What are the likely causes and first‑line management for nasal congestion in a child?

Pediatric Nasal Congestion: Causes and First-Line Management

Saline nasal irrigation is the primary treatment for nasal congestion in children of all ages, as it removes debris, reduces tissue edema, and promotes drainage without risk of adverse effects. 1

Likely Causes by Age and Presentation

Infants and Young Children

• Viral upper respiratory tract infections are the most common cause, accounting for the vast majority of acute nasal congestion episodes 2, 3
• Neonatal rhinitis and generalized nasal airway obstruction are frequent in newborns 3
• Milk/soy allergies may contribute to chronic congestion in infants 3
• Fewer than 1 in 15 children develop true bacterial sinusitis during or after a common cold 1, 2

School-Age Children

• Allergic rhinitis affects 10-14% of the population and typically develops around age 10 years, though 30% have onset after age 30 4
• Viral rhinosinusitis remains the predominant acute cause 4
• Bacterial sinusitis should be suspected only with specific clinical patterns: persistent symptoms >10 days without improvement, high fever ≥39°C for ≥3 days, or worsening after initial improvement 1, 2

Key Diagnostic Clues

• Allergic rhinitis: nasal itching, paroxysmal sneezing, clear watery discharge, ocular symptoms, and symptoms before age 20 4, 1
• Bacterial infection: purulent discharge, facial pain, fever, and nasal smear showing abundant neutrophils with intracellular bacteria 1
• Structural problems: unilateral symptoms suggest foreign body, septal deformity, polyp, or rarely tumor 4

First-Line Management Algorithm

Step 1: Saline Irrigation (All Ages)

• Use isotonic saline as it is more effective than hypertonic or hypotonic solutions for chronic nasal symptoms 1
• Administer via nasal spray, drops, or irrigation device depending on child's age and cooperation 1, 5
• In infants, combine with gentle nasal suctioning to remove secretions and improve breathing 1, 2
• This intervention has demonstrated greater improvement in nasal airflow, quality of life, and total symptom scores compared to placebo 1, 2

Step 2: Age-Specific Medication Restrictions

Children <6 Years

• Absolutely avoid oral decongestants and antihistamines due to documented fatalities (54 deaths with decongestants, 69 with antihistamines between 1969-2006) and lack of proven efficacy 1, 2
• Do not use topical decongestants in children <1 year due to narrow therapeutic window and risk of cardiovascular/CNS toxicity 1
• Antihistamines provide no benefit for simple nasal congestion and carry sedation risks 1, 2

Children ≥6 Years

• Oral decongestants (pseudoephedrine) may be used cautiously for short-term relief, though they can cause insomnia, irritability, and elevated blood pressure 1
• Second-generation antihistamines (cetirizine, loratadine, fexofenadine) are appropriate only if allergic rhinitis is confirmed, not for simple congestion 6

Step 3: Intranasal Corticosteroids for Persistent Symptoms

If congestion persists >10 days or allergic rhinitis is confirmed, intranasal corticosteroids are the most effective medication class for controlling nasal symptoms. 1, 7

Age-Appropriate Options

• Age ≥2 years: fluticasone furoate, mometasone furoate, triamcinolone 1, 2
• Age ≥4 years: fluticasone propionate 6
• Age ≥6 years: beclomethasone, budesonide, flunisolide 6

Key Advantages

• Reduce inflammation around sinus ostia and encourage drainage 1
• Do not cause rebound congestion unlike topical decongestants 1
• No measurable impact on linear growth at recommended pediatric doses for fluticasone propionate, mometasone furoate, and budesonide 1
• Direct spray away from nasal septum to minimize local irritation 1

Step 4: Adjunctive Therapies for Specific Symptoms

For Isolated Rhinorrhea

• Ipratropium bromide 0.03% nasal spray for children ≥6 years with perennial rhinitis 1
• Ipratropium bromide 0.06% for children ≥5 years with common cold-associated rhinorrhea 1
• Adverse effects include epistaxis (9% vs 5% with saline) and nasal dryness (5% vs 1% with saline) 1
• Combining ipratropium with intranasal corticosteroid yields greater improvement than either agent alone 1

For Allergic Rhinitis with Lower Airway Disease

• Montelukast may be added for children ≥6 months (perennial) or ≥2 years (seasonal) with concurrent asthma 1

Critical Safety Warnings

Topical Decongestant Rebound

• Never use topical decongestants (oxymetazoline, phenylephrine) for >3 days as rebound congestion (rhinitis medicamentosa) develops as early as day 3-4 1, 2
• If rebound occurs, discontinue immediately and start intranasal corticosteroids 1

Antibiotic Stewardship

• Reserve antibiotics only for children meeting strict bacterial sinusitis criteria 1
• Even with persistent symptoms, observation for an additional 3 days is reasonable before starting antibiotics 1
• Routine nasopharyngeal cultures are not helpful as pathogenic bacteria are recovered in up to 92% of asymptomatic healthy children 1

Red Flags Requiring Specialist Referral

• Unilateral, purulent, bloody, or malodorous discharge suggests foreign body and warrants otolaryngology evaluation 1
• Chronic congestion in neonates requires urgent evaluation as they are obligate nasal breathers and minor obstruction can be life-threatening 1
• Respiratory distress signs: oxygen saturation <92%, respiratory rate >70/min in infants <1 year or >50/min in older children, grunting, apnea 2
• Refractory symptoms despite appropriate medical therapy warrant allergist/immunologist consultation 1
• Suspected underlying conditions: immune deficiency, cystic fibrosis, primary ciliary dyskinesia 1

Supportive Care Measures

• Maintain adequate hydration 1
• Use supported sitting position for infants 1
• Eliminate environmental tobacco smoke exposure 1
• Educate families on managing fever, preventing dehydration, and recognizing deterioration 2
• Review if not improving after 48 hours 2