Azelastine Dosing for a 5-Year-Old Child with Allergic Rhinitis

For a 5-year-old child with seasonal allergic rhinitis, administer azelastine nasal spray 0.1% (Astelin) as 1 spray per nostril twice daily. 1

FDA-Approved Dosing by Age

Children ages 5–11 years: The FDA-approved dose is 1 spray per nostril twice daily using azelastine 0.1% (Astelin) for seasonal allergic rhinitis 1
This dosing applies specifically to the 0.1% formulation (137 µg per spray), which is the only concentration approved for children as young as 5 years 2
The 0.15% formulation (Astepro) is approved only for children ≥6 years, making it inappropriate for a 5-year-old 2

Proper technique is critical to minimize side effects and maximize efficacy:

Prime the pump before first use (4 sprays or less until fine mist appears) 1
Have the child blow their nose gently before administration 1
Keep the child's head tilted downward toward their toes during spraying—this is essential to prevent medication from dripping into the throat where it causes bitter taste 1
Insert spray tip ¼ to ½ inch into nostril, hold bottle vertically upright, and press rapidly and firmly to produce a fine mist (not a stream) 1
Alternate nostrils between sprays 1
Breathe gently and do not tilt head back after dosing to avoid drawing medication into the throat 1

Azelastine provides clinically significant symptom relief within 15 minutes of administration, making it particularly useful for episodic symptoms or pretreatment before allergen exposure 3, 2
It effectively relieves nasal congestion, an outcome that oral antihistamines address poorly 2
The medication can be used as either first-line or second-line therapy for allergic rhinitis in children 2

Bitter taste is the primary barrier to compliance in children:

Approximately 19.7% of patients report bitter taste, which is the most common side effect 3
This can be minimized by ensuring proper head-down positioning during administration 1, 4
Epistaxis (nosebleed) occurs in some children but is generally mild 2
Somnolence occurs in only 0.4–3% of children, a rate comparable to placebo, making sedation concerns minimal at this age 2, 5
Headache may occur but is uncommon 2

Recent high-quality evidence from 2025 demonstrates that azelastine is safe and well tolerated in children ages 6–11 years with perennial allergic rhinitis, with somnolence reported in only 1 patient out of 486 subjects 5
The medication has limited systemic absorption due to targeted nasal delivery, making it appropriate for pediatric use 2
Unlike first-generation antihistamines, azelastine does not cause significant sedation or performance impairment in most children 3, 5

Use azelastine in a 5-year-old when:

The child has episodic nasal symptoms requiring rapid relief 2
Pretreatment before anticipated allergen exposure is needed 2
The child has not achieved adequate control with oral antihistamines 2
Nasal congestion is a prominent symptom, as azelastine addresses this better than oral antihistamines 2, 4

If bitter taste becomes intolerable despite proper technique, consider switching to an intranasal corticosteroid (such as triamcinolone, which is approved for children ≥2 years) 6
Intranasal corticosteroids remain more effective than azelastine for overall symptom control in allergic rhinitis, though azelastine has a faster onset 3, 7
For moderate-to-severe allergic rhinitis, intranasal corticosteroids should be considered first-line therapy, with azelastine reserved for breakthrough symptoms or when rapid relief is needed 3, 6
Repriming is required if 3 or more days have elapsed since last use (2 sprays until fine mist appears) 1