What are the key questions to ask in the history of a 31-month-old child born at 29 weeks, prescribed nasal saline and fluticasone (fluticasone), who is here for follow-up?

Key History Questions for 31-Month-Old Former Premature Infant on Nasal Saline and Fluticasone

Treatment Efficacy and Symptom Assessment

Assess whether the current fluticasone regimen is controlling symptoms adequately, as intranasal corticosteroids require regular use for optimal effect and may take days to weeks to reach full benefit. 1, 2

• Nasal symptoms: Ask specifically about nasal congestion, rhinorrhea (clear vs. colored discharge), sneezing frequency, and nasal itching over the past 2 weeks 3
• Sleep quality: Inquire about mouth breathing during sleep, snoring, apnea episodes, and nighttime cough, as these indicate inadequate symptom control 3, 4
• Daytime symptoms: Ask about chronic throat clearing, sniffing, snorting, halitosis, and gaping mouth during the day 3
• Behavioral changes: Document irritability, poor appetite, or general sense of not feeling well, which are common manifestations in young children with poorly controlled rhinitis 3

Medication Adherence and Administration Technique

Verify proper administration technique, as improper use significantly reduces efficacy and increases local side effects like epistaxis. 2, 5

• Dosing frequency: Confirm the child is receiving fluticasone daily (not as-needed), as intranasal corticosteroids are maintenance therapy requiring regular use 2
• Administration technique: Ask if the parent primes the bottle before use, shakes it prior to spraying, has the child blow their nose first, keeps the head upright, and directs the spray away from the nasal septum 2, 5
• Timing of nasal saline: Confirm nasal saline irrigations are performed before administering fluticasone spray, not after 2
• Missed doses: Document frequency of missed doses over the past 2 weeks

Adverse Effects Monitoring

Screen for common adverse effects, particularly epistaxis, which occurs in 4-20% of patients on long-term intranasal corticosteroids. 2, 5

• Epistaxis: Ask about nosebleeds, their frequency, severity, and whether they occur after medication administration 5
• Nasal irritation: Inquire about nasal burning, stinging, or discomfort with spray use 5
• Systemic effects: Ask about unusual bruising, mood changes, or increased infections, though systemic effects are rare at recommended doses 5
• Taste disturbances: Document any complaints of bad taste, though this is more common with intranasal antihistamines 3

Growth and Development Assessment

Document growth parameters, as intranasal corticosteroids may cause growth velocity reduction in susceptible pediatric patients, though studies show no effect at recommended doses of fluticasone. 1, 2, 5

• Height and weight: Measure and plot on growth chart; compare to previous measurements 5
• Developmental milestones: Assess age-appropriate developmental progress
• Growth concerns: Ask parents if they have noticed any changes in growth pattern

Prematurity-Related Complications

Evaluate for complications related to prematurity at 29 weeks, particularly chronic lung disease and reactive airway disease, which frequently coexist with rhinitis symptoms. 3

• Respiratory symptoms: Ask about wheezing, cough, chest tightness, or increased work of breathing 3
• Exercise tolerance: Document activity level and whether symptoms worsen with exertion
• Oxygen requirement history: Confirm if the child required supplemental oxygen after birth and duration of use
• Recurrent infections: Ask about frequency of upper respiratory infections, otitis media, or sinusitis 3

Trigger Identification and Environmental History

Identify specific triggers to determine if symptoms are allergic, nonallergic, or mixed rhinitis, as this guides treatment optimization. 3

• Seasonality: Ask if symptoms are worse during specific seasons or perennial 3
• Environmental exposures: Document exposure to tobacco smoke, pets, dust, mold, strong odors (perfumes, cleaning products), and daycare attendance 3
• Family history: Confirm family history of allergic rhinitis, asthma, or atopic dermatitis 3
• Symptom triggers: Ask what makes symptoms better or worse (cold air, indoor vs. outdoor environments) 3

Complications and Comorbidities

Screen for complications such as sinusitis or otitis media, and comorbid conditions like asthma, which occur frequently with rhinitis. 3

• Sinus symptoms: Ask about facial pain/pressure, purulent nasal discharge, or fever suggesting acute rhinosinusitis 6
• Ear symptoms: Document ear pain, hearing difficulties, or ear fullness suggesting otitis media 3
• Eye symptoms: Ask about eye itching, redness, or tearing, which suggest allergic component 3
• Lower airway symptoms: Inquire about persistent cough, wheezing, or shortness of breath 3

Treatment Response Timeline

Determine if adequate treatment duration has elapsed, as fluticasone may show improvement within 12 hours but requires days to weeks for full benefit. 1, 5

• Symptom onset: Clarify when current symptoms began relative to starting fluticasone
• Improvement timeline: Ask when parents first noticed improvement (if any) after starting treatment 5
• Previous treatments: Document what medications were tried before fluticasone and their effectiveness 3