Nasal Congestion Management

Introduction to Nasal Congestion

• Nasal congestion can be a significant issue in infants, particularly those under 2-6 months who are obligate nasal breathers, making proper management crucial for adequate breathing, feeding, and sleep 1

Benefits of Saline Solution

• Buffered saline solution is recommended by the American Academy of Pediatrics to clear mucus and moisturize nasal passages, improving nasal airflow and quality of life in infants 2
• Buffered hypertonic (3%-5%) saline is completely safe with no cardiovascular effects and provides modest benefit for symptom relief, helping to clear mucus and moisturize nasal passages, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 3, 1

Medication Recommendations

• The American Academy of Pediatrics states that intranasal decongestants are not recommended for infants due to insufficient data 2
• The American Academy of Pediatrics advises against using antihistamines as primary treatment for nasal congestion in infants without evidence of allergy 2
• Intranasal antihistamines like azelastine are more effective for nasal congestion than oral preparations 4
• Azelastine can be used as first- or second-line therapy and is especially useful for patients with episodic nasal symptoms or as pretreatment prior to allergen exposure 4

• The following dosages are recommended:

  Medication	Dosage
  Flonase	200mcg once daily (2 sprays in each nostril) or 100mcg twice daily (1 spray in each nostril twice daily)
  Zyrtec (cetirizine)	5mg once daily, with or without food

• Intranasal corticosteroids are the most effective medication class for controlling all major symptoms of allergic rhinitis, as recommended by the American College of Allergy, Asthma, and Immunology 5, 1
• Combination therapy with an intranasal corticosteroid and an intranasal antihistamine (e.g., azelastine) has shown greater symptom reduction than either agent alone, according to the American College of Allergy, Asthma, and Immunology 6, 1

Non-Pharmacological Interventions

• External nasal dilator strips can provide temporary symptomatic relief for mild to moderate nasal congestion, with external nasal dilator strips being the most effective retail nasal appliance for improving nasal congestion, as recommended by the European Respiratory Society 7, 1
• Implementing allergen avoidance strategies based on identified triggers can help alleviate symptoms, such as using air filtration systems, bed covers, removal of pets if allergic, and acaricides for dust mite control, as recommended by the American Academy of Allergy, Asthma, and Immunology 4, 8, 1

Monitoring and Referral

• The American Academy of Allergy, Asthma, and Immunology recommends assessing response to therapy within 2-4 weeks of initiating treatment and considering allergen testing and immunotherapy if symptoms persist despite optimal therapy, with consultation with an allergist/immunologist when symptoms are prolonged, complications exist, or treatment is ineffective 4, 8, 9, 1
• Referral to an allergist or otolaryngologist may be warranted for patients with persistent symptoms, as recommended by the American Academy of Otolaryngology 1
• Patients on sympathomimetic medication should have their blood pressure monitored closely, and those on anticoagulants should be aware of the potential increased risk of epistaxis with intranasal medications, as recommended by the American College of Allergy, Asthma, and Immunology 1
• For patients with persistent symptoms despite optimal pharmacologic therapy, immunotherapy (sublingual or subcutaneous) should be offered, as it provides long-term benefits even after discontinuation and may prevent development of new allergies or asthma, as recommended by the American Academy of Allergy, Asthma, and Immunology 4, 8, 9, 1

Safety Considerations

• Common side effects of azelastine include bitter taste (reported in 8-19.7% of patients) and somnolence (reported in 0.9-11.5% of patients) 4, 1
• Patients should be monitored for signs of somnolence, especially at initiation of therapy, and cautioned about the potential for sedation, especially when driving or operating machinery 4
• Oral decongestants should be avoided as they can increase blood pressure and cause palpitations, insomnia, and irritability, with pseudoephedrine increasing systolic blood pressure by 0.99 mmHg and heart rate by 2.83 beats/min, as warned by the American Heart Association and the American Academy of Allergy, Asthma, and Immunology 1
• First-generation antihistamines should be avoided due to sedation and anticholinergic effects, as recommended by the American Academy of Sleep Medicine and the American Academy of Allergy, Asthma, and Immunology 1