What is the treatment for allergic rhinitis in a child?

Treatment of Allergic Rhinitis in Children

Intranasal corticosteroids are the most effective first-line treatment for allergic rhinitis in children, superior to oral antihistamines and leukotriene receptor antagonists for controlling all nasal symptoms, particularly nasal congestion. 1

First-Line Treatment: Intranasal Corticosteroids

Intranasal corticosteroids should be the initial therapy for most children with allergic rhinitis, as they are more effective than antihistamines, leukotriene antagonists, or their combination. 1

Age-Specific Recommendations:

• Children ≥4 years: Fluticasone propionate nasal spray is FDA-approved and effective 2
• Children ≥2 years: Multiple intranasal corticosteroids (fluticasone propionate, mometasone furoate, budesonide) have demonstrated safety and efficacy 1
• Onset of action: 3-12 hours, with maximal benefit after continuous use 1

Safety Profile in Children:

• No clinically significant systemic effects at recommended doses, including no consistent effects on growth, HPA axis, bone density, or ocular pressure 1
• Studies with fluticasone propionate, mometasone furoate, and budesonide showed no growth suppression at recommended doses 1
• Growth suppression only reported with beclomethasone dipropionate exceeding recommended doses or in toddlers 1

Second-Line Treatment: Second-Generation Antihistamines

When intranasal corticosteroids are not tolerated or parents refuse them, second-generation antihistamines (cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine) are safe alternatives with excellent safety profiles in young children. 1, 3

Age-Specific Antihistamine Options:

• Cetirizine: Approved for children as young as 6 months for perennial allergic rhinitis 1
• Levocetirizine: Provides rapid onset and long duration of antihistaminic effect 3
• Montelukast (leukotriene receptor antagonist): Approved for seasonal allergic rhinitis in children ≥2 years and perennial allergic rhinitis in children ≥6 months 1, 4

Important Safety Caveat:

Avoid first-generation antihistamines and OTC cough/cold medications in children <6 years due to serious safety concerns, including 69 fatalities associated with antihistamines between 1969-2006, with inadequate efficacy data in controlled trials. 1

Combination Therapy for Moderate-to-Severe Disease

For adolescents ≥12 years with moderate-to-severe symptoms, combination intranasal corticosteroid plus intranasal antihistamine (fluticasone propionate + azelastine) provides superior symptom control compared to either agent alone, with reductions in total nasal symptom scores of 5.31-5.7 out of 24 versus 3.84-5.1 for intranasal corticosteroid alone. 1

Additional Treatment Options

Montelukast:

• Less effective than intranasal corticosteroids but may be preferred when parents are "steroid-phobic" or when treating concurrent mild persistent asthma 1
• Particularly useful for combined upper and lower airway disease 1
• No dosage adjustment needed in children; well-tolerated 4

Oral Decongestants:

• Use with extreme caution in children <6 years; associated with agitated psychosis, ataxia, hallucinations, and death in infants and young children 1
• Generally well-tolerated in children >6 years at appropriate doses 1

Topical Decongestants:

• Not recommended for continuous use due to risk of rhinitis medicamentosa (can develop within 3 days to 6 weeks) 1
• No effect on itching, sneezing, or nasal secretion 1

Saline Irrigation:

• Modest benefit as sole or adjunctive therapy, safe and well-tolerated 1
• Isotonic and hypertonic solutions reduce symptoms and improve quality of life 1

Treatment Algorithm by Severity

Mild Intermittent Symptoms (<4 days/week or <4 weeks/year):

1. Second-generation oral antihistamine (cetirizine, loratadine, fexofenadine) 5
2. OR intranasal antihistamine (azelastine, olopatadine) 5

Moderate-to-Severe or Persistent Symptoms (>4 days/week and >4 weeks/year):

1. Intranasal corticosteroid as monotherapy (fluticasone, mometasone, budesonide) 1, 5
2. Add intranasal antihistamine if inadequate response (for adolescents ≥12 years) 1
3. Consider montelukast if concurrent asthma or parental steroid concerns 1

Long-Term Considerations

Early treatment with cetirizine in children sensitized to grass pollen or house dust mites may reduce asthma development by 50%, though this prophylactic effect requires further study. 1

Allergen immunotherapy (subcutaneous or sublingual) may reduce asthma development in children with allergic rhinitis and represents the only disease-modifying treatment option. 1