Are nasal steroids (NS) helpful in infants with upper respiratory tract infections (URTI)?

Nasal Steroids Are Not Recommended for Infants with URTI

Nasal corticosteroids should not be used in infants with upper respiratory tract infections, as they lack evidence of benefit in this population and URTIs are self-limiting viral illnesses that resolve without intervention. 1

Why Nasal Steroids Are Not Appropriate

Lack of Evidence in Infants

• The European Position Paper on Rhinosinusitis (EPOS 2020) found very low quality evidence for nasal corticosteroids in children with post-viral acute rhinosinusitis and explicitly states they cannot advise on their use in children. 1
• The only pediatric studies evaluating nasal steroids were conducted in older children (ages 2-14 years) with post-viral rhinosinusitis, not typical URTIs in infants, and these studies added steroids on top of antibiotics (which themselves are ineffective for viral infections). 1
• Even in adults with post-viral rhinosinusitis, nasal corticosteroids showed only a small effect on symptom reduction with no improvement in quality of life. 1

URTIs Are Self-Limiting

• Acute upper respiratory tract infections in infants are predominantly viral and self-resolve within 7-10 days without treatment. 1, 2
• The natural history of these infections does not warrant pharmacologic intervention with steroids. 1

Strong Recommendations Against Steroids in Related Conditions

• The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation against using intranasal or systemic steroids for otitis media with effusion (a common complication of URTIs), citing a preponderance of harm over benefit. 1
• This recommendation is based on Grade A evidence from systematic reviews of well-designed randomized controlled trials. 1

What Actually Helps Infants with URTI

Saline Nasal Irrigation: The Evidence-Based Choice

• Nasal saline irrigation is the only intervention with demonstrated benefit for infants with URTIs, showing improvement in rhinological symptoms and reduction in antibiotic prescriptions. 3
• Saline lavage followed by gentle aspiration is safe, effective, and well-tolerated in neonates and infants, who are obligate nasal breathers and cannot clear secretions independently. 4
• High-volume saline rinsing has larger effects on purulent rhinorrhea and post-nasal drip compared to low-volume rinsing. 5

What to Avoid

• Antibiotics are not indicated for viral URTIs and should not be prescribed routinely. 1, 5, 2
• Antihistamines and decongestants show no benefit and are not recommended, with the American Academy of Pediatrics specifically advising against topical decongestants in children under 1 year due to narrow therapeutic windows and cardiovascular/CNS risks. 1, 5
• Over-the-counter cough and cold medications should not be used in children under 2 years due to lack of efficacy and potential for serious toxicity. 5

When to Reassess or Refer

Red Flags Requiring Immediate Attention

• Respiratory rate >70 breaths/min in infants or persistent high fever despite supportive care warrant immediate medical evaluation. 5
• Displaced globe, difficulty breathing, or other alarm symptoms require immediate referral. 5

Follow-Up Timing

• Reassess if symptoms worsen at any time or fail to improve within 48-72 hours of initial management. 5
• If symptoms persist beyond 10 days without improvement, consider bacterial rhinosinusitis (though this is uncommon in infants). 2

Clinical Bottom Line

For infants with uncomplicated URTIs, supportive care with saline nasal irrigation is the evidence-based approach. Nasal steroids have no role in this population due to lack of efficacy data, the self-limiting nature of viral URTIs, and the availability of safer, proven alternatives. 1, 3, 4