Can a 10‑year‑old child weighing ~51 kg with a history of seasonal allergies receive a 30 mg intramuscular injection of Kenalog (triamcinolone acetonide) for acute sinusitis?

Intramuscular Kenalog for Pediatric Sinusitis: Not Recommended

A 30 mg intramuscular injection of Kenalog (triamcinolone acetonide) should NOT be administered to this 10-year-old child for acute sinusitis. This route and indication are not supported by current pediatric sinusitis guidelines, and intranasal corticosteroids are the appropriate first-line therapy for the underlying seasonal allergies.

Why Intramuscular Kenalog Is Inappropriate

Guideline-Based Treatment for Acute Bacterial Sinusitis

• The American Academy of Pediatrics recommends amoxicillin as the first-line antimicrobial agent for uncomplicated acute bacterial sinusitis in children, with dosing of 45 mg/kg per day in 2 divided doses for children ≥2 years without recent antibiotic exposure 1
• For children with moderate-to-severe illness, recent antibiotic use, or daycare attendance, high-dose amoxicillin-clavulanate (80-90 mg/kg per day) is recommended 1
• Parenteral corticosteroids are contraindicated for rhinitis and sinusitis due to greater potential for prolonged adrenal suppression, muscle atrophy, and fat necrosis 2

Specific Concerns with Intramuscular Triamcinolone

• Intramuscular triamcinolone acetonide has unique pharmacokinetics with prolonged systemic effects due to low solubility, slow absorption from the injection site, and low renal clearance 3
• The 30 mg dose represents a significant systemic corticosteroid burden for a 51 kg child, with potential for hypothalamic-pituitary-adrenal axis suppression that can persist for weeks 3
• There is no evidence base supporting intramuscular corticosteroids for acute sinusitis in children—this is an off-label use without guideline support 1

Appropriate Management Strategy

For Acute Bacterial Sinusitis

• Antibiotic therapy is the cornerstone of treatment if bacterial sinusitis is diagnosed based on persistent symptoms (>10 days without improvement), severe onset (high fever ≥39°C and purulent nasal discharge for ≥3 consecutive days), or worsening symptoms after initial improvement 1
• Amoxicillin 45 mg/kg per day in 2 divided doses for 10-14 days is first-line for this child (assuming no recent antibiotic exposure and no daycare attendance) 1

For Underlying Seasonal Allergies

• Intranasal triamcinolone acetonide is FDA-approved and highly effective for children ≥2 years with allergic rhinitis 1, 2
• Dosing for ages 6-11 years: 2 sprays per nostril once daily (220 mcg total daily dose) 1
• This formulation provides local anti-inflammatory effects without systemic absorption or HPA axis suppression at therapeutic doses 4, 5
• Symptom relief begins within 12-16 hours, with maximal efficacy in days to weeks of regular use 6, 2

Safety Profile of Intranasal vs. Intramuscular Route

• Intranasal triamcinolone acetonide at standard doses (110-220 mcg/day) does not suppress adrenal function and shows no effect on growth in children 5, 1
• Long-term intranasal use (up to 12 months) in children shows no impact on height or weight compared to predicted values 1, 5
• In contrast, intramuscular corticosteroids carry risk of prolonged systemic effects including growth suppression, adrenal suppression, and metabolic disturbances 2

Common Pitfalls to Avoid

• Do not use parenteral corticosteroids for rhinosinusitis—even a single intramuscular injection can cause prolonged adrenal suppression lasting weeks to months 2
• Do not confuse the intranasal formulation (safe, guideline-recommended) with intramuscular formulation (contraindicated for this indication) 1, 2
• If a short course of systemic corticosteroids is deemed absolutely necessary for severe intractable symptoms, use oral prednisone for 5-7 days maximum, not intramuscular depot preparations 2
• The child's history of seasonal allergies suggests an allergic component that would benefit from ongoing intranasal corticosteroid therapy, not a one-time systemic injection 1, 2

Recommended Treatment Plan

1. Diagnose the primary problem: Determine if this is acute bacterial sinusitis (requiring antibiotics) or allergic rhinosinusitis (requiring intranasal steroids) 1
2. If bacterial sinusitis: Prescribe amoxicillin 45 mg/kg per day divided twice daily for 10-14 days 1
3. For seasonal allergies: Initiate intranasal triamcinolone acetonide 2 sprays per nostril once daily (220 mcg/day) 1, 2
4. Teach proper technique: Use contralateral hand to direct spray away from nasal septum to minimize epistaxis risk 2
5. Follow-up: Reassess in 48-72 hours if bacterial sinusitis, or 2-4 weeks if primarily allergic rhinitis 1, 2