How should nasal congestion be managed in a newborn less than 28 days old?

Management of Nasal Congestion in Newborns Less Than 28 Days Old

Saline nasal irrigation followed by gentle aspiration is the primary and safest treatment for nasal congestion in newborns, as medications are contraindicated in this age group due to documented fatalities and narrow therapeutic windows. 1, 2

Why This Matters in Newborns

Newborns are obligate nasal breathers until 2-6 months of age, and their nasal passages contribute 50% of total airway resistance. 3 Even minor nasal obstruction can create near-total airway blockage and potential fatal respiratory failure in this population. 3, 4 This makes prompt recognition and appropriate management critical.

First-Line Treatment: Saline Irrigation with Gentle Suctioning

Use isotonic saline nasal irrigation as your primary therapy. 1 Isotonic saline is more effective than hypertonic or hypotonic solutions for nasal symptoms. 1 The mechanism works by removing debris, reducing tissue edema, and promoting drainage without risk of adverse effects. 1, 2

Technique

• Instill saline drops into each nostril 2, 5
• Follow with gentle suctioning of the nostrils using a bulb syringe or nasal aspirator 6, 1
• This combination has been shown to lower the risk of developing acute otitis media and rhinosinusitis compared to saline alone 5

Absolute Medication Contraindications

Never use any of the following in newborns:

• Oral decongestants and antihistamines are absolutely contraindicated in children under 6 years due to documented fatalities—between 1969-2006, there were 54 decongestant-related deaths and 69 antihistamine-related deaths in children ≤6 years, with 43 decongestant deaths occurring in infants under 1 year. 6, 1, 3

• Topical decongestants should not be used in infants under 1 year because of the narrow margin between therapeutic and toxic doses, which increases risk for cardiovascular and CNS side effects. 6, 1, 3

• Over-the-counter cough and cold medications have no proven efficacy in this age group and add unnecessary toxicity risk. 6, 1

When to Escalate Care

Red Flags Requiring Immediate Evaluation

Monitor for signs of respiratory distress that indicate need for hospitalization: 3, 7

• Oxygen saturation <90-92% on room air 6, 3
• Nasal flaring and "head bobbing"—statistically associated with hypoxemia 3
• Grunting—indicates increased severity of respiratory compromise 6, 3, 7
• Retractions (subcostal, intercostal, or suprasternal) 3, 7
• Tachypnea (respiratory rate >60 breaths/minute) 7, 8
• Cyanosis—denotes severe hypoxemia 3, 7
• Inability to feed or maintain adequate oral intake 3

Differential Diagnosis to Consider

Unilateral obstruction suggests anatomic abnormality such as choanal atresia or nasal septal deviation and requires urgent ENT evaluation. 3

Associated symptoms requiring further workup: 3

• Choking, apneic spells, or aspiration during feeds → consider laryngopharyngeal reflux (LPR)
• Recurrent pneumonia or oxygen desaturation specifically during feeds → evaluate for aspiration with videofluoroscopic swallow study
• Persistent symptoms despite treatment → consider primary ciliary dyskinesia

Most common cause: Viral upper respiratory infection, which even when mild can create near-total obstruction in obligate nasal breathers. 3, 2

Supportive Care Measures

• Maintain upright or supported sitting position to help expand lungs and improve respiratory symptoms 6
• Ensure adequate hydration through continued breastfeeding or formula feeding as tolerated 6
• Monitor temperature closely as hypothermia is a risk in sick neonates 6
• Address environmental factors including tobacco smoke exposure 1

Common Pitfall to Avoid

Do not assume food allergy (particularly milk/soy) is the cause—it accounts for only 0.3% of rhinitis symptoms in children and is vastly overestimated by parents. 3 Viral infection is far more likely.

Hospital Management if Admitted

If oxygen saturation falls below 92%, provide supplemental oxygen via nasal cannulae, head box, or face mask. 6 Where the nose is blocked with secretions, gentle suctioning may help, but avoid deep nasopharyngeal suctioning as it has been associated with longer hospital stays. 6 Nasogastric tubes should be avoided in severely ill infants as they compromise breathing, especially in those with small nasal passages. 6