In a 7 kg infant (~1–2 months old) with five days of nasal congestion, cough and intermittent fever who was treated with phenylephrine nasal spray (Disudrin) without improvement, what is the appropriate management?

Management of Persistent Nasal Congestion and Cough in a 7 kg Infant

Stop the phenylephrine nasal spray (Disudrin) immediately—it is both ineffective and potentially dangerous in infants, and switch to supportive care with saline irrigation and nasal aspiration as the primary treatment. 1, 2, 3

Why Phenylephrine Must Be Discontinued

• The FDA and American Academy of Pediatrics explicitly advise against using over-the-counter cold medications, including phenylephrine-containing products, in children younger than 6 years. 1
• Between 1969 and 2006, there were 54 fatalities associated with decongestants in children, with 41 deaths occurring in children under 2 years of age. 1
• Oral and topical decongestants like phenylephrine have been associated with serious adverse effects in infants including agitated psychosis, ataxia, hallucinations, and death—even at recommended doses. 1
• Phenylephrine is extensively metabolized in the gut, significantly reducing its bioavailability when administered orally, making it ineffective for nasal congestion. 2
• The FDA recently proposed removing oral phenylephrine from over-the-counter products because it is ineffective at FDA-approved doses to treat sinonasal congestion. 3

Appropriate First-Line Management

Saline nasal irrigation followed by gentle aspiration is the safest and most effective treatment for nasal congestion in infants. 4, 5

• Neonates and infants are obligate nasal breathers until at least two months old, making nasal obstruction particularly problematic and potentially causing respiratory distress, feeding difficulties, and altered sleep cycles. 4
• Saline nasal lavage is recommended as adjunct therapy for rhinosinusitis and in most cases of nasal congestion or obstruction in newborns and infants. 4
• Nasal aspiration with a medical device, combined with isotonic saline solution during viral rhinitis, has been shown to lower the risk of developing acute otitis media and rhinosinusitis compared to saline solution alone. 5
• Due to efficacy, ease of use, tolerability, and lack of alternative medications in children younger than 12 years, nasal irrigation with physiological saline solution followed by gentle aspiration represents the most effective method for prevention and control of nasal congestion in infants. 4

Clinical Assessment for Complications

Evaluate for bacterial sinusitis or lower respiratory tract infection given the 5-day duration of symptoms with fever. 6, 7

Consider Acute Bacterial Sinusitis If:

• Persistent symptoms: Nasal discharge (any quality) or daytime cough lasting ≥10 days without improvement. 6
• Worsening symptoms: New onset or worsening fever, daytime cough, or nasal discharge after initial improvement. 6
• Severe symptoms: Persistent fever ≥39°C with purulent nasal discharge for at least 3 consecutive days. 6

Consider Bronchiolitis If:

• The infant shows wheezing, increased work of breathing, or lower respiratory tract signs beyond nasal congestion and cough. 7
• Bronchiolitis commonly affects infants and children younger than 2 years, with nasal congestion and rhinorrhea in the first 1-3 days, followed by worsening symptoms with wheezing over several days. 7

Antibiotic Decision Algorithm

For persistent symptoms (≥10 days) without severe features, observation for an additional 3 days is appropriate before starting antibiotics. 6

• The 2013 AAP guideline allows for additional observation of children presenting with persistent illness, with commencement of antibiotic therapy if the child does not improve clinically within several days or if there is clinical worsening at any time. 6
• Children presenting with severe or worsening illness should receive immediate antibiotic therapy. 6
• If antibiotics are warranted for confirmed bacterial sinusitis, amoxicillin with or without clavulanate is first-line therapy. 6

For bronchiolitis, antibiotics are NOT indicated unless there is confirmed bacterial pneumonia. 7

• Management of bronchiolitis is supportive, including nasal suctioning, oxygen (if hypoxemic), and hydration. 7
• Use of bronchodilators (albuterol, epinephrine) and systemic corticosteroids is not recommended in infants ages 1-23 months. 7

What NOT to Use

Avoid antihistamine-decongestant combinations—they are ineffective for viral upper respiratory infections in children. 8

• Controlled trials consistently show that antihistamine-decongestant combination products are not effective for symptoms of upper respiratory tract infections. 8
• Antihistamines have no additive effect over standard treatment in post-viral acute rhinosinusitis. 8

Do not use cough suppressants or expectorants—they provide no benefit in children. 6

• A recent randomized controlled trial showed that diphenhydramine and dextromethorphan were no different than placebo in reducing nocturnal cough or sleep disturbance in children. 6

Practical Management Plan

1. Discontinue phenylephrine immediately and counsel parents on the risks of OTC cold medications in infants. 1, 3
2. Initiate saline nasal irrigation (isotonic solution) 2-3 times daily followed by gentle nasal aspiration using a bulb syringe or nasal aspirator device. 4, 5
3. Reassess in 24-48 hours for signs of clinical improvement or worsening. 6
4. If symptoms persist beyond 10 days total or worsen at any time, consider bacterial sinusitis and either observe for 3 additional days or start amoxicillin 45 mg/kg/day divided twice daily. 6
5. If lower respiratory signs develop (wheezing, increased work of breathing, hypoxemia), evaluate for bronchiolitis and provide supportive care only. 7

Key Pitfall to Avoid

The most common error is continuing ineffective and potentially harmful OTC cold medications in infants rather than switching to evidence-based supportive care with saline irrigation. 1, 8, 3