What are the treatment options for allergic rhinitis in children?

Treatment Options for Allergic Rhinitis in Children

Intranasal corticosteroids are the most effective first-line medication for treating allergic rhinitis in children, particularly for moderate to severe symptoms or when nasal congestion is predominant. 1

First-Line Treatment Options

Intranasal Corticosteroids

• Most effective medication class for controlling all symptoms of allergic rhinitis, including nasal congestion, sneezing, itching, and rhinorrhea 2, 1
• Preferred options for children:
  • Fluticasone propionate (Flonase): FDA approved for children ≥4 years 1
  • Mometasone furoate (Nasonex): FDA approved for children ≥2 years 1
• Safety profile: Studies in children have shown no significant effect on growth with recommended doses of fluticasone propionate, mometasone furoate, and budesonide 2
• Common side effects: Epistaxis (nose bleeds), headache, nasal irritation 1
• Administration technique: Direct spray away from nasal septum to minimize bleeding 1

Second-Generation Antihistamines

• Effective for mild symptoms or when sneezing and itching are predominant 1
• Options with established safety in young children:
  • Cetirizine, desloratadine, fexofenadine, levocetirizine, and loratadine 2, 3
  • Available in liquid formulations or oral disintegrating tablets for ease of administration 3
• Well-tolerated with minimal sedation compared to first-generation antihistamines 3
• Loratadine syrup has been shown to be effective and safe in children 3-12 years 4
• Cetirizine may be more effective than loratadine for symptom relief in young children 5

Treatment Algorithm Based on Symptom Severity

Mild Intermittent Symptoms

• Second-generation oral antihistamine as needed 1
• Avoid first-generation antihistamines due to sedation and anticholinergic effects 1

Moderate-Severe or Persistent Symptoms

1. Intranasal corticosteroid as first-line treatment 1
2. For inadequate response, consider:
   • Adding a second-generation antihistamine 1
   • Combination therapy (intranasal corticosteroid + intranasal antihistamine) 1

Predominant Nasal Congestion

• Intranasal corticosteroid is most effective 1, 6
• Avoid prolonged use of topical decongestants due to risk of rhinitis medicamentosa (rebound congestion) 2

Predominant Sneezing/Itching

• Second-generation antihistamine may be used, though intranasal corticosteroids are still more effective overall 1

Additional Treatment Options

Leukotriene Receptor Antagonists (LTRAs)

• Montelukast is approved for:
  • Perennial allergic rhinitis in children ≥6 months 2, 7
  • Seasonal allergic rhinitis in children ≥2 years 2, 7
• Less effective than intranasal corticosteroids but may be considered when:
  • Patient has coexisting asthma 2
  • Parents are concerned about steroid use 2
• Safety profile is well-established in children 3

Saline Nasal Irrigation

• Beneficial as adjunctive treatment for symptoms of rhinorrhea 2
• Safe for all age groups 2

Important Cautions and Considerations

Safety Concerns in Young Children

• OTC cough and cold medications containing decongestants and first-generation antihistamines should be avoided in children under 6 years due to safety concerns 2
• Between 1969-2006, there were 54 fatalities associated with decongestants and 69 fatalities associated with first-generation antihistamines in children 2

Comorbidities

• Allergic rhinitis in children is associated with otitis media with effusion, sinusitis, and asthma 1
• Proper treatment may improve control of these conditions 1

When to Consider Referral

• Persistent symptoms requiring continuous medication 1
• Inadequate response to pharmacologic therapy 1

By following this evidence-based approach to treating allergic rhinitis in children, clinicians can effectively manage symptoms while minimizing risks, ultimately improving quality of life and preventing complications.