Decongestants, antihistamines and nasal irrigation for acute sinusitis in children

For the current issue of the Journal, we asked Dr Kate Runkle to comment on and put into context the recent Cochrane Review on decongestants, antihistamines and nasal irrigation for acute sinusitis in children. The efficacy of decongestants, antihistamines and nasal irrigation in children with clinically diagnosed acute sinusitis has not been systematically evaluated. Selection criteria: Randomized controlled trials (RCTs) and quasi-RCTs that evaluated children <18 years of age with acute sinusitis, defined as 10 to 30 days of rhinorrhea, congestion or daytime cough, were included. Trials involving children with chronic sinusitis and allergic rhinitis were excluded. Data analysis: Two review authors independently assessed each study for inclusion. Of the 662 studies identified through the electronic and manual searches, none met all of the inclusion criteria. There is no evidence to determine whether the use of antihistamines, decongestants or nasal irrigation is efficacious in children with acute sinusitis. Further research is needed to determine whether these interventions are beneficial in the treatment of children with acute sinusitis. The full text of the Cochrane Review is available in The Cochrane Library: Shaikh N, Wald ER. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD007909. DOI: 10.1002/14651858.CD007909.pub4. Kids get a lot of colds! The average child <5 years of age will experience two to seven viral upper respiratory infections (URIs) per year (1). In Canada, a 1995 analysis of linked computerized databases reported that 64% of 61,165 children <5 years of age made 140,892 primary care visits for respiratory infections (2); of those, 61% were diagnosed with sinusitis. A longitudinal, prospective cohort study from the United States reported, however, that only 8% of viral URIs will progress to bacterial sinusitis (3). Furthermore, when strict clinical criteria are used to make a diagnosis, the prevalence of sinusitis in all URIs presenting in the primary care setting is only 9% (4). The gold standard to make a diagnosis of acute bacterial sinusitis is a maxillary sinus aspirate; however, this procedure has not been performed routinely since the 1980s (5). Currently, we rely on less invasive clinical criteria to diagnose sinusitis. These are based on patient histories and predictable symptom patterns: nasal discharge or congestion of any colour or consistency, with or without daytime cough that persists 10 days or beyond without improvement; fever ≥39°C with purulent nasal discharge for a minimum of three days; or worsening or new nasal congestion, cough and fever after a period of three to four days of improved symptoms following a URI (6). There are no physical examination findings or imaging results included in the diagnostic criteria for sinusitis. However, contrast-enhanced computed tomography or magnetic resonance imaging should be performed if complications are suspected (6). Even when diagnostic criteria are strictly applied, 20% to 40% who meet the criteria for sinusitis actually simply have a protracted uncomplicated viral URI, identified by a complete lack of evidence of sinusitis on Water's view radiograph (7). Historical features, such as mild symptoms, lack of green nasal discharge and lack of sleep disturbance, are more likely to be associated with uncomplicated viral URI (7). The peak incidence of sinusitis is between one and six years of age (8,9). Only the ethmoid and maxillary sinuses are present at birth, whereas the frontal and sphenoid aerate between five and six years of age. A child <1 year of age is unlikely to have sinusitis. In the era of the maxillary sinus aspirates, the bacteria isolated included mostly Streptococcus pneumoniae, nontypeable Haemophilus influenzae and Moraxella catarrhalis (10). No microbiology studies, however, have been published since the introduction of the 13-valent pneumococcal conjugate vaccine (5). We can extrapolate from more recent studies that evaluated middle ear aspirates in otitis media, that the predominance of S pneumoniae is decreasing while that of H influenzae is increasing (5). According to the new American Academy of Pediatrics (AAP) clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years (6), any child who meets the clinical criteria for acute bacterial sinusitis should be placed on an antibiotic. For those, however, who meet only criteria 1 (persistent nasal symptoms), a further three-day observation period is appropriate before antimicrobials are prescribed (6). They recommend either amoxicillin-clavulanate (90 mg/kg/day) (5) or high-dose amoxicillin (90 mg/kg/day) as a first-line antibiotic choice. Depending on the resistance patterns of S pneumonia, low-dose amoxicillin may also be used. The AAP recommends a minimum 10-day course of antibiotics (6), although some clinicians may choose to discontinue the antibiotics after a five-day course if the child has improved. Any child with systemic illness, complications of sinusitis or who is not tolerating oral antibiotics should be admitted for parenteral antibiotics. Judicious antimicrobial treatment of sinusitis can theoretically minimize or prevent bacteria-derived complications such as meningitis, brain abscess or sinus venous thrombosis (5). All the above studies, however, are underpowered to analyze these rare outcomes. Moreover, it is not uncommon for children to present with these complications with no clear history of preceding sinusitis. To further ‘muddy the waters’, a recent systematic review found conflicting results regarding the benefits of antibiotics in sinusitis in four randomized trials (11). Two of the studies showed no difference between the antimicrobial and placebo arm (12,13). One study, however lacked strict inclusion criteria and used a low dose of cefuroxime (<20 mg/kg/day) (12). The two studies by Wald et al (14,15) used strict inclusion criteria, based on the AAP guidelines, and showed that the treatment arm had significantly improved symptom reporting scores and cure ratings than placebo. Conversely, the use of adjunctive therapies, such as antihistamines, decongestants, steroids and nasal irrigation, to treat sinusitis is not controversial. There are no data to support their use in children and all are associated with potentially adverse events (5,6,11,16). Nasal steroids have been shown to provide some benefit in adults; however, there are little data to support their use in children (11) and are not included in this Cochrane review (16). Given the lack of any additional evidence to support the use of the other adjunctive therapies reported in this Cochrane review (16), I would not change my practice to include them in the management of paediatric sinusitis.

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