (Burke,14 Damoiseaux,15 Le Saux,17 Neumark,19 Jedrychowski22) and was not reported in three studies (Tahtinen,20
Greenberg,21 Smith23)

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Fig 2 Flow of included observational studies of respiratory tract infections in children

BMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

Page 18 of 19

RESEARCH

Fig 5 Proportion of children with symptoms of cough. Symptom duration before study onset ranged between <48 hours(Jedrychowski22) to <14 days (Bernard30) and was not reported in one study (Kusel37)

Fig 6 Proportion of children with symptoms of croup. Mean symptom duration before study onset was reported as 0.8 (2.4)
days (Bjornson31), 1.04 (1) days (Cruz32), and 21 (54) hours (Geelhoed33)

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Fig 4 Proportion of children with symptoms of sore throat. Symptom duration before study onset ranged between 24 hours(median) (Nelson26) to less than one week (Ruperto28) and was not reported in one study (Olympia27). *Children with group
A streptococcal infection; †children without group A streptococcal infection or other culture. (Pooling not possible becauseof lack of data)

BMJ 2013;347:f7027 doi: 10.1136/bmj.f7027 (Published 11 December 2013)

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RESEARCH

Fig 8 Proportion of children with symptoms of common cold. Symptom duration before study onset was not reported in fivestudies (Hutton, Macknin, Gruber, Pappas, Steinweg), Jedrychowski et al reported duration <48 hours.22 *Placebo arm;†no treatment arm; ‡children with clear rhinorrhoea; §children with purulent rhinorrhoea

Fig 9 Proportion of children with non-specific respiratory symptoms. Symptom duration before study onset ranged between≤24 hours (Taylor 200343) to 8.7 (5.1) mean days (Kristo41) and was not reported in five studies (Carabin,45 Kusel,37 Mitra,7Taylor 2010,52 Von Linstow54). *Middle meatal pathogen present; †middle meatal pathogen absent

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Fig 7 Proportion of children with symptoms of bronchiolitis. Symptom duration before study was median four days in threestudies (Patel,34 Plint 2009,35 Plint 200439) and not reported in one study (Petruzella38)