Is the prescribed regimen—ciprofloxacin‑dexamethasone otic drops for bilateral acute otitis externa, saline nasal irrigation for acute frontal sinusitis, fluticasone nasal spray for allergic rhinitis, and loratadine tablets for allergy—appropriate for a pediatric patient with a BMI in the 85th‑to‑<95th percentile, and should any adjustments be made (e.g., loratadine dose based on age, omission of dexamethasone if tympanic membrane perforation)?

Assessment of Prescribed Pediatric Regimen

The prescribed regimen is largely appropriate, but requires two critical verifications: confirm the child's age is ≥6 months for ciprofloxacin-dexamethasone use, and ensure tympanic membrane integrity before administering otic drops. Additionally, the loratadine dose must be adjusted based on the child's specific age within the pediatric range.

Acute Otitis Externa Management

Ciprofloxacin-Dexamethasone 0.3-0.1% Otic Drops

The prescription is correct for bilateral acute otitis externa if the child is ≥6 months old and has intact tympanic membranes.

• Ciprofloxacin-dexamethasone is FDA-approved for acute otitis externa in patients ≥6 months, with dosing of 4 drops twice daily for 7 days 1
• This combination is superior to ciprofloxacin alone, achieving 90% clinical cure rates versus 78% with ofloxacin monotherapy 2
• The addition of dexamethasone reduces granulation tissue formation and accelerates symptom resolution compared to antibiotic alone 3, 4
• Clinical cure rates reach 90.9% with this combination versus 83.9% with neomycin/polymyxin B/hydrocortisone 5

Critical Safety Verification Required

Before administering any otic drops, you must confirm tympanic membrane integrity through otoscopic examination.

• Ciprofloxacin-dexamethasone is contraindicated if tympanic membrane perforation is present without specific documentation of safety 1
• Only fluoroquinolone otic preparations (ofloxacin or ciprofloxacin-dexamethasone) should be used when membrane status is uncertain, as aminoglycoside-containing drops are ototoxic 6
• The prescription correctly instructs the child to lie on their side for 1-2 minutes after instillation, which facilitates proper drug delivery 6

Acute Frontal Sinusitis Management

Antibiotic Therapy Decision

For acute frontal sinusitis in a pediatric patient, you must first determine whether this represents severe-onset, worsening-course, or persistent symptoms to decide if systemic antibiotics are indicated.

• Severe-onset (fever ≥39°C for ≥3 consecutive days with purulent discharge) or worsening-course (initial improvement followed by deterioration) requires immediate amoxicillin or amoxicillin-clavulanate 6
• Persistent symptoms (nasal discharge/cough for ≥10 days without improvement) allows either antibiotic therapy or additional observation with shared decision-making 6
• The prescription lacks systemic antibiotics, which is only appropriate if this represents mild persistent sinusitis where observation is chosen 6

Saline Nasal Irrigation

Neti pot sinus wash is appropriate as adjunctive therapy for acute bacterial sinusitis in children old enough to cooperate with the technique (typically ≥4 years).

• Saline irrigation provides symptomatic relief and may facilitate drainage 6
• Ensure proper technique to avoid complications; the child must be developmentally capable of performing the procedure safely

Allergic Rhinitis Management

Fluticasone Nasal Spray

Fluticasone 50 mcg (1 spray per nostril twice daily) is appropriate and represents first-line therapy for pediatric allergic rhinitis if the child is ≥4 years old.

• Intranasal corticosteroids are the most effective medication class for nasal congestion in children ≥2 years 7
• Fluticasone propionate (Flonase) is FDA-approved for children ≥4 years at 1-2 sprays per nostril daily 6
• At recommended doses, intranasal corticosteroids do not cause clinically significant systemic effects or growth suppression 6, 7
• The 30-day duration is appropriate for establishing symptom control 6

Loratadine Dosing

The loratadine 10 mg daily dose is ONLY correct if the child is ≥6 years old; children 2-5 years require 5 mg daily.

• Age 2-5 years: 5 mg (half tablet or 5 mL syrup) once daily
• Age ≥6 years: 10 mg (one tablet) once daily
• The prescription lists "1 tablet" of 10 mg, which must be verified against the child's actual age 6
• Loratadine is a non-sedating antihistamine appropriate for allergic rhinitis but less effective than intranasal corticosteroids as monotherapy 6

BMI Considerations

The child's BMI (85th-95th percentile, classified as overweight) does not require medication dose adjustments for any of the prescribed agents.

• Otic drops are dosed by drops per ear, not by weight 1
• Intranasal medications are dosed by sprays, independent of body weight 7
• Loratadine dosing is age-based, not weight-based, in pediatric patients 6

Critical Action Items Before Dispensing

1. Verify child's exact age to confirm:

   • ≥6 months for ciprofloxacin-dexamethasone 1
   • ≥4 years for fluticasone nasal spray (if using Flonase brand)
   • Correct loratadine dose (5 mg if 2-5 years; 10 mg if ≥6 years)

2. Confirm tympanic membrane integrity via otoscopy before using otic drops 1

3. Clarify sinusitis severity to determine if systemic antibiotics (amoxicillin) should be added 6

4. Assess developmental capability for neti pot use (typically requires age ≥4 years for safe technique)