An evidence-based approach to streamline care and support effective management
Nasal congestion is among the most common pediatric complaints in primary care. Most cases can be confidently managed by PCPs with straightforward, evidence-based steps that help families find relief sooner. This approach is designed to equip and support PCPs in guiding families effectively, while ensuring that specialty referral to Pediatric Otolaryngology – Head and Neck Surgery (OHNS) is available when advanced evaluation is needed.
When to Manage in Primary Care
Children presenting with nasal congestion—with or without snoring or mouth breathing—should begin treatment in the primary care setting. This structured regimen helps resolve symptoms and supports efficient, coordinated care.
Initial Step: Medical Management (Six-Week Trial)
Start with a six-week trial of nasal steroid therapy, paired with saline irrigation.
All ages:
- Begin with nasal saline spray or rinse twice daily (BID).
- Apply nasal steroid spray immediately after saline to improve delivery and comfort.
- Saline is especially useful when thick rhinorrhea, crusting or dryness contributes to congestion.
- Consistent use of both helps clear mucus and enhance symptom relief.
Nasal steroid by age:
- Age 2–4 years: Flonase Sensimist (fluticasone furoate), one spray per nostril once daily. Use the gentle mist formulation for younger children.
- Ages ?4 years: Flonase (fluticasone propionate), one spray per nostril once daily.
- Ages >10 years: Flonase, two sprays per nostril once daily.
Additional recommendations:
- Consider referral to an allergist if environmental allergies are suspected.
- If improvement is seen after six weeks, continue the regimen for a full three-month duration.
If Symptoms Persist After Six Weeks
If there is no improvement after consistent, proper use:
- Consider a lateral neck X-ray to assess for adenoid hypertrophy.
- Refer to Pediatric OHNS for an expedited telemedicine appointment within six weeks.
- Note in referral: “Completed full six-week trial, no response.”
- Continue nasal steroid + saline through to the ENT visit (for a total of approximately three months).
Nasal Spray Technique: Key Points for Families
Proper technique ensures effectiveness and minimizes irritation.
Preparation:
- Verify that the nasal spray is not expired before use to ensure safety and effectiveness.
- Have the child gently blow their nose to clear the nostrils if needed.
- Prime the spray if it is the first use or if it has not been used for more than 14 days.
Administration:
- Have the child sit upright and tilt the head slightly forward.
- Insert the spray tip into one nostril, closing the other with a finger.
- Press down the pump as the child gently breathes in through the nose.
- Breathe out through the mouth.
- Repeat on the other side.
- Avoid blowing the nose for 15 minutes after use.
After use:
- Wipe the spray tip with a clean tissue after each use.
Encourage daily consistency—pairing nasal sprays with a routine (e.g., after brushing teeth) and using simple rewards to promote adherence.
Monitoring and Safety
- Watch for mild side effects (sore throat, bloody nose, increased cough).
- Contact the health care provider if symptoms persist, worsen or new issues arise.
- Store medicine at room temperature, away from sunlight.
- Discard expired bottles, and document start dates for ongoing tracking.
Why Follow This Pathway
This approach supports effective, evidence-based management in primary care while avoiding unnecessary procedures such as nasopharyngoscopy. It helps ensure that specialty care is reserved for children who truly need advanced evaluation.
Referral Instructions
If referral is needed after the six-week trial, please note:
“Completed full six-week trial, no response.”
Refer to Pediatric OHNS for an expedited telemedicine appointment (within six weeks).
Referral link: ucsfbenioffchildrens.org/clinics/ear-nose-and-throat-clinic/refer
Scan the QR code below to access referral instructions:
Co-developed by Pediatric Otolaryngology (ENT/OHNS) at UCSF Benioff Children’s Hospitals and UCSF Benioff Children’s Physicians (UBCP)
