Prednisolone is NOT Appropriate for This Clinical Presentation
Prednisolone should not be prescribed for this 13-year-old with uncomplicated allergic rhinitis, frontal sinus tenderness, and middle ear effusion without purulent drainage. The clinical picture does not meet criteria for systemic corticosteroid use, and intranasal corticosteroids are the evidence-based first-line treatment for this presentation.
Why Systemic Corticosteroids Are Inappropriate Here
The FDA label for prednisolone indicates it is approved for "severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment" 1—this patient has not failed first-line therapy and does not have severe/incapacitating disease.
Guidelines explicitly reserve short courses of oral corticosteroids (5-7 days) only for "very severe or intractable symptoms that significantly impact quality of life" 2, which is not described in this case.
Long-term or repeated systemic corticosteroids are contraindicated for allergic rhinitis management 2, 3
What Should Be Prescribed Instead
Intranasal corticosteroids are the definitive first-line treatment for this patient:
The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends intranasal corticosteroids as first-line monotherapy for allergic rhinitis, as they are the most effective medication class for controlling all nasal symptoms including congestion, rhinorrhea, sneezing, and itching 4, 2
For a 13-year-old, appropriate options include:
Symptom relief begins within 12 hours, with maximal efficacy in days to weeks of regular use 3
Addressing the Sinus Tenderness and Ear Fluid
The frontal sinus tenderness without purulent drainage does not indicate bacterial sinusitis requiring antibiotics—you correctly recognized this 5
Intranasal corticosteroids are highly effective for sinus inflammation associated with allergic rhinitis by decreasing mucosal edema, promoting drainage, and reducing inflammation 4, 5
The middle ear fluid with slight erythema likely represents eustachian tube dysfunction secondary to allergic inflammation, which will improve with intranasal corticosteroid treatment 6
If Additional Symptom Control Is Needed
For moderate-to-severe symptoms not responding to intranasal corticosteroid monotherapy after 2 weeks, add an intranasal antihistamine (azelastine) rather than systemic therapy 2, 6
Second-generation oral antihistamines (cetirizine, loratadine, fexofenadine) can be added for prominent sneezing and itching, though evidence shows minimal additional benefit when combined with intranasal corticosteroids 4
Critical Safety Considerations in Pediatrics
Intranasal corticosteroids at recommended doses show no effect on growth, HPA axis suppression, or other systemic effects in children 4, 3, 7
Systemic corticosteroids like prednisolone carry risks of growth suppression, adrenal suppression, and other adverse effects that are completely unnecessary for this clinical scenario 1, 7
The prednisolone dose prescribed (15 mg daily for 5 days) exposes this child to systemic corticosteroid effects without addressing the underlying allergic inflammation as effectively as topical therapy 4, 8
Common Pitfall Being Made Here
The major error is using systemic corticosteroids for routine allergic rhinitis symptoms. This represents overtreatment with a medication that has greater adverse effect potential and is less effective than the guideline-recommended first-line therapy 4, 2. The presence of sinus tenderness and ear fluid does not change this recommendation—these findings are common complications of allergic rhinitis that respond well to intranasal corticosteroids 5.