What is the recommended intranasal antihistamine (INH) for a 7-year-old child with allergic rhinitis?

Intranasal Antihistamines for Allergic Rhinitis in a 7-Year-Old Child

For a 7-year-old child with allergic rhinitis, either azelastine or olopatadine intranasal antihistamine is recommended, with azelastine being the preferred option due to its approval for both seasonal and perennial allergic rhinitis. 1, 2

Available Options for 7-Year-Olds

For children aged 7, two intranasal antihistamines are FDA-approved:

1. Azelastine (Astelin/Astepro)

   • Formulations:
     • 0.1% solution (137 μg per spray) - Approved for seasonal AR and vasomotor rhinitis
     • 0.15% solution (205.5 μg per spray) - Approved for both seasonal AND perennial AR
   • Dosing: 1 spray per nostril twice daily for ages 6-11 years 1, 3

2. Olopatadine (Patanase)

   • 0.6% solution (665 μg per spray)
   • Approved only for seasonal AR
   • Dosing: 1 spray per nostril twice daily for ages 6-11 years 1

Advantages of Intranasal Antihistamines

• Rapid onset of action (15 minutes) 4
• More effective for nasal congestion than oral antihistamines 1, 2
• Show benefit even in patients who fail oral antihistamine treatment 1
• Can be used as first-line or second-line therapy 1
• Targeted delivery to nasal tissues while limiting systemic effects 1

Considerations for Pediatric Use

• Azelastine has demonstrated efficacy and safety in children as young as 5 years old 5
• Intranasal antihistamines are particularly useful for:
  • Episodic nasal symptoms
  • Pretreatment prior to allergen exposure 1
  • Children with prominent nasal congestion 2

Potential Side Effects to Monitor

• Bitter taste (most common complaint)
• Epistaxis (nosebleeds)
• Somnolence (drowsiness) - though recent studies show rates of only 0.4-3%, similar to placebo 1
• Headache 1

Administration Tips

1. Keep head tilted downward when spraying
2. Alternate sprays between nostrils
3. Breathe gently to avoid medication going into throat (which causes bitter taste) 3
4. If taste aversion occurs with one formulation, consider trying the other intranasal antihistamine 1

Important Precautions

• Follow-up with a clinician is advised to assess response and side effects 1
• If somnolence occurs, consider switching to an intranasal corticosteroid
• The twice-daily dosing requirement may affect adherence in some children 1
• Caution parents about avoiding spraying in the eyes 3

Alternative Options

If intranasal antihistamines are not tolerated or ineffective, intranasal corticosteroids are another excellent option for children with allergic rhinitis, with mometasone furoate (Nasonex) approved for children as young as 2 years 1, 2, 6.