What are the treatment guidelines for pediatric patients with allergic rhinitis?

Treatment Guidelines for Pediatric Allergic Rhinitis

First-Line Therapy: Intranasal Corticosteroids

Intranasal corticosteroids are the most effective first-line treatment for pediatric allergic rhinitis, providing superior control of all four major symptoms (nasal congestion, rhinorrhea, sneezing, and itching) compared to all other medication classes. 1, 2, 3

Age-Specific Intranasal Corticosteroid Recommendations

• For children ≥4 years: Fluticasone propionate 100 mcg once daily or mometasone furoate are recommended as first-line therapy, with onset of therapeutic effect between 3-12 hours 3, 4, 5
• For children 2-3 years: Second-generation oral antihistamines (cetirizine or loratadine) should be used as first-line treatment instead, as intranasal corticosteroids have limited safety data in this age group 3
• For infants 6-23 months: Montelukast is the only FDA-approved medication for perennial allergic rhinitis in this age group, though it is less effective than intranasal corticosteroids 3, 6

Dosing Details for Intranasal Corticosteroids

• Fluticasone propionate 100 mcg once daily is as effective as 200 mcg once daily in children aged 4-11 years, making the lower dose preferable 4, 5
• Once-daily morning administration improves adherence and has demonstrated no interference with the hypothalamic-pituitary-adrenal axis in children 4, 5
• Treatment should be continued for at least 2-4 weeks for full therapeutic benefit, as symptom improvement is progressive 7, 5

Second-Line Therapy: Oral Antihistamines

Second-generation oral antihistamines (cetirizine, loratadine) are recommended as second-line therapy or as first-line for children 2-3 years old, providing relief of sneezing, rhinorrhea, and itching but less effective for nasal congestion. 1, 3

Age-Specific Antihistamine Dosing

• Children ≥6 years: Cetirizine 10 mg once daily or loratadine 10 mg once daily 8
• Children 2-5 years: Cetirizine 5 mg once daily 8, 3
• Infants 6-11 months: Cetirizine 0.25 mg/kg twice daily (off-label for allergic rhinitis) 3

Key Antihistamine Considerations

• Cetirizine has rapid onset of action within 1 hour, making it advantageous when quick symptom control is needed 8
• Cetirizine may cause mild drowsiness at 10 mg doses, particularly in patients with low body mass; consider morning dosing if this occurs 8, 3
• Dose reduction by 50% is required in moderate renal impairment; avoid in severe renal impairment 8

Third-Line Therapy: Leukotriene Receptor Antagonists

Montelukast is less effective than intranasal corticosteroids but offers the advantage of treating both upper and lower airway symptoms when asthma coexists. 1, 3

Montelukast Dosing by Age

• Children 6-14 years: 5 mg chewable tablet once daily 6
• Children 2-5 years: 4 mg chewable tablet or oral granules once daily 6
• Infants 6-23 months: 4 mg oral granules once daily 6

When to Consider Montelukast

• Particularly useful when parents refuse intranasal corticosteroids due to steroid concerns 3
• Appropriate for children with both allergic rhinitis and asthma, as it treats both conditions 1
• Can be combined with a second-generation antihistamine for improved symptom control when intranasal corticosteroids are refused 3

Combination Therapy Approach

Adding a second-generation oral antihistamine to an intranasal corticosteroid may be considered if symptoms persist after 2-4 weeks of monotherapy, though evidence for additional benefit is limited. 2, 3

• The American College of Physicians found that adding an oral antihistamine to an intranasal corticosteroid has not been proven to provide additional benefit for nasal symptom control 2
• For children ≥12 years with inadequate response to intranasal corticosteroid alone, adding intranasal antihistamine (azelastine) as a separate product may be considered, though evidence in younger children is lacking 8
• Montelukast plus a second-generation antihistamine provides reasonable symptom control as an alternative when intranasal corticosteroids are refused 3

Critical Safety Warnings: What to Avoid

Never use OTC cough and cold combination products in children under 6 years due to lack of efficacy and significant safety concerns, including 54 fatalities associated with decongestants and 69 with antihistamines between 1969-2006. 3

Specific Medications to Avoid

• First-generation antihistamines (diphenhydramine, chlorpheniramine) should never be used in children under 6 years due to significant safety concerns including sedation and anticholinergic effects 3
• Oral decongestants should not be used in children under 6 years except with extreme caution, as they have been associated with agitated psychosis, ataxia, hallucinations, and death in infants and young children 3
• Topical decongestants should be avoided for continuous use due to risk of rhinitis medicamentosa, which may develop within 3 days 3
• Oral corticosteroids should be reserved only for severe, intractable cases unresponsive to other treatments, not for routine management 2
• Intramuscular corticosteroids (Kenalog) should not be used for routine management of allergic rhinitis 2

Adjunctive Therapies

Saline nasal irrigation is beneficial as adjunctive treatment, though less effective than intranasal corticosteroids when used alone. 1

• Isotonic and hypertonic saline solutions provide modest benefit for reducing symptoms and improving quality of life 1
• Can be used safely in all age groups as monotherapy or combined with other treatments 1

Immunotherapy Considerations

Allergen-specific immunotherapy (subcutaneous or sublingual) should be considered for children with inadequate response to pharmacotherapy, particularly those with dust mite or pollen allergies. 8

• Evidence suggests immunotherapy may prevent development of asthma and new allergen sensitizations in children with allergic rhinitis 1, 8
• Typically not considered in very young children due to communication difficulties regarding systemic reactions 8
• Most appropriate for children who have failed optimal pharmacotherapy or require prolonged medication use 8

Comorbidity Management

Always assess for asthma in children with allergic rhinitis, as 40% have coexisting asthma, and treatment of rhinitis improves asthma control. 1

• Inquiry about difficulty breathing, cough, wheezing, and exercise tolerance should occur at every visit 1
• Spirometry should be performed whenever asthma is suspected 1
• Leukotriene receptor antagonists are particularly appropriate for patients with both conditions 1
• Treatment of allergic rhinitis with intranasal corticosteroids reduces bronchial hyperreactivity and improves asthma control 1

Other Associated Conditions to Evaluate

• Atopic dermatitis: 57.6% of children with early childhood eczema develop allergic rhinitis as part of the "allergic march" 1
• Sleep-disordered breathing: Appropriate treatment of allergic rhinitis improves sleep quality and reduces daytime somnolence 1
• Otitis media with effusion: Comorbidity varies from 16.3% to 89%; intranasal corticosteroids may hasten resolution 1
• Adenoid hypertrophy: Must be considered in children with allergic rhinitis or sinonasal disease 1

Common Pitfalls to Avoid

• Do not assume combination therapy is always superior to monotherapy—intranasal corticosteroid alone is often sufficient and should be optimized before adding other agents 2
• Do not prescribe intranasal antihistamines in children under 6 years—they lack FDA approval in this age group 3
• Do not use the combination product azelastine-fluticasone in children under 12 years—it is only FDA-approved for ages ≥12 years 8
• Do not forget to adjust cetirizine dosing in renal impairment—halve the dose in moderate impairment and avoid in severe impairment 8