Management of Allergic Rhinitis in Children
Intranasal corticosteroids are the first-line treatment for children 4 years and older with moderate-to-severe allergic rhinitis, as they are the most effective medication class for controlling nasal symptoms and improving quality of life. 1, 2
Initial Assessment and Classification
- Classify allergic rhinitis as intermittent versus persistent, and mild versus moderate-to-severe based on symptom frequency and impact on school performance and quality of life 1
- Identify specific allergen triggers through skin prick testing or serum-specific IgE antibodies to guide avoidance strategies and determine immunotherapy candidacy 2
- Screen for comorbid asthma in all children with allergic rhinitis, particularly those with cough or lower respiratory symptoms, as treating rhinitis may reduce asthma symptoms and prevent asthma development 2
Pharmacologic Treatment Algorithm
First-Line: Intranasal Corticosteroids
For children ≥4 years with moderate-to-severe symptoms, start with intranasal corticosteroids (fluticasone propionate, mometasone furoate, or budesonide) at 100 mcg once daily (1 spray per nostril). 2, 3
- Intranasal corticosteroids are superior to oral antihistamines for nasal congestion, the predominant symptom in perennial allergic rhinitis 4, 5
- Maximum effect may take several days, though symptom improvement can begin within 12 hours 3
- If inadequate response after 4-7 days, increase to 200 mcg daily (2 sprays per nostril once daily), which is the maximum dose for children 3
- Once control is achieved, attempt to decrease back to 100 mcg daily for maintenance 3
Second-Line: Add Oral Antihistamine
For children with persistent symptoms despite intranasal corticosteroids, add a second-generation oral antihistamine (cetirizine 5-10 mg daily, loratadine, or desloratadine). 2
- Antihistamines are particularly effective for histamine-mediated symptoms including itching, sneezing, and rhinorrhea, especially in seasonal/pollen-induced rhinitis 6, 4
- Second-generation antihistamines avoid the sedation and cognitive impairment associated with first-generation agents 1
- The combination of oral antihistamine plus intranasal corticosteroid provides more comprehensive symptom control than either agent alone 2
Alternative: Intranasal Antihistamine
For inadequate response to intranasal corticosteroids alone, consider adding intranasal antihistamine rather than oral antihistamine, as this combination is more effective than intranasal corticosteroid monotherapy. 1
- Intranasal antihistamines work faster than intranasal corticosteroids but are less effective for nasal congestion 1
- The fixed combination of intranasal antihistamine plus intranasal corticosteroid is highly effective but typically reserved for adolescents 6
Leukotriene Receptor Antagonists
- Leukotriene receptor antagonists (montelukast) are less effective than intranasal corticosteroids but may be considered when intranasal medications are refused or poorly tolerated 1, 5
Environmental Control Measures
Implement allergen avoidance strategies based on specific IgE testing results, as environmental control is a critical component of management. 2
- For dust mite allergy: Control indoor humidity, use allergen-impermeable mattress and pillow covers, wash bedding weekly in hot water 2
- For mold sensitivity: Repair water leaks, improve ventilation in bathrooms and kitchens, control humidity 2
- For animal dander: Remove pets from the home or at minimum exclude from bedrooms, use HEPA air filters 2
Common pitfall: Evidence does not support the efficacy of mite-proof covers alone, air filtration systems as monotherapy, or delayed pet exposure in preventing allergic rhinitis 5
Dosing Strategy: Continuous vs. As-Needed
Use continuous daily dosing rather than as-needed dosing for children with perennial allergic rhinitis due to ongoing allergen exposure. 2
- For adolescents ≥12 years with seasonal allergic rhinitis, as-needed use of intranasal corticosteroids (not exceeding 200 mcg daily) may be effective, though scheduled regular use provides greater symptom control 3
- As-needed efficacy has not been established in children <12 years 3
Monitoring and Treatment Escalation
Evaluate treatment response after 2-4 weeks of continuous therapy. 2
If Partial Improvement:
- Increase intranasal corticosteroid dose to maximum (200 mcg daily) if not already at this dose 2
- Add intranasal antihistamine to intranasal corticosteroid 2
- Verify proper nasal spray technique, as poor technique is a common cause of treatment failure 4
If Minimal Improvement:
- Reassess diagnosis and verify medication adherence 2
- Consider allergist referral for further evaluation 7
Allergen Immunotherapy
Consider allergen immunotherapy (subcutaneous or sublingual) for children with persistent symptoms despite optimal medical therapy for 3-6 months. 2
Subcutaneous Immunotherapy (SCIT)
- Recommended for children with allergic rhinitis, with potential benefits including symptom reduction and prevention of asthma development 1
- Effective for both seasonal (pollen) and perennial (dust mite) allergens 1
Sublingual Immunotherapy (SLIT)
- For pollen-induced allergic rhinitis in children: SLIT is conditionally recommended with moderate-quality evidence 1
- For dust mite-induced allergic rhinitis in children: SLIT should only be administered in rigorously designed clinical trials due to very low-quality evidence 1
- Local adverse effects occur in approximately 35% of patients but are generally mild 1
Long-Term Benefits
- Immunotherapy provides disease-modifying effects including prevention of new allergen sensitivities and reduced progression to asthma 1, 2
- Treatment duration typically 3-5 years for sustained benefit 1
Special Considerations by Age
Children <2 Years
- Intranasal corticosteroids have limited evidence in this age group and are not recommended as first-line 7
- Second-generation oral antihistamines (cetirizine, loratadine) are the safest choice for children <6 years 7
Children <6 Years
- Avoid over-the-counter cough and cold medications containing decongestants or first-generation antihistamines due to lack of efficacy and significant safety concerns, including 123 fatalities reported between 1969-2006. 7
- Avoid topical nasal decongestants due to risk of rebound congestion 7
Adjunctive Therapies
Nasal Saline Irrigation
- Nasal lavage is safe, inexpensive, and effective for removing secretions, allergens, and mediators 6, 8
- Hypertonic saline solutions provide additional decongestant activity 6