Intranasal Corticosteroids for Persistent Nasal Congestion
For a child with allergic rhinitis whose nasal congestion is not responding to antihistamines, intranasal corticosteroids are the definitive next treatment—they are the single most effective medication class for controlling all symptoms of allergic rhinitis, particularly nasal congestion, which antihistamines address poorly. 1, 2
Why Intranasal Corticosteroids Are Superior
Intranasal corticosteroids control all four cardinal symptoms of allergic rhinitis—sneezing, itching, rhinorrhea, and nasal congestion—with particular efficacy for congestion, the symptom that antihistamines fail to adequately address 2, 3
They are more effective than combined antihistamine plus leukotriene antagonist therapy in most studies, making montelukast (option B) an inferior choice 1, 2
The 2017 Joint Task Force guidelines give a strong recommendation for intranasal corticosteroids over leukotriene receptor antagonists for initial treatment, with clinically meaningful differences in nasal symptom reduction 1, 2
All available intranasal corticosteroids (fluticasone, mometasone, budesonide, triamcinolone) have similar clinical efficacy regardless of differences in potency—choice can be based on patient preference, cost, and availability 2, 4
Why Other Options Are Inadequate
Oral Decongestants (Option A)
Oral decongestants do not address the underlying allergic inflammation and provide only temporary symptomatic relief of congestion without affecting sneezing, itching, or rhinorrhea 2, 5
They should be used with caution in children due to side effects including insomnia, irritability, and palpitations 1
Decongestants have no role as monotherapy when antihistamines have already failed, as they do not treat the allergic process 6
Allergy Immunotherapy (Option B)
Allergen immunotherapy is effective for allergic rhinitis but is reserved for patients whose symptoms cannot be adequately controlled by avoidance and medication, or who require excessive amounts of medication 1
It is not the appropriate next step when first-line pharmacotherapy (intranasal corticosteroids) has not yet been tried 1
Topical Decongestants (Option D, if "Decongasting" refers to topical agents)
Topical decongestants must never be used for more than 3 days due to the risk of rhinitis medicamentosa (rebound congestion), which can develop as early as day 3-4 of continuous use 7, 5
They have no effect on itching, sneezing, or nasal secretion 1
If this option refers to oral decongestants, the same limitations apply as discussed above 1
Safety Profile in Children
Clinical studies of fluticasone propionate, mometasone furoate, and budesonide at recommended pediatric doses demonstrate no measurable impact on linear growth 7, 6
Growth suppression has been reported only when beclomethasone dipropionate exceeds recommended dosing or is used in toddlers 1, 7
Local adverse effects such as nasal irritation, bleeding, or septal perforation are rare when the spray is administered correctly (directing spray away from the nasal septum) 7, 4
The onset of therapeutic effect occurs between 3 and 12 hours, with maximum effect potentially requiring 2 weeks 1
Critical Clinical Pitfall
Adding an oral antihistamine to intranasal corticosteroids generally does not provide additional benefit in controlled trials, though some patients with severe symptoms may benefit from combination therapy 1, 2, 5
The patient has already failed antihistamine monotherapy, so continuing or adding antihistamines is unlikely to be beneficial 2
Answer: C. Intranasal steroids