Treatment of Nasal Congestion and Runny Nose in Children
For most children with nasal congestion and runny nose from viral upper respiratory infections, supportive care with reassurance is the preferred approach, as most cases resolve without medication; when treatment is needed, oral decongestants (pseudoephedrine) can be used in children over 12 years, but all over-the-counter cough and cold medications must be avoided in children under 6 years due to documented fatalities. 1, 2
Age-Based Treatment Algorithm
Children Under 6 Years
- Avoid all OTC cough and cold medications entirely, including antihistamine-decongestant combinations, due to lack of established efficacy and 54 decongestant-related and 69 antihistamine-related fatalities documented between 1969-2006 in this age group 1
- Supportive care is the primary approach: teach nose-blowing, use saline nasal sprays, and provide reassurance to parents that symptoms typically resolve by age 8-10 years 3
- Most viral upper respiratory infections improve within 10 days without intervention 2
Children Over 12 Years and Adults
- First-line treatment: Oral pseudoephedrine 60mg every 4-6 hours as needed for symptomatic relief of nasal congestion 1, 4
- Screen for contraindications before prescribing: hypertension (monitor blood pressure), glaucoma, and urinary retention 1, 2
- Alternative: Topical decongestants (oxymetazoline) for maximum 3 days only if rapid relief is needed 1, 2
Critical Warnings About Topical Decongestants
Rhinitis medicamentosa (rebound congestion) can develop as early as day 3 of regular topical decongestant use, making it essential to limit use to 3-5 days maximum 1, 2. While some patients may not develop rebound until 4-6 weeks, the variability in individual response necessitates instructing all patients about this risk when use exceeds 3 days 2.
What NOT to Use
Antihistamines Are Ineffective for Viral Infections
- Antihistamine-decongestant combinations provide no benefit over decongestants alone for viral upper respiratory infections and should not be used 1
- Antihistamines lack efficacy because viral infections do not have the histamine-mediated inflammatory component present in allergic rhinitis 1
- Controlled trials consistently show antihistamine-decongestant combinations are ineffective for upper respiratory tract infection symptoms 1
Exception: Allergic Rhinitis
If the child has documented allergic rhinitis (not just a viral cold), the treatment approach differs entirely:
- Intranasal corticosteroids are the most effective medication class for controlling all four major symptoms: sneezing, itching, rhinorrhea, and nasal congestion 2
- These should be used at the lowest effective dose in children, with sprays directed away from the nasal septum 2
- Second-generation oral antihistamines are effective for allergic rhinitis but not for viral infections 5
When to Suspect Bacterial Sinusitis Instead
Most children with thick, colored nasal mucus have a viral infection, not bacterial sinusitis (fewer than 1 in 15 children develop true bacterial sinusitis during or after a common cold) 2. Consider bacterial sinusitis only when:
- Persistent pattern: Runny nose or daytime cough for ≥10 days without improvement 2
- Severe pattern: Fever ≥39°C (102.2°F) for ≥3 consecutive days with thick, colored nasal discharge 2
- Worsening pattern: Initial improvement followed by new-onset fever ≥38°C (100.4°F) or substantial increase in symptoms 2
For bacterial sinusitis, insufficient data exist to recommend antihistamines or decongestants as adjuvant therapy in children 2.
Common Pitfalls to Avoid
- Do not prescribe combination antihistamine-decongestant products for viral infections—they add cost, side effects, and no benefit 1
- Do not use topical decongestants beyond 3-5 days—explicitly warn parents about rebound congestion risk 1, 2
- Do not assume colored nasal discharge means bacterial infection—this commonly occurs with viral colds and improves by day 10 2
- Monitor for oral decongestant side effects: insomnia, loss of appetite, irritability, and palpitations 2, 1