What is the recommended treatment approach and dosing for pediatric rhinitis?

From the Guidelines

The most effective treatment approach for pediatric rhinitis involves the use of intranasal corticosteroids, such as fluticasone propionate or mometasone furoate, for moderate to severe symptoms, due to their ability to reduce inflammation and improve quality of life, as evidenced by studies including 1. When considering treatment options, it's essential to identify the type and severity of symptoms. For mild allergic rhinitis, second-generation oral antihistamines like cetirizine or loratadine can be used as first-line treatments. However, for moderate to severe symptoms, intranasal corticosteroids are the most effective option, with studies showing they are more effective than the combined use of an antihistamine and a leukotriene antagonist 1. Some key points to consider when using intranasal corticosteroids in pediatric patients include:

• The recommended dose for fluticasone propionate is 1-2 sprays per nostril daily for children ≥4 years, and for mometasone furoate, it is 1 spray per nostril daily for children ≥2 years.
• Environmental control measures, such as allergen avoidance and saline nasal irrigation, are also essential in managing pediatric rhinitis.
• Regular reassessment is crucial to monitor treatment response and adjust therapy as needed, particularly during growth periods, as intranasal corticosteroids can have a transient effect on growth suppression in children, although this is dependent on the specific medication and dose used, as well as the technique of administration and concomitant use of other corticosteroids 1.
• Local side effects, such as nasal irritation and bleeding, can occur but are rare and can be minimized with proper administration technique and periodic examination of the nasal septum. Overall, the goal of treatment is to improve quality of life, reduce symptoms, and minimize the risk of complications, and intranasal corticosteroids are a key component of this approach, as supported by studies including 1 and 1.

From the FDA Drug Label

Children age 4 to 11 should use a lower dose of Fluticasone Propionate Nasal Spray, USP for a shorter period of time Ages | Children 4 to 11 years of age | Users 12 years of age and older Dosage | 1 spray in each nostril once daily | Up to 2 sprays in each nostril once daily Duration before checking with a doctor | Up to 2 months of use a year | Up to 6 months of daily use

The recommended treatment approach for pediatric rhinitis is to use Fluticasone Propionate Nasal Spray, USP at a dose of 1 spray in each nostril once daily for children aged 4 to 11 years. The duration of use should not exceed 2 months a year before checking with a doctor. For children who need to use the spray for longer than 2 months a year, it is recommended to consult with a doctor to ensure it is safe to continue use 2.

• Key considerations:
  • Children should use the spray for the shortest amount of time necessary to achieve symptom relief.
  • Long-term use of intranasal glucocorticoids like Fluticasone Propionate Nasal Spray, USP may cause slower growth rates in some children.
  • It is essential to follow the instructions for priming the pump and using the spray correctly to get a full dose and achieve relief.
• Important notes:
  • Children under 4 years of age should not use Fluticasone Propionate Nasal Spray, USP.
  • Adults should supervise the use of the spray for children aged 4 to 11 years. 2

From the Research

Treatment Approach

• The goal of treatment in pediatric allergic rhinitis is to provide effective prevention of or relief from allergic rhinitis symptoms as safely and effectively as possible 3.
• Removing or avoiding allergens is always advised; however, pharmacotherapy is often a necessity 3.
• The options for treating allergic rhinitis in children are the same as those for adults, and the clinician can expect the same level of efficacy 4.

Pharmacologic Options

• Systemic decongestants are associated with irritability and insomnia, particularly in children 3.
• Antihistamines are widely used; however, first-generation antihistamines are known to cause dry mouth and sedation 3.
• Oral corticosteroids are very effective but can have unwanted systemic effects 3.
• Intranasal corticosteroids have been shown to be the most effective form of pharmacologic treatment for allergic rhinitis 3, 5, 6.
• Topical corticosteroid is now accepted as safe and most effective in controlling all symptoms of both allergic and nonallergic rhinitis 5, 6.

Dosing

• Fluticasone propionate aqueous nasal spray is a new once-daily topical corticosteroid preparation, effective in children 5 to 11 years of age with perennial allergic rhinitis 5.
• In children as young as 4 years, 100 micrograms of fluticasone propionate aqueous nasal spray given once daily is as effective as 200 micrograms given once daily 6.
• Mometasone furoate (MF) nasal spray has been studied in children 3 to 12 years of age and has been shown to be effective with once-daily dosing 3.

Safety and Efficacy

• There is no evidence of effects on adrenal function by morning plasma cortisol concentration between the two groups treated with fluticasone propionate and placebo 5, 6.
• Fluticasone propionate was safe and effective in children aged 5 to 11 years with perennial allergic rhinitis 5.
• Intranasal corticosteroids, including mometasone furoate, beclomethasone dipropionate, and budesonide, have an improved risk-benefit ratio compared with older corticosteroids and are now considered the drug of choice for pediatric allergic rhinitis 3.