What is the recommended management for allergic rhinitis in a 5-year-old girl with sneezing, itchy eyes, and nasal congestion?

Allergy Relief for a 5-Year-Old Girl

For a 5-year-old girl with allergic rhinitis symptoms (sneezing, itchy eyes, nasal congestion), start with an oral second-generation antihistamine such as cetirizine 5 mg once daily, and if symptoms persist or nasal congestion is prominent after 1-2 weeks, add an intranasal corticosteroid such as fluticasone propionate 1 spray per nostril daily. 1, 2

First-Line Treatment: Oral Antihistamines

Start with cetirizine 5 mg once daily for children aged 2-5 years, which is FDA-approved and available over-the-counter. 1 This addresses the histamine-mediated symptoms that are most common in allergic rhinitis:

• Sneezing and itching (nose, eyes, throat) respond particularly well to antihistamines 1, 3
• Rhinorrhea (runny nose) is effectively controlled 1, 4
• Itchy, watery eyes improve with oral antihistamines 2

Important considerations for cetirizine:

• Administer in the morning to minimize potential sedation, though rates are low (0.4-3%) at recommended doses 1
• Common side effects include possible drowsiness, headache, and dry mouth 1
• Continue daily use throughout allergen exposure periods for optimal control 1

Second-Line Treatment: Intranasal Corticosteroids

If symptoms persist after 1-2 weeks of antihistamine therapy, or if nasal congestion is a prominent symptom from the start, add an intranasal corticosteroid. 2, 1

For a 5-year-old, appropriate options include:

Fluticasone Propionate (Flonase)

• Dosing: 1 spray per nostril once daily 2
• FDA-approved for ages ≥4 years 2
• Available over-the-counter 5
• Most effective for nasal congestion, which is inflammation-driven 1, 3

Mometasone Furoate (Nasonex)

• Dosing: 1 spray per nostril once daily 2
• FDA-approved for ages ≥2 years 2
• Requires prescription 2

Fluticasone Furoate (Veramyst)

• Dosing: 1-2 sprays per nostril once daily 2
• FDA-approved for ages ≥2 years 2
• Requires prescription 2

Critical points about intranasal corticosteroids:

• Maximum effect requires several days to weeks of regular daily use—these are maintenance medications, not rescue therapy 6, 5
• Intranasal corticosteroids are more effective than oral antihistamines for controlling all symptoms of allergic rhinitis, especially nasal congestion 1, 4
• Start before allergen exposure when pollen patterns are predictable for seasonal allergies 7
• Common side effects include epistaxis (nosebleeds), headache, and pharyngitis 2
• Safe for long-term use and do not cause rebound congestion 7
• For children 4-11 years, limit use to 2 months per year before checking with a doctor due to potential effects on growth rate 5

Proper Administration Technique

Correct nasal spray technique is essential for efficacy:

• Prime the bottle before first use 6
• Shake before each spray 6
• Use contralateral hand technique (right hand for left nostril, left hand for right nostril) to angle spray away from nasal septum 6
• This reduces epistaxis risk and improves medication delivery 6

Combination Therapy Approach

For inadequate response to monotherapy, combine oral antihistamine with intranasal corticosteroid using separate devices. 1 This provides:

• Antihistamine coverage for itching, sneezing, and rhinorrhea 1
• Corticosteroid control of inflammation and nasal congestion 1, 3

Adjunctive Measures

Nasal saline irrigation is safe, inexpensive, and effective for removing allergens, secretions, and mediators from nasal passages. 2, 3 Hypertonic solutions provide additional decongestant activity. 3

Allergen avoidance should be implemented when specific triggers are identified. 8, 4

When to Consider Allergy Testing and Immunotherapy

Consider referral for allergy testing if:

• Symptoms persist despite appropriate pharmacotherapy 1
• Specific allergen identification would guide avoidance strategies 1

Allergen immunotherapy (subcutaneous or sublingual) is effective for allergic rhinitis but is typically not initiated in children under 5 years due to: 2

• Difficulty communicating about systemic reactions 2
• Injections can be traumatic for very young children 2
• However, immunotherapy has been shown safe and effective in children as young as 3 years in controlled studies 2

Common Pitfalls to Avoid

• Do not use intranasal corticosteroids as rescue therapy—they require regular daily use for effectiveness 6, 5
• Do not stop treatment when symptoms improve—continue throughout allergen exposure period 5
• Do not use topical decongestants (like oxymetazoline) for more than 3 days due to rebound congestion risk 7
• Do not expect immediate relief from intranasal corticosteroids—counsel parents that full effect takes days to weeks 6, 5
• Ensure proper technique with visual demonstration to parents and child to maximize efficacy 6

Follow-Up

Reassess response after 2 weeks of treatment to determine if therapy adjustment is needed. 1 Monitor for medication side effects, particularly sedation with antihistamines and epistaxis with nasal corticosteroids. 2, 1