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

In brief

• Children get 6 to 10 colds a year on average, and most colds settle in 7 to 10 days.
• Paracetamol or ibuprofen, fluids, saline drops, gentle nasal suction and honey (over age 1) are what help.
• Avoid over-the-counter cough and cold syrups in young children, and codeine cough medicines in any child.
• A cough can linger for 2–3 weeks, but a cough beyond 3 weeks or a fever beyond 3–5 days should be checked.
• Children in high-risk groups should be seen early, because rapid tests and antivirals within 48 hours can change outcomes.
• Get urgent help for fast or laboured breathing, blue lips, stridor at rest, unusual drowsiness, seizures, refusing fluids, or a fever above 38°C in a baby under 3 months.

We see children with colds, coughs and fevers at our Punggol clinic. Book a child health appointment.

Why children get URTIs so often

Children get 6 to 10 colds a year on average, and in the first years of childcare it can feel endless. The reasons:

• Their immune systems are still developing, so each virus is a first encounter.
• Childcare, school and play mean shared toys, shared space, and hands to faces many times an hour.
• Their airways are narrower, so minor inflammation causes more obvious symptoms.

Frequent early colds are normal immune development, not weakness or immunodeficiency. Most children need the clinic less often as they move through primary school.

A typical childhood URTI

Most follow a similar course to adults:

• Day 1–3: fever, runny nose, irritability, poor appetite, sometimes a mild cough.
• Day 3–7: congestion may feel worse; the cough develops or peaks; night waking is common.
• Day 7–10: most symptoms settle.
• After day 10: the runny nose and congestion are mostly gone, but a cough can linger for up to 2–3 weeks. This post-viral cough, in a child who is well and improving, is not a reason for antibiotics.

When a lingering cough needs review, not just time

A cough lasting more than 3 weeks, or with unusual features, should be reviewed. Causes we consider in children:

• Pneumonia: a persistent, productive cough with fever, fast breathing or reduced activity.
• Bacterial complications such as sinusitis or a chest infection: a high fever that persists or returns, “double-sickening”, or focal chest signs.
• Whooping cough (pertussis): bouts of coughing, sometimes with a “whoop” on breathing in or vomiting afterwards. It can occur even in vaccinated children whose immunity has waned.
• Asthma: cough worse at night or with exercise, a family history of allergy (atopy), and triggers such as cold air.
• Post-nasal drip or allergic rhinitis: a tickle in the throat, with cough worse when lying down.
• An inhaled foreign body: a sudden cough after a choking episode, particularly in toddlers.
• Gastro-oesophageal reflux: in infants, cough worse after feeds or when lying down.
• Tuberculosis: cough with weight loss, night sweats, or contact with a known TB case.
• Rarer causes, usually with other features: cystic fibrosis, primary ciliary dyskinesia, immune deficiency and structural airway problems.

Fever peaks in the first few days. Fever lasting beyond 3–5 days, or returning after settling, needs a visit. That is a different signal from a lingering cough.

What helps a child with a URTI

• Paracetamol or ibuprofen for fever and discomfort. We give you the exact dose in mL for your child’s weight; please don’t use a sibling’s or cousin’s dose.
• Fluids: small sips often. If you are breastfeeding, continue on demand.
• Saline nasal drops or spray: safe at any age and often very effective. Use as often as needed, including before feeds in infants.
• Nasal suction for infants and toddlers: a few drops of saline, then gentle suction with a bulb syringe or nasal aspirator (e.g. NoseFrida-type devices). Very young infants breathe mainly through the nose, so clearing it can greatly improve feeding and sleep. Once or twice before feeds and at bedtime is usually enough; gentle works better than forceful.
• Decongestant nose drops or sprays (e.g. Iliadin / oxymetazoline) for short-term relief, at bedtime or before a feed, when a blocked nose is disrupting sleep or feeding. They are not for continuous use. Iliadin comes in three strengths in Singapore; use the right one:
  • Iliadin Baby (0.01%): infants up to 1 year. The dose is very small: 1 drop per nostril up to 4 weeks of age, then 1–2 drops per nostril from about 5 weeks to 1 year, 2–3 times a day.
  • Iliadin Children (0.025%): children 1 to 6 years.
  • Iliadin Adult (0.05%): children aged 6 and above, and adults. Do not use adult strength in younger children. The higher concentration can cause significant side effects at their size.
  • Do not use any strength for more than about 5 days in a row. After that, rebound congestion (rhinitis medicamentosa) makes the nose worse.
• Honey: for children over 1 year of age, a teaspoon at bedtime has reasonable evidence for easing cough. Never give honey to babies under 12 months, because of the risk of infant botulism.
• Rest, a cool room and upright feeding, with humidified air if the air is very dry.

And the most underrated treatment of all: time.

What not to give young children, and why

Over-the-counter cough and cold medicines

International authorities agree that over-the-counter (OTC) cough and cold medicines should not routinely be used in young children, up to about age 4. The age cut-offs differ, but the reasoning is the same:

A CDC-led review found 1,519 emergency department visits by children under 2 years in 2004–2005 for adverse events from these medicines. An FDA safety review found 54 reported child deaths linked to decongestants and 69 to antihistamines between 1969 and 2006 in children under 6, most of them under 2.

So don’t give combined “children’s cough-cold-fever” syrups (antihistamines, decongestants or cough suppressants) under age 2 without a doctor’s specific instruction. From 2 to 5, their benefit over simple supportive care is modest at best.

Antihistamines still have clear uses in young children. Paediatricians commonly prescribe them for hives (acute urticaria), allergic rhinitis, drug or food allergy reactions, mosquito bite reactions and seasonal allergies. The caution is about using them for a cough or runny nose from a viral cold, where the benefit is marginal and the risk is not.

The risk-benefit question

Parents reasonably ask: “A cough or runny nose doesn’t kill. How serious can the medicine be?”

Adverse events in young children are rare but real. They include convulsions, dangerous heart rhythms, respiratory depression and, in a small number of reported cases worldwide, death. An uncomplicated viral URTI in a healthy child is uncomfortable but not dangerous. So the trade is a rare but catastrophic risk, for modest benefit at best, against a near-zero risk from symptoms that settle on their own. HSA’s “unless a doctor has weighed benefits against risks” wording is slightly more permissive than the AAP’s under-4 position, but the practical caution is the same.

Why young children are especially susceptible

Infants and toddlers handle drugs differently from adults:

• Immature liver enzymes. The cytochrome P450 enzymes (CYP3A4, CYP2D6, CYP1A2, CYP2C9 and others) that break down most drugs mature at different ages, some only after several years. A standard dose can build up unpredictably.
• Slower kidney clearance. At birth, a baby’s glomerular filtration rate (allowing for body size) is only about a sixth of an adult’s. It roughly doubles in the first week and reaches adult levels by about 1 to 2 years of age. Drugs cleared by the kidneys stay longer in young infants.
• A more permeable blood-brain barrier, so sedating antihistamines, opioids and some decongestants act more strongly on the brain at lower doses.
• More body water and less fat, which changes how drugs distribute.
• Lower plasma protein binding, leaving more active “free” drug.
• Genetic variation, which a first exposure can reveal. An example is a CYP2D6 “ultra-rapid metaboliser” child given codeine (see below).

So adverse drug reactions in young children are harder to predict, and the safe margin is narrower and less well understood. Hence the default in children: don’t give it unless we’re sure it’s worth it.

Local data on these adverse events is limited, so HSA largely relies on international safety signals. Absence of local data does not mean absence of risk.

Codeine-containing cough syrups

Some children’s cough syrups used to contain codeine or pholcodine. Since 2016, HSA has restricted codeine-containing cough medicines in children under 12. In 2018 the FDA went further, restricting all codeine and hydrocodone cough medicines for children under 18.

The reasons:

• The liver converts codeine to morphine using the enzyme CYP2D6.
• Ultra-rapid metabolisers, including some children, reach dangerous morphine levels even at standard doses.
• Deaths from respiratory depression have been reported, particularly in children given codeine after tonsillectomy or adenoidectomy.
• They can’t easily be identified without genetic testing, which isn’t routine.

How common is this in Singapore? A 2024 study of the multi-ethnic SG10K_Health cohort (1,850 whole genomes) found that ultra-rapid metabolisers outnumbered poor metabolisers about 2-fold. Global data put their frequency at around 1% in Chinese and Japanese populations, somewhat higher in Singapore’s Indian group, and 20–30% in Middle Eastern and North African populations, to which some travellers and relatives belong. Overall, 46% of Singaporeans carry a CYP2D6 variant with direct implications for drug dosing. They are uncommon here, but missing one has severe consequences.

Codeine cough medicines have essentially no role in children, and we don’t prescribe them for this age group. Paracetamol, rest and honey (over age 1) are safer.

Mucolytics and the “phlegmy” cough

Parents often ask for something to “loosen the mucus” when a toddler’s cough sounds phlegmy. It’s an understandable instinct, but:

• Mucolytics (bromhexine, ambroxol, carbocisteine, acetylcysteine) have poorly established safety in children under 2. The Cochrane review found too little data to draw conclusions for under-2s.
• In children aged 2 and older, benefit is limited and inconsistent. Meta-analyses find modest symptom reduction at best.
• Regulators have acted: New Zealand’s Medsafe restricted bromhexine in children in 2015, and the European Medicines Agency has reviewed ambroxol and bromhexine safety.
• Young children’s airways naturally sound phlegmy, often regardless of how much mucus there is. Their airways are small, and mucus in the nose and throat makes a gurgly or rattly sound that you can hear, and often feel, through the chest. This is usually harmless and settles as the cold clears. It is different from two specific conditions that cause noisy breathing between colds too: laryngomalacia, a floppy voice box that causes a high-pitched noise on breathing in (stridor), and tracheomalacia, a soft windpipe that can cause a persistent wheeze or a brassy cough. Noisy breathing that continues when your child is well should be checked.

For a healthy child with a phlegmy-sounding cold, the best approach is usually saline, fluids, time and reassurance, not a mucolytic syrup.

Which children are at higher risk

Most children with a URTI can be cared for at home. The children below are more prone to complications and may need earlier review, rapid testing and sometimes antivirals:

• Premature babies, especially in their first 1–2 winters
• Infants under 6 months, for RSV and flu
• Chronic lung disease: severe asthma, chronic lung disease of prematurity, bronchopulmonary dysplasia, cystic fibrosis
• Significant heart conditions, especially unrepaired congenital heart disease
• A weakened immune system, from illness or medicines (chemotherapy, long-term steroids, biologics, after a transplant)
• Neurological or neuromuscular conditions that affect swallowing or clearing secretions
• Down syndrome, which carries higher rates of respiratory complications
• Household contacts of high-risk people, such as a newborn sibling or a grandparent on chemotherapy

If your child is in one of these groups and catches a respiratory infection, come in early rather than waiting.

Protecting high-risk children: vaccination

The most important protection is given before illness, not during it:

• Annual flu vaccine from age 6 months (inactivated; live-attenuated options exist for some ages internationally). Singapore’s national schedule recommends it for all children aged 6 months to under 5 years, and for older children with chronic conditions. It is fully subsidised for eligible Singaporean children at CHAS GP clinics and polyclinics.
• COVID-19 boosters for children with chronic conditions, as per current MOH recommendations.
• Pneumococcal vaccine, part of the standard NCIS.
• Whooping cough (pertussis) vaccine, also part of the NCIS. Vaccinating parents, siblings and caregivers (“cocooning”) helps protect young babies who have not yet had their own doses.
• RSV prevention. Nirsevimab (Beyfortus), a monoclonal antibody given as a single injection, is registered in Singapore for babies in their first RSV season, and for children up to 2 years who remain at high risk in their second. It gives a season’s protection. It is not on the national schedule or MOH’s subsidised vaccine list, so the full cost applies. RSV vaccination in pregnancy is another evolving option. Ask us which suits your family.

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

Rapid testing in the clinic — what it can tell us

Rapid antigen tests (RATs)

Combined panels, often called 5-in-1 ART tests, detect COVID-19, influenza A and B, RSV and adenovirus from one nasal swab in about 15 minutes. Now much more accurate, they are useful for:

• high-risk children, where identifying flu and starting antivirals within 48 hours changes outcomes
• household outbreaks, to guide isolation and decide whether contacts need preventive treatment
• telling apart the several germs that can cause fever and cough

Rapid strep antigen testing

For children 3 years and older with a sore throat, a rapid strep swab (15 minutes in clinic) helps decide on antibiotics (see Sore throat in children, below).

Respiratory PCR panels

These broader, more sensitive laboratory tests often cover 20+ pathogens, including Bordetella pertussis, parainfluenza, metapneumovirus, mycoplasma and chlamydophila. Results take about 24 hours. They are available at KTMC at a cost (not subsidised). We use them when a clearer answer will change management, for example:

• a prolonged cough that might be whooping cough
• a high-risk child, where a specific result will guide antivirals
• an unclear severe illness

Your GP’s local view

We see and swab children with colds every week, so we often have a real-time sense of which viruses are circulating locally. If several classmates have the same symptoms, tell us; it shapes what we look for.

Antivirals for high-risk children

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

• It works best within 48 hours of symptoms starting, with some modest benefit up to 5 days.
• It helps children in the high-risk groups above, children under 2 (flu can be severe at this age), and severely unwell children of any age.
• In healthy older children with uncomplicated flu, the benefit is modest and must be weighed against side effects (nausea, occasional vomiting, rare neuropsychiatric effects).
• The dose is weight-based in children and needs careful calculation.

Reducing family spread

Oseltamivir also reduces the amount of virus the child sheds. If the household includes high-risk contacts (a newborn sibling, a pregnant parent, a grandparent on chemotherapy), treating the sick child early meaningfully lowers their chance of catching flu. In specific situations we also consider post-exposure prophylaxis with oseltamivir for the high-risk contact.

Sore throat in children

Strep throat (group A streptococcal pharyngitis) peaks in children aged 5 to 10 years, with meaningful numbers through adolescence (10–15). It is uncommon in children under 3, where most sore throats are viral. In under-3s, group A strep usually shows as “streptococcosis” (thick nasal discharge, fever, swollen glands) rather than a classic sore throat.

Classic features in school-age children:

• Fever, often above 38°C
• Pus on the tonsils (white or yellow spots)
• Tender lymph nodes at the front of the neck
• No cough or runny nose: a pure sore throat rather than a full cold

Routine strep testing under age 3 is generally not recommended, because strep throat is unlikely and incidental strep carriage is more common. When confirmed, treatment is usually a 10-day course of penicillin (or an alternative for penicillin allergy). This:

• shortens symptoms by about 1 day
• shortens the infectious period; a child can usually return to school 24 hours after starting antibiotics
• lowers the risk of rare but serious complications, rheumatic fever and post-streptococcal glomerulonephritis

A sore throat with an obvious runny nose, cough or conjunctivitis is almost always viral and doesn’t need antibiotics.

Acute otitis media (ear infection)

Common in young children, especially after a cold, because their Eustachian tubes are short and horizontal. Signs include ear pain, ear pulling in children too young to talk, fever, and sometimes difficulty hearing.

How we manage it:

• Antibiotics straight away, usually amoxicillin, for a child under 2 with both ears infected, any child with ear discharge, a child who is very unwell (high fever, severe pain), or a child at higher risk of complications.
• Otherwise, watchful waiting for 48–72 hours with paracetamol or ibuprofen is often appropriate, particularly over age 2 with mild to moderate symptoms. We sometimes give a back-up antibiotic prescription to start if symptoms don’t improve. Many cases settle without antibiotics.
• Pain-relieving ear drops (not antibiotic drops) can help, but not if the eardrum has burst.

Recurrent ear infections, or ear infections with hearing loss or speech delay, need referral to an ENT specialist.

RSV and bronchiolitis

Respiratory syncytial virus (RSV) causes ordinary colds in older children and adults. In infants it can cause bronchiolitis, an inflammation of the smallest airways, with wheeze, cough, fast breathing and sometimes difficulty feeding.

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

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

RSV season in Singapore often runs through the wetter months. Nirsevimab, a monoclonal antibody given as a single injection, can protect babies through their first RSV season (see Protecting high-risk children, above).

Croup

A viral infection, usually parainfluenza, that causes a barking, “seal-like” cough, often at night. There may be stridor, a high-pitched noise when breathing in. It is commonest from 6 months to 3 years.

• Mild croup (no stridor at rest): cool air or steam can help, with reassurance and paracetamol.
• Moderate to severe croup (stridor at rest, chest pulling in): needs urgent review. A single dose of oral dexamethasone is very effective.
• Severe croup (distress, blue colour, drowsiness): call 995.

Stridor at rest, particularly in a child who looks unwell, is urgent. Please don’t wait.

When to come in

Book an appointment if:

• your child is in a high-risk group (see above) and has caught a respiratory infection
• a fever above 38°C lasts beyond 3–5 days, or returns after settling
• a cough lasts more than 3 weeks
• there is no improvement after 7–10 days, or your child gets worse after first improving
• there is a severe sore throat, particularly with fever and no cough (possible strep)
• there is ear pain, particularly with fever or in a young child
• an infant has been feeding poorly for more than 24 hours
• you are simply worried and want your child seen

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

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

Protecting the household when a child is sick

• Wash hands often, especially before feeding or touching other children.
• Don’t kiss babies when you have symptoms. Anyone with a cough or cold should wear a mask around newborns.
• Don’t share utensils, bottles or pacifiers.
• Ventilate indoor spaces.
• Postpone contact with high-risk family members (newborns, older people with chronic disease, anyone on immunosuppressive treatment) while your child is feverish or coughing heavily.
• Clean high-touch surfaces such as toys, the changing table and car seat handles.
• Ask us about preventive antivirals for high-risk household contacts, for example when flu is confirmed at home and someone is pregnant or on chemotherapy.

Return to school or childcare

Exclusion periods protect your child’s recovery and the other children. They are set partly by MOH/ECDA guidance and partly by each school, so please check with your school or preschool too.

General principle: a child is safer to return once they are fever-free for 24 hours without paracetamol or ibuprofen, and eating, drinking and playing close to normally. A lingering cough or mild runny nose in an otherwise well child is not a reason to stay home, and keeping them home doesn’t reliably reduce spread.

Specific rules:

• Hand, foot and mouth disease (HFMD): per MOH guidance, until all blisters have dried and crusted and the child is fever-free. This typically takes 7 to 10 days from onset, but can be longer. Many preschools require a doctor’s clearance.
• Chickenpox (varicella): until all lesions have crusted over, typically 5 to 7 days from rash onset.
• Confirmed strep throat (Group A streptococcal pharyngitis): at least 24 hours after starting appropriate antibiotics, and fever-free.
• Test-confirmed influenza: typically 5–7 days from symptom onset, and fever-free for 24 hours without medication.
• Acute viral conjunctivitis (“pink eye”): many schools require exclusion until the discharge settles, and some are stricter. Adenoviral conjunctivitis is highly contagious.
• Gastroenteritis (vomiting or diarrhoea): until at least 48 hours after the last episode. Some schools use 24 hours; 48 is safer for highly contagious causes such as rotavirus or norovirus.
• Measles, mumps, pertussis, diphtheria: notifiable, with specific MOH-mandated exclusion periods. If you suspect one, come in urgently and we’ll coordinate.

An ordinary viral URTI needs no exclusion beyond the “fever-free and well enough” rule. If you’re unsure, or the school wants a clearance note, come in and we’ll assess.

Cross-links

• Colds, coughs, sore throats and sinusitis — adult guide, including cough medicines explained
• Beyond the Jab: Navigating Flu Season in Singapore
• Asthma in children — what parents need to know, if a recurring cough is more than a cold
• Childhood vaccinations (NCIS)

Get in touch

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

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

Email — admin@ktmc.sg

References

Guidelines and authority positions

• Agency for Care Effectiveness (ACE). Upper respiratory tract infections — rational antimicrobial use. ACE Clinical Guideline, Ministry of Health, Singapore. May 2026. ace-hta.gov.sg
• Health Sciences Authority Singapore (HSA). Cough and cold medicines for children — what you should know. hsa.gov.sg
• HSA. Restrictions on the use of codeine-containing products in children and adolescents. 2016. hsa.gov.sg
• US Food and Drug Administration (FDA). Use Caution When Giving Cough and Cold Products to Kids. fda.gov
• American Academy of Pediatrics (AAP). Position on OTC cough and cold medications in children under 4.
• FDA. Restricts use of cough and cold medicines with codeine or hydrocodone for kids (2018).
• National Institute for Health and Care Excellence (NICE). Fever in under 5s: assessment and initial management. NICE guideline NG143. 2019. nice.org.uk
• National Institute for Health and Care Excellence (NICE). Otitis media (acute): antimicrobial prescribing. NICE guideline NG91. 2018, updated 2022. nice.org.uk
• Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. American Academy of Pediatrics clinical practice guideline. Pediatrics. 2013;131(3):e964–e999.
• Agency for Care Effectiveness (ACE). Nirsevimab for prevention of respiratory syncytial virus-associated lower respiratory tract disease in infants during their first RSV season. ACE Drug Guidance, Ministry of Health, Singapore. 1 July 2026. ace-hta.gov.sg
• National Drug Formulary (NDF), Singapore. Beyfortus solution for injection in pre-filled syringe 100 mg/1.0 mL [SIN17138P]: product information. ndf.gov.sg
• National Drug Formulary (NDF), Singapore. Iliadin solution for nose 0.01% [SIN06533P], Iliadin solution 0.025% [SIN03162P] and 0.05% [SIN03163P]: product information. ndf.gov.sg

Specific evidence

• Chalumeau M, Duijvestijn YCM. Acetylcysteine and carbocysteine for acute upper and lower respiratory tract infections in paediatric patients without chronic broncho-pulmonary disease. Cochrane Database Syst Rev. 2013;(5):CD003124 — limited efficacy; safety not established under 2.
• Medsafe New Zealand. Changes to the use of bromhexine or codeine-containing cough and cold medicines in children. 2015.
• European Medicines Agency. Ambroxol and bromhexine — Article 31 referral. Safety review of paediatric use.
• Oduwole O, Udoh EE, Oyo-Ita A, Meremikwu MM. Honey for acute cough in children. Cochrane Database Syst Rev. 2018;(4):CD007094.
• Jefferson T, Jones M, Doshi P, et al. Neuraminidase inhibitors (oseltamivir) for preventing and treating influenza in adults and children. Cochrane Database Syst Rev. 2014;(4):CD008965.
• Centor RM, et al. Centor criteria for streptococcal pharyngitis.
• Smeets NJL, IntHout J, van der Burgh MJP, et al. Maturation of GFR in term-born neonates: an individual participant data meta-analysis. J Am Soc Nephrol. 2022;33(7):1277–1292.
• Iacobelli S, Guignard JP. Maturation of glomerular filtration rate in neonates and infants: an overview. Pediatr Nephrol. 2021;36:1439–1446.
• Golob Jančič S, Močnik M, Marčun Varda N. Glomerular filtration rate assessment in children. Children (Basel). 2022;9(12):1995.
• Bedwell J, Zalzal G. Laryngomalacia. Semin Pediatr Surg. 2016;25(3):119–122.
• Wallis C, Alexopoulou E, Antón-Pacheco JL, et al. ERS statement on tracheomalacia and bronchomalacia in children. Eur Respir J. 2019;54:1900382.

This information is for general education only and is not a substitute for medical advice. Paediatric management must be individualised by age, weight, and specific clinical situation — please speak with our team. v1.1 · October 2026 (v1.0 April 2026) · Review due April 2028.