What is the appropriate treatment for persistent nasal congestion with mucus in a 1‑year‑old infant?

Management of Nasal Congestion with Mucus in a 1-Year-Old Infant

First-Line Treatment: Saline Nasal Irrigation

Saline nasal irrigation is the primary and safest treatment for nasal congestion in a 1-year-old infant. 1

• Saline irrigation removes debris from the nasal cavity and temporarily reduces tissue edema to promote drainage. 1
• This intervention has demonstrated greater improvement in nasal airflow, quality of life, and total symptom scores compared with placebo in pediatric patients. 1
• Administer saline drops or spray 2–3 times daily, followed by gentle suctioning of the nostrils when the nose is blocked with secretions. 1

Medications to Avoid in This Age Group

Do not prescribe oral decongestants or antihistamines in children under 6 years of age. 1

• The FDA's Nonprescription Drugs and Pediatric Advisory Committees explicitly recommend against these agents due to potential toxicity and lack of proven efficacy. 1
• Evidence includes 54 fatalities associated with decongestants and 69 fatalities associated with antihistamines in children under 6 years. 1
• Oral decongestants in infants and young children have been associated with serious adverse effects including agitated psychosis, ataxia, hallucinations, and death. 1
• Antihistamines lack efficacy for simple nasal congestion and carry sedation risks in this age group. 1

When Topical Decongestants May Be Considered

• If saline irrigation alone is insufficient, topical decongestants like xylometazoline may be considered for very short-term use only (no more than 3 days), with extreme caution due to the narrow margin between therapeutic and toxic doses. 1

Intranasal Corticosteroids: Not Indicated for Simple Congestion

• Intranasal corticosteroids such as mometasone furoate are approved for children aged 2 years and older for allergic rhinitis only, not for simple viral nasal congestion. 1, 2
• Mometasone furoate nasal spray is labeled for children aged 2 years and older at a dose of one spray per nostril once daily, but this indication is for allergic rhinitis, not acute viral upper respiratory infections. 3, 2
• Nasal corticosteroids are not supported by current evidence for symptomatic relief from the common cold. 1

Antibiotics: Not Indicated

• Antibiotics are not recommended for routine use in common cold or acute purulent rhinitis, as fewer than 1 in 15 children develop true bacterial sinus infection during or after a common cold. 1
• Most viral upper respiratory infections resolve spontaneously within 7–10 days without antibiotics. 4

When to Seek Medical Evaluation

Seek medical evaluation if any of the following occur:

• Nasal congestion persists beyond 10 days without improvement. 1
• Fever ≥39°C (102.2°F) for at least 3 consecutive days. 1
• Symptoms worsen after initial improvement ("double sickening"). 1
• Respiratory distress signs: oxygen saturation <92%, cyanosis, respiratory rate >70 breaths/min, difficulty breathing, grunting, or intermittent apnea. 1
• Not feeding or signs of dehydration. 1

Supportive Care at Home

• Ensure adequate hydration. 1
• Monitor for signs of deterioration. 1
• Children cared for at home should be reviewed if deteriorating or not improving after 48 hours. 1

Common Pitfalls to Avoid

• Do not use antihistamine-decongestant-analgesic combinations; they show no evidence of effectiveness in young children. 1
• Do not use steam or heated humidified air; these have no demonstrated benefits for treating the common cold. 1
• Do not use echinacea; it has not been shown to provide benefits for treating colds. 1
• Do not prescribe antibiotics based solely on purulent nasal discharge; this finding alone does not confirm bacterial infection. 4