What is the recommended starting dose of fluticasone propionate (Flonase) nasal spray for a 5‑year‑old child with allergic rhinitis?

Fluticasone Propionate (Flonase) Dosing for a 5-Year-Old

For a 5-year-old child with allergic rhinitis, administer fluticasone propionate nasal spray 1 spray (50 µg) per nostril once daily, for a total daily dose of 100 µg. 1

Age-Specific Dosing

• Children aged 4–11 years should receive 1 spray per nostril once daily (total 100 µg/day), which is half the adult dose. 1
• This dosing is FDA-approved and supported by multiple clinical trials demonstrating efficacy and safety in children as young as 4 years. 2, 3
• The 100 µg once-daily dose has been shown to be as effective as the 200 µg dose in pediatric patients, with no additional benefit from the higher dose. 3, 4

Duration Limitations for Pediatric Use

• Children aged 4–11 years should not use fluticasone propionate for longer than 2 months per year without consulting a physician. 2
• This precaution exists because long-term intranasal corticosteroids may slow growth rate in some children, though whether this affects ultimate adult height remains unknown. 2
• If your patient requires treatment beyond 2 months annually, schedule a follow-up to reassess the diagnosis, evaluate treatment response, and monitor growth. 2

Onset and Maintenance Expectations

• Symptom relief typically begins within 12 hours, with some patients experiencing benefit as early as 3–4 hours, but maximal efficacy requires days to weeks of regular daily use. 1
• Counsel families that fluticasone is a maintenance medication, not a rescue therapy—consistent daily use is essential even when symptoms improve. 1
• For seasonal allergic rhinitis with predictable patterns, initiate treatment before symptom onset and continue throughout the allergen exposure period for optimal control. 1

Administration Technique (Critical for Efficacy and Safety)

• Prime the bottle before first use by shaking and releasing test sprays away from the face. 1
• Have the child blow their nose before each dose. 1
• Keep the head upright during administration (not tilted back). 1
• Use the contralateral hand technique: hold the bottle in the opposite hand relative to the nostril being treated (right hand for left nostril, left hand for right nostril) to naturally angle the spray away from the nasal septum. 1, 5
• Instruct the child to breathe in gently during spraying. 1
• This technique reduces epistaxis risk by fourfold compared to ipsilateral spraying. 5

Safety Profile in Children

• The most common adverse effects are headache, pharyngitis, epistaxis (typically blood-tinged secretions), and nasal burning or irritation. 1
• At recommended doses, fluticasone propionate does not suppress the hypothalamic-pituitary-adrenal axis in children, as demonstrated by normal morning plasma cortisol levels in clinical trials. 6, 3, 4
• Studies show no effect on growth at the 100 µg daily dose when used as directed. 1, 5
• Systemic absorption is minimal because swallowed drug is not absorbed from the gastrointestinal tract; only the portion absorbed through nasal mucosa contributes to systemic exposure. 7

Clinical Efficacy Evidence

• In children aged 5–11 years with perennial allergic rhinitis, fluticasone propionate 100 µg once daily significantly decreased total symptom scores at 2 and 4 weeks compared to placebo (P < 0.01 and P < 0.05, respectively). 6
• Individual symptoms including nasal blockage, sneezing, and rhinorrhea showed significant improvement at 2 weeks (P < 0.05 to P < 0.01). 6
• For seasonal allergic rhinitis in children aged 4–11 years, both investigator-rated and patient-rated symptom scores demonstrated significant improvement with 100 µg daily versus placebo over 2–4 weeks. 3, 4

Important Contraindications

• Do not use in children with documented hypersensitivity to fluticasone propionate or any formulation component. 1

Common Pitfalls to Avoid

• Do not share the bottle between family members—inserting the nozzle into the nose can spread germs. 2
• Do not discontinue when symptoms improve—this is maintenance therapy requiring consistent use for sustained benefit. 1
• Do not exceed 2 months of use per year in children aged 4–11 without physician consultation. 2
• If epistaxis becomes problematic (more than occasional blood-tinged mucus), verify proper spray technique and consider periodic nasal examination to check for septal erosions. 1, 5