What are the guidelines for using steroid nasal sprays, such as fluticasone propionate (fluticasone), in pediatric patients with allergic rhinitis?

Guidelines for Using Steroid Nasal Sprays in Pediatric Patients with Allergic Rhinitis

Intranasal corticosteroids like fluticasone propionate are the first-line therapy for pediatric allergic rhinitis, with age-specific dosing recommendations of 1 spray per nostril daily for children 4-11 years and 2 sprays per nostril daily for those 12 years and older. 1, 2, 3

Age-Specific Recommendations

• Fluticasone propionate (Flonase) is FDA-approved for children ≥4 years of age at a dosage of 1 spray per nostril (50 μg per spray) daily 1, 2
• For children 2-3 years, fluticasone furoate (Veramyst) is approved at 1-2 sprays per nostril (27.5 μg per spray) daily 2
• Mometasone furoate (Nasonex) is approved for children as young as 2 years at a dosage of 1 spray per nostril daily 1
• Children aged 4-11 years should use intranasal steroids for no longer than 2 months per year without consulting a physician due to potential concerns about growth effects 3
• Adolescents (≥12 years) and adults should consult a physician if using for longer than 6 months continuously 3

Proper Administration Technique

• Prime the bottle before first use 1
• Shake the bottle prior to spraying to decrease viscosity and allow creation of fine mist 1
• Have the child blow their nose prior to using the spray 1
• Keep the head in an upright position during administration 1
• Hold the spray in the opposite hand in relation to the nostril being treated (contralateral technique) to reduce risk of epistaxis 1
• Instruct the child to breathe in gently during spraying 1
• Do not close the opposite nostril during administration 1
• If nasal saline irrigations are recommended, perform them prior to administering the steroid spray 1

Efficacy and Safety

• Intranasal corticosteroids are the most effective pharmacologic treatment for allergic rhinitis in children 4
• Fluticasone propionate 100 μg daily has been shown to be as effective as 200 μg daily in children 4-11 years old with seasonal allergic rhinitis 5
• Studies show that fluticasone propionate is effective for perennial allergic rhinitis in children 5-11 years old at a dose of 100 μg daily 6
• Morning plasma cortisol concentrations remain similar between fluticasone propionate and placebo groups in pediatric studies, suggesting minimal impact on the hypothalamic-pituitary-adrenal axis 5, 6
• Fluticasone propionate has minimal systemic activity because the swallowed portion is not absorbed from the gut, making its therapeutic ratio very favorable 7

Common Side Effects and Contraindications

• Common side effects include headache, pharyngitis, epistaxis, nasal burning or irritation, nausea, vomiting, asthma symptoms, and cough 1, 2
• Contraindicated in patients with history of hypersensitivity to fluticasone or its components 2, 3
• The contralateral spray technique (using opposite hand to spray) reduces epistaxis risk by four times compared to ipsilateral technique 1

Patient Education

• Teach proper administration technique using visual aids or demonstrations, as studies show significantly higher competency in children taught using animated cartoons 1
• Inform patients/parents that onset of action may be delayed (12 hours) with maximal efficacy reached in days to weeks 1
• Advise regular use rather than as-needed approach to maintain symptom control 1
• Do not share nasal spray bottles between patients to prevent spread of germs 3
• Once-daily dosing of fluticasone propionate is as effective as twice-daily dosing, which may improve adherence 8