What is the best way to manage a runny nose in an infant?

Management of Runny Nose in Infants

Saline nasal irrigation is the primary and safest treatment for runny nose in infants, with gentle nasal suctioning as needed to clear secretions. 1, 2

First-Line Treatment: Saline Irrigation

• Use saline nasal drops or spray to help remove mucus and temporarily reduce tissue swelling, which promotes drainage and improves nasal airflow 2, 3
• Saline irrigation has demonstrated superior improvement in nasal airflow, quality of life, and total symptom scores compared to placebo in pediatric patients 2
• This approach is safe, well-tolerated, and has no serious adverse events reported in the literature 3

Mechanical Clearance

• Gentle suctioning of the nostrils may help when the nose is blocked with secretions, particularly in infants who cannot blow their own noses 4, 1
• Nasal aspiration with a medical device combined with isotonic saline has been shown to lower the risk of developing acute otitis media and rhinosinusitis compared to saline alone 3
• Infants are obligate nasal breathers until at least 2 months of age, making nasal clearance particularly important for feeding and breathing 5

Medications to AVOID

• Do NOT use over-the-counter cough and cold medications in children under 2 years of age due to lack of proven efficacy and serious safety concerns 1
• Between 1969-2006, there were 54 fatalities associated with decongestants in children under 6 years (43 deaths in infants under 1 year) and 69 fatalities associated with antihistamines (41 deaths in children under 2 years) 1
• Avoid topical decongestants in infants under 1 year due to narrow margin between therapeutic and toxic doses, increasing risk for cardiovascular and CNS side effects 1
• Oral antihistamines are not beneficial for simple nasal congestion and carry sedation risks 2

When Short-Term Decongestants May Be Considered

• If saline irrigation alone is insufficient, topical xylometazoline may be considered for very short-term use (maximum 3 days) in older infants, but only with appropriate dosing 2, 6
• The risk of severe side effects with xylometazoline is low if dosage is adequate, though guidelines remain cautious 6
• This should be reserved for cases where nasal obstruction is causing significant feeding difficulties or respiratory distress 6

Supportive Care Measures

• Ensure adequate hydration to help thin secretions 1
• Keep the infant in a supported sitting position when possible to help expand lungs and improve breathing 1
• Provide information to families about preventing dehydration and identifying signs of deterioration 1

Red Flags Requiring Medical Evaluation

• Seek immediate medical attention if the infant shows:
  • Respiratory rate >70 breaths/min 4, 1
  • Difficulty breathing, grunting, or cyanosis 4, 1
  • Oxygen saturation <92% (if measured) 4, 1
  • Not feeding well or signs of dehydration 4, 1
  • Persistent high fever ≥39°C for 3+ consecutive days 1

Follow-Up Recommendations

• Review by a healthcare provider is indicated if symptoms are deteriorating or not improving after 48 hours 1
• Most viral upper respiratory infections resolve within 1-3 weeks, though 10% may persist beyond 20-25 days 1
• If nasal congestion persists beyond 10 days without improvement, or worsens after initial improvement, medical evaluation should be sought to rule out bacterial sinusitis 2

Common Pitfalls to Avoid

• Do not assume colored nasal discharge indicates bacterial infection—color does not reliably distinguish viral from bacterial infection in young children 1
• Avoid empirical antibiotic treatment for simple runny nose, as fewer than 1 in 15 children develop true bacterial sinus infection during or after a common cold 2
• Do not use chest physiotherapy, as it is not beneficial and should not be performed in children with respiratory infections 1