What is the best medication for pediatric rhinosinusitis?

Best Medications for Pediatric Rhinosinusitis

For pediatric rhinosinusitis, herbal medicines such as BNO1016 tablets, Pelargonium sidoides drops, and Myrtol capsules have shown significant impact on symptoms without significant adverse events, making them the most appropriate first-line treatment options.1

Understanding Pediatric Rhinosinusitis

• Rhinosinusitis in children is a common condition that can be classified as viral, post-viral, or bacterial 1
• Acute post-viral rhinosinusitis is a self-limiting disease in most children 1
• Bacterial rhinosinusitis usually follows a viral infection or allergic rhinitis and carries potential for serious complications if left untreated 2

Evidence-Based Treatment Recommendations

First-Line Treatments

• Herbal medicines have shown significant impact on symptoms of acute post-viral rhinosinusitis without significant adverse events 1

  • BNO1016 tablets
  • Pelargonium sidoides drops
  • Myrtol (and other essential oil) capsules

• Bacterial lysates (specifically OM-85-BV) have shown benefit in shortening the duration of illness in children with post-viral rhinosinusitis 1

• Nasal saline irrigation may be beneficial on theoretical grounds, though evidence quality is low 1

  • High-volume saline rinsing may have larger effects on purulent rhinorrhea and post-nasal drip compared to low-volume rinsing 1

Medications NOT Recommended for Children

• Antibiotics are not recommended for children with acute post-viral rhinosinusitis as they are not associated with greater cure or significant improvement 1

  • Only consider antibiotics if bacterial infection is strongly suspected, with amoxicillin as first choice for children under 5 years 3

• Nasal corticosteroids - despite showing some effectiveness in reducing total symptom score, the EPOS2020 steering group cannot advise their use in children with acute post-viral rhinosinusitis due to very low quality evidence 1

• Antihistamines show no additive effect over standard treatment and are not recommended 1

• Over-the-counter cough and cold medications should not be used in children under 2 years due to lack of proven efficacy and potential for serious toxicity 3

  • Between 1969-2006, there were 54 fatalities associated with decongestants in children under 6 years 3
  • During the same period, 69 fatalities were associated with antihistamines in children under 6 years 3

• Decongestants (oral/nasal) - no studies have evaluated their effect on resolution or reduction of symptoms of post-viral rhinosinusitis in children 1

  • The American Academy of Pediatrics advises against using topical decongestants in children under 1 year due to narrow margin between therapeutic and toxic doses 3

Special Considerations for Bacterial Rhinosinusitis

If bacterial rhinosinusitis is strongly suspected or confirmed:

• Amoxicillin is the first-line therapy for uncomplicated acute bacterial rhinosinusitis in children 2, 4

  • Dosage: 45 mg/kg/day divided every 12 hours for mild infections; 90 mg/kg/day for more severe infections 5, 6

• For high-risk children (those in daycare or recently treated with antibiotics) who show no improvement with standard amoxicillin:

  • Amoxicillin-clavulanate at high dose (90 mg/kg/day of the amoxicillin component) 2
  • Dosing for children aged 3 months and older: 45 mg/kg/day every 12 hours for more severe infections 5

• For penicillin-allergic patients:

  • Second or third-generation oral cephalosporins (cefdinir, cefpodoxime, cefuroxime) 2
  • Clarithromycin as an alternative 2

When to Seek Medical Attention

• Immediate referral is required if any of these alarm symptoms are present 1:

  • Periorbital edema/erythema
  • Displaced globe
  • Double vision
  • Signs of sepsis
  • Reduced visual acuity
  • Neurological signs

• Parents should seek medical attention if the child exhibits 3:

  • Respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children)
  • Difficulty breathing, grunting, or cyanosis
  • Not feeding well or signs of dehydration
  • Persistent high fever or worsening symptoms

Follow-up Recommendations

• Reassess management if there is either worsening of symptoms or failure to improve within 72 hours of initial management 1
• Children being cared for at home should be reviewed if symptoms are deteriorating or not improving after 48 hours 3

Important Caveats

• Chest physiotherapy is not beneficial and should not be performed in children with respiratory infections 3
• Environmental factors like tobacco smoke exposure should be addressed as they can exacerbate respiratory symptoms 3
• For persistent cough beyond 4 weeks, further evaluation may be needed to identify underlying causes 3