What is the best treatment for post nasal drip in a 13-month-old patient?

Treatment of Post-Nasal Drip in a 13-Month-Old

For a 13-month-old with post-nasal drip, use nasal saline irrigation as the primary treatment, as this is the only intervention with any supporting evidence in young children and carries minimal risk. 1

Primary Treatment Approach

Nasal Saline Irrigation

• Saline nasal irrigation is the safest and most appropriate first-line therapy for infants and toddlers with post-nasal drip. 1
• While the evidence quality is very low, one small study found larger effects with high-volume versus low-volume saline rinsing specifically for purulent rhinorrhea and post-nasal drip. 1
• Saline can be expected to be beneficial rather than harmful on theoretical grounds, as it helps thin secretions and mechanically clear mucus. 1
• Use isotonic saline drops or gentle spray formulations appropriate for infants, applied 2-4 times daily or as needed. 1

What NOT to Use in This Age Group

Intranasal Corticosteroids - Age Restriction

• Mometasone furoate (Nasonex) is FDA-approved only for children ≥2 years of age. 1
• At 13 months, this child is too young for mometasone, which requires a minimum age of 2 years (dosing would be 1 spray per nostril daily = 100 mcg total for ages 2-11 years). 1, 2
• Fluticasone furoate (Veramyst) and triamcinolone acetonide (Nasacort) are also approved only for ≥2 years. 1
• Fluticasone propionate (Flonase) is approved for ≥4 years. 1

Antihistamines - No Evidence in Children

• The EPOS 2020 guidelines found one study evaluating antihistamines in children with post-viral rhinosinusitis showing no additive benefit over placebo. 1
• Based on very low quality evidence, antihistamines cannot be recommended for post-nasal drip in young children. 1

Antibiotics - Not Indicated

• Antibiotics are not associated with greater cure or significant improvement in children with acute post-viral rhinosinusitis and should not be used. 1
• Post-viral rhinosinusitis is self-limiting, and the EPOS 2020 steering group advises against antibiotic use in children for this condition. 1

Clinical Approach Algorithm

1. Confirm the diagnosis: Post-nasal drip in infants typically manifests as throat clearing, cough (especially when lying down), irritability during feeding, or visible mucus in the posterior pharynx. 3, 4

2. Identify the underlying cause: Common etiologies in this age group include:

   • Viral upper respiratory infections (most common) 1
   • Adenoid hypertrophy (though less common at 13 months) 5
   • Allergic rhinitis (less likely at this age but possible) 5
   • Gastroesophageal reflux (consider if feeding-related symptoms present) 4

3. Initiate saline irrigation: Use age-appropriate saline drops or gentle spray 2-4 times daily, particularly before feeds and sleep. 1

4. Provide supportive care: Elevate the head of the crib slightly, use a cool-mist humidifier, and ensure adequate hydration. 3

5. Reassess in 2-3 weeks: If symptoms persist beyond typical viral illness duration (10-14 days) or worsen, consider referral to pediatric otolaryngology to evaluate for structural causes like adenoid hypertrophy. 4, 5

Important Caveats

• Most post-nasal drip in infants is self-limiting and related to viral upper respiratory infections. 1
• The sensation of post-nasal drip may not correlate with actual visible secretions on examination. 4, 6
• Persistent symptoms beyond 3-4 weeks, unilateral symptoms, or associated warning signs (failure to thrive, recurrent infections, breathing difficulties) warrant specialist evaluation. 4
• Avoid over-the-counter cough and cold medications in children under 2 years due to safety concerns and lack of efficacy. 1