What is the first-line treatment for allergic rhinitis in children?

From the Guidelines

The first-line treatment for allergic rhinitis in children is intranasal corticosteroids (INCSs) such as fluticasone propionate or mometasone furoate, typically dosed as 1-2 sprays in each nostril once daily. These medications effectively reduce nasal congestion, sneezing, itching, and rhinorrhea by decreasing inflammation in the nasal passages. For children 2-11 years old, lower doses are recommended (usually 1 spray per nostril), while adolescents can use adult dosing. Second-generation oral antihistamines like cetirizine (5-10mg daily), loratadine (5-10mg daily), or fexofenadine (30-60mg twice daily for ages 2-11,60-180mg daily for older children) can be used as alternatives or adjuncts, particularly for predominant sneezing and itching symptoms. These newer antihistamines are preferred as they cause less sedation than first-generation options. Environmental control measures should also be implemented, including avoiding identified allergens, using air purifiers, frequent washing of bedding in hot water, and keeping windows closed during high pollen seasons. INCSs are preferred as first-line therapy because they target the underlying inflammatory process rather than just blocking histamine effects, providing more comprehensive symptom relief with minimal systemic absorption and side effects, as supported by the most recent guidelines from the Joint Task Force on Practice Parameters 1.

Some key points to consider when treating allergic rhinitis in children include:

• The use of INCSs as first-line therapy due to their effectiveness in reducing nasal congestion, sneezing, itching, and rhinorrhea
• The preference for second-generation oral antihistamines over first-generation options due to their reduced sedative effects
• The importance of environmental control measures in managing allergic rhinitis symptoms
• The consideration of combination therapy with an intranasal antihistamine and an intranasal corticosteroid for moderate to severe seasonal allergic rhinitis, as suggested by recent studies 1.

Overall, the treatment of allergic rhinitis in children should prioritize the use of INCSs as first-line therapy, with consideration of alternative or adjunctive treatments based on individual patient needs and symptom severity.

From the Research

First Line Treatment for Allergic Rhinitis in Children

• The first line treatment for mild intermittent or mild persistent allergic rhinitis in children may include a second-generation H1 antihistamine (eg, cetirizine, fexofenadine, desloratadine, loratadine) or an intranasal antihistamine (eg, azelastine, olopatadine) 2.
• For moderate to severe allergic rhinitis in children, a nasal steroid is the treatment of choice 3.
• Intranasal corticosteroids, such as fluticasone propionate, are considered first-line treatment for moderate to severe allergic rhinitis 4, 2.
• The treatment should be selected based on the severity and frequency of symptoms and patient preference 2.

Treatment Options

• Second-generation H1 antihistamines (eg, cetirizine, fexofenadine, desloratadine, loratadine) are effective for mild intermittent or mild persistent allergic rhinitis 2.
• Intranasal antihistamines (eg, azelastine, olopatadine) can be used as an alternative to oral antihistamines 2.
• Intranasal corticosteroids (eg, fluticasone, triamcinolone, budesonide, mometasone) are effective for moderate to severe allergic rhinitis 4, 2, 5.

Combination Therapy

• Combination therapy of an intranasal corticosteroid and an oral antihistamine may be considered for patients with moderate to severe allergic rhinitis who do not respond to monotherapy 4, 5.
• The combination of fluticasone propionate and loratadine was found to have efficacy comparable to that of intranasal corticosteroid alone 4, 5.