What are the recommended management strategies for nasal congestion in children under five years old?

Management of Nasal Congestion in Children Under Five

First-Line Treatment: Saline Nasal Irrigation

Saline nasal irrigation is the primary recommended treatment for nasal congestion in children under five years of age, as it safely removes debris from the nasal cavity and temporarily reduces tissue edema to promote drainage. 1

Evidence Supporting Saline Use:

• Saline irrigation demonstrates greater improvement in nasal airflow, quality of life, and total symptom scores compared to placebo in pediatric patients 1
• Both isotonic saline (0.9%) and hypertonic seawater (2.3%) solutions provide significant relief in nasal congestion, weakness, sleep quality, and nutrition compared to no treatment 2
• The European Position Paper on Rhinosinusitis considers nasal saline irrigation an option for relieving symptoms of acute upper respiratory tract infections, particularly in children 3

Practical Application:

• Gentle suctioning of the nostrils may help when the child's nose is blocked with secretions 3
• Parents should be taught proper nose-blowing techniques and encouraged to use saline sprays as simple non-invasive measures 4

Medications to AVOID

Oral decongestants and antihistamines must be avoided in children under 6 years of age due to documented fatalities and lack of proven efficacy. 1, 5

Critical Safety Data:

• Between 1969 and 2006, there were 54 documented fatalities associated with decongestants in children under 6 years, with 43 deaths occurring in infants under 1 year 5
• An additional 69 fatalities were associated with antihistamines in this age group 1
• The FDA's Nonprescription Drugs and Pediatric Advisory Committees formally recommended against OTC cough and cold medications, including nasal decongestants, in children below 6 years 5

Specific Agents to Avoid:

• Topical vasoconstrictors (imidazoline derivatives) have a narrow margin between therapeutic and toxic doses in children below 1 year, increasing risk for cardiovascular and CNS side effects 5
• Antihistamines lack efficacy for simple nasal congestion and carry sedation risks in children under 6 years 1
• Antihistamine-decongestant-analgesic combinations show no evidence of effectiveness in young children 3

Additional Ineffective Treatments

The following interventions should NOT be used for simple nasal congestion in young children:

• Nasal corticosteroids: Current evidence does not support their use for symptomatic relief from the common cold 3
• Antibiotics: Not recommended for routine use in common cold or acute purulent rhinitis, as fewer than 1 in 15 children develop true bacterial sinus infection during or after a common cold 3, 1
• Steam/heated humidified air: No demonstrated benefits for treating the common cold 3
• Echinacea: Not shown to provide benefits for treating colds 3

Second-Line Options (Use with Extreme Caution)

If saline irrigation alone is insufficient, topical decongestants like xylometazoline may be considered for very short-term use only (maximum 3 days), but only in children over 1 year of age. 1, 5

Critical Limitations:

• The narrow margin between therapeutic and toxic doses makes these agents particularly dangerous in infants 5
• Use beyond 3 days risks rhinitis medicamentosa (rebound congestion) 5
• This should be considered only when nasal congestion is severe enough to interfere with feeding or breathing

When to Seek Medical Evaluation

Medical evaluation should be sought if nasal congestion persists beyond 10 days without improvement, is accompanied by fever ≥39°C (102.2°F) for at least 3 days, or worsens after initial improvement, to rule out bacterial sinusitis. 1

Additional Red Flags Requiring Evaluation:

• Oxygen saturation <92% or cyanosis 3
• Respiratory rate >70 breaths/min in infants <1 year or >50 breaths/min in older children 3
• Difficulty breathing, grunting, or intermittent apnea 3
• Not feeding or signs of dehydration 3
• Nasal polyps (indicating possible cystic fibrosis) 4
• Periorbital cellulitis 4

Conservative Management Approach

The main treatment strategy for rhinosinusitis in children should be conservative, not surgical, as most children grow out of adenoid hypertrophy and recurrent colds by age 8-10 years. 4

Supportive Care:

• Families need information on managing pyrexia, preventing dehydration, and identifying deterioration 3
• Children cared for at home should be reviewed if deteriorating or not improving after 48 hours 3
• "Watchful waiting" is advised, as the problem usually resolves with time through growth and maturation of the immunological response 4