What are the recommended treatments for nasal congestion in children?

Treatment of Nasal Congestion in Children

Saline nasal irrigation is the first-line treatment for nasal congestion in children of all ages, as it is both safe and effective with minimal side effects. 1, 2, 3, 4

First-Line Treatments

Saline Nasal Irrigation

• For infants and young children:

  • Use isotonic saline drops or spray followed by gentle aspiration with a nasal aspirator 2, 4
  • Apply 1-2 drops per nostril, wait 1-2 minutes, then use bulb syringe or nasal aspirator
  • Can be used as frequently as needed without risk of side effects
  • Particularly important for infants under 2 months who are obligate nasal breathers 2

• For older children:

  • Isotonic or hypertonic saline irrigation using a squeeze bottle or neti pot
  • Studies show 86% of children can tolerate nasal saline irrigation when properly instructed 3
  • 84% of parents report improvement in nasal symptoms with consistent use 3

Second-Line Treatments

Intranasal Corticosteroids

• Most effective medication for treating allergic rhinitis and nasal congestion 1, 5
• Safe for children when used at recommended doses 1
• Options include fluticasone, mometasone, and budesonide
• Direct spray away from nasal septum to minimize irritation 1
• Onset of action between 3-12 hours; full benefit may take days 1
• Can be used for both allergic and non-allergic rhinitis, including vasomotor rhinitis 1

Antihistamines

• Second-generation (non-sedating) antihistamines only:

  • Cetirizine, loratadine, fexofenadine, desloratadine
  • Well-tolerated with good safety profiles in children 1
  • Modest effect on nasal congestion but helpful for other rhinitis symptoms 5

• Avoid first-generation antihistamines:

  • Not recommended due to sedative properties that can worsen learning problems 5
  • Studies show minimal efficacy for cough and cold symptoms in children 1

Third-Line/Limited Use Treatments

Decongestants

• Topical decongestants (e.g., oxymetazoline):

  • Use only for short-term relief (maximum 3 consecutive days) 1, 6
  • Risk of rhinitis medicamentosa (rebound congestion) with prolonged use 1
  • Not recommended for regular or prolonged use in children 1

• Oral decongestants (e.g., pseudoephedrine):

  • Should be avoided in children under 6 years due to risk of serious adverse effects 1, 6
  • For children over 6 years, use with caution and only for short periods 1
  • Side effects include insomnia, irritability, and rarely more serious cardiovascular effects 1
  • FDA advisory committees have recommended against OTC cough and cold medications in young children 1

Treatment Algorithm Based on Age and Severity

For Infants (0-2 years):

1. Saline nasal drops followed by gentle aspiration
2. Adequate hydration and humidification
3. Consider consulting pediatrician if symptoms persist beyond 10 days

For Children (2-6 years):

1. Saline nasal irrigation/spray
2. For allergic rhinitis: Consider intranasal corticosteroids under medical supervision
3. Second-generation antihistamines for allergic symptoms
4. Avoid oral decongestants completely

For Children (6+ years):

1. Saline nasal irrigation
2. Intranasal corticosteroids for moderate-severe or persistent symptoms
3. Second-generation antihistamines for allergic symptoms
4. Short-term use of topical decongestants (≤3 days) for severe congestion only
5. Oral decongestants only in select cases and for brief periods

Important Considerations

• Neonates and young infants are obligate nasal breathers until at least 2 months of age, making nasal congestion potentially serious 2
• Antimicrobial therapy should be restricted to children with sinusitis symptoms that don't improve after 10 days 1
• Combination therapy of intranasal corticosteroid with brief oxymetazoline use may provide enhanced relief in severe cases 6
• Regular monitoring of the nasal septum is recommended when using intranasal corticosteroids to check for mucosal erosions 1

Common Pitfalls to Avoid

• Using topical decongestants for more than 3 days, which can lead to rebound congestion
• Prescribing first-generation antihistamines, which can cause sedation and impair learning
• Overlooking the importance of proper technique when teaching families about nasal irrigation
• Assuming children won't tolerate nasal saline irrigation (studies show 86% can tolerate it) 3
• Using oral decongestants in children under 6 years or in those with certain medical conditions

When properly implemented, these treatment approaches can significantly improve nasal congestion symptoms in children while minimizing risks of adverse effects.