What is the initial approach to managing rhinitis (inflammation of the nasal passages) in infants less than one year of age with symptoms lasting more than 4 months?

Management of Rhinitis in Infants Less Than One Year of Age with Duration More Than 4 Months

For infants less than one year of age with rhinitis lasting more than 4 months, avoid pharmacological treatment with decongestants or antihistamines due to safety concerns, and instead focus on environmental management, saline irrigation, and careful evaluation for underlying causes. 1

Initial Assessment

When evaluating an infant with prolonged rhinitis (>4 months), consider these key factors:

• Rule out serious underlying conditions:

  • Anatomical abnormalities
  • Immunodeficiency
  • Cystic fibrosis
  • Gastroesophageal reflux disease
  • Primary ciliary dyskinesia

• Distinguish between types of rhinitis:

  • Allergic rhinitis (less common in infants but possible)
  • Non-allergic, non-infectious rhinitis
  • Recurrent infectious rhinitis
  • Adenoid hypertrophy (common cause of persistent nasal symptoms)

Treatment Algorithm

First-line Management:

1. Environmental Control Measures:

   • Eliminate tobacco smoke exposure
   • Reduce dust mite exposure (wash bedding in hot water, remove stuffed toys)
   • Control indoor humidity (40-50%)
   • Minimize pet allergen exposure if relevant

2. Nasal Saline Irrigation:

   • Use preservative-free isotonic saline drops
   • Apply before feeds and sleep
   • Helps clear secretions and moisturize nasal passages

Important Safety Considerations:

• Avoid OTC cough and cold medications in infants:

  • The FDA and American Academy of Pediatrics strongly advise against using OTC decongestants and antihistamines in children under 6 years, especially infants under 1 year 1
  • Significant safety concerns exist with 43 reported fatalities in infants under 1 year associated with decongestants 1

• Avoid topical decongestants:

  • Topical vasoconstrictors should be used with extreme caution in infants under 1 year due to narrow margin between therapeutic and toxic doses 1
  • Risk of cardiovascular and CNS side effects is higher in infants 1

For Persistent Symptoms After First-line Management:

• Consider referral to specialist (pediatric allergist or ENT) for:
  • Evaluation of underlying causes
  • Consideration of additional diagnostic testing
  • Assessment for adenoid hypertrophy or other anatomical issues

Special Considerations

Allergic Rhinitis in Infants:

• Though less common in infants, allergic rhinitis can occur
• Look for signs such as:
  • Allergic shiners (dark circles under eyes)
  • Allergic crease (horizontal line across the nose)
  • Mouth breathing
  • Recurrent sneezing episodes

Recurrent Acute Bacterial Sinusitis:

• If symptoms suggest recurrent bacterial infections, evaluate for:
  • Immunoglobulin deficiencies
  • Anatomical abnormalities
  • Other predisposing conditions 1

Common Pitfalls to Avoid

1. Overuse of medications: Avoid prescribing antihistamines and decongestants in infants due to safety concerns and lack of proven efficacy 1

2. Missing underlying conditions: Persistent rhinitis in infants warrants evaluation for conditions like GERD, immunodeficiency, or anatomical abnormalities

3. Misdiagnosing normal nasal secretions: Infants normally have more nasal secretions than older children; distinguish pathological from physiological

4. Ignoring environmental factors: Failure to address environmental triggers (smoke exposure, allergens) can lead to persistent symptoms

5. Delayed specialist referral: If symptoms persist despite appropriate first-line measures, timely referral to a specialist is important

Remember that rhinitis in infants requires careful evaluation and management with a focus on safety. The evidence strongly cautions against using pharmacological treatments like decongestants and antihistamines in this vulnerable age group due to significant safety concerns.