Every day in clinic, I meet children whose parents tell me that they have chronic “stuffy nose”, most of them have already been on months of nasal steroid spray (like Flonase) and antihistamines (like zyrtec or claritin and generic equivalents) but still not better. Most parents tell me that the child sounds like they have a cold, but this is daily and lasts for months! For school aged children, even if they asked the child to “blow” their nose, nothing seems to come out. Often the children become daily mouthbreathers because their noses “don’t work”. So what is wrong and how can we treat it? First, when we talk about “stuffy nose”, what is really going on is that the mucous membrane or lining inside our nasal passages, specifically those covering the turbinates, get engorged and so there is decreased room for air to flow through the nasal passages.
As a pediatric Ear, Nose, and Throat specialist, my differential diagnosis (conditions which I believe are causing these signs and symptoms) are different depending on the age of the child as well as what other associated symptoms parents reports.
Newborns and Infants Up to 12 Months of Age
Newborns and young babies are obligate nasal breathers, which means even though humans can breathe through our mouths, newborn infants can’t do that as well so they will always be trying to breathe through their nose as the nose is the only organ which humidifies the air. Until about 4-6 months of age, anytime babies’ nose are congested or “stuffy”, they are likely to make snorting noises and seem to “struggle” a little bit without turning blue or having any serious breathing difficulty. I always remind parents that young babies do not know how to actively “sniff in” their snot, or ‘blow” their noses.
1)They simply can’t blow their nose or sniff mucus up their nose! In this age group is simply nasal congestion from mucus, boogers, and milk which they spit up after feeding. Spit up of milk in infants often comes out of the mouth but also into the back of their nasopharynx (center of the head) and back of the nostrils. It is no wonder that they seem to be “stuffy” so much of the time. This is NOT allergies, and usually all that is appropriate to do is removing boogers gently with a moist Q-tip (right at the nostrils if and only when you see stuff there), and you may also place saline drops into the nostril which will make them sneeze (then blowing out the stuff), or perhaps help the snot go back towards their throat so they can swallow it. It is not safe to use “decongestant” drops like “Afrin” or (neosynephrine) in newborns, and I certainly do not recommend using nasal steroids in children younger than age 12 months! Absolutely no antihistamines should be given to babies. Always talk to your primary care physician if you are concerned.
2)Natural reaction related to reflux (backwash of stomach contents). Spit up that come from the stomach into the esophagus is called gastroesophageal reflux, and if spit up comes up out of the mouth than it is called laryngopharyngeal (larynx for voice box, and pharyngeal for throat) reflux. When milk and spit up comes up and every time it does, and even when milk is not coming out of their little mouths, it is associated with nasal congestion. One example to help you understand how the digestive system is related to the nasal physiology, simply gag yourself next time you are brushing your teeth. As soon as you start gagging, you will notice your eyes tearing and your nose becoming congested. This is because our bodies are made such that whenever there is activation of the digestive process the nose is stimulated as well. It is possible that if your baby spits up more often and more severe than another baby, then he/she may have worse nasal congestion.
3)Anatomical obstruction from structural abnormalities. Rare but possible causes include “nasolacrimal duct cyst” where the tear duct system has a small cyst that may be in the nasal passage causing actual blockage of airflow. An ENT specialist can perform nasopharyngoscopy in the office, in which a very skinny (2mm) flexible “spaghetti-like” scope is gently inserted into your child’s nostrils and carefully and quickly passed along deep into the nasal passages of your infant to make sure there is nothing blocking his/her nasal passage. Another rare reason is “choanal atresia” of one or both sides of the back of the nasal passage. This is when the bony plate persists which separates the nasal passage from the space in the center of the head which allows airflow to go from the nostrils down into the throat. Again, an ENT can simply use a scope to see if the back of your babie’s nostrils are open. In the hospital when babies are born, nurses will pass a skinny catheter into their nostrils to makes sure it passes all the way down the throat. This will help them suction out mucus and fluid, but also confirm that a baby does not have this condition. Those with choanal atresia of one side only usually have terrible and constant runny nose of just the one side, the side which is has the choanal atresia.
4)Viral infections, RSV (Respiratory syncytial virus), adenovirus, rhinovirus, influenza, etc. If your baby is having stuffiness from a “cold”, then it is more common than not that the nose will be “running” with clear stuff. Similar to adults, when we get a cold, often times the first sign is excessive sneezing and runny nose. I rarely see a child with chronic stuffy nose that is ALSO runny. Active runny noses are usually likely due to actual viral infections and/or flare up of allergies.
Toddlers (Age 1-2)
1)Reflux. Babies really do not need to drink milk from a bottle after their first birthday, and in fact it’s bad for their teeth if they still go to bed with a bottle. I can’t tell you how many mothers I meet that continue to allow their babies to have milk at bedtime. As they start eating table foods, and all kinds of other foods and are given juice or other sugar containing beverages other than water and milk, I believe that babies who go to bed with stuff in their tummies are likely to have undigested “stuff” which can cause indigestion, natural backwash of the stomach content, and then stuff nose because of the backwash.
2)Frequent upper respiratory tract illnesses. This is also often blamed by medical professionals as well as families. Babies may experience viral illnesses (colds) at least 7-10 times per year, especially if they go to daycare and preschool where “germs” and “viruses” are freely exchanged in the world of baby socialization. Let’s hope your childcare providers practice constant hand washing and good hygiene, and that they take care of cleaning the communal toys, books, as well as hygiene of all things and activities to a reasonable degree so that your baby is as healthy as can be. No matter what our daycare providers and we as parents do, there is no way to keep children in a bubble so it’s completely expected that our young children will get sick and get sick often in the early years. There is often no simple “cure” for the runny and stuffy noses of this age group. Make sure your toddler does not have middle ear fluid or chronic ear infections if their nose is always problematic. While there is no proven causal link between ear infections and stuffy nose, I definitely have often observed young babies who have chronic ear infections and need ear tubes also have chronic stuffy noses. One can argue that the mucosal lining of the nose may be inflamed the same way that the middle ear mucosal lining is inflamed as well.
3)Constipation. As I often ask parents what their toddler is eating once they start eating table foods, I find that often times they drink a great deal of milk, eat cheese, yogurt, and as a result have a highly acidic diet (dairy becomes highly acidic in warm temperature, hence the longer it sits in the digestive track the more acidic it becomes). With my own daughter, this seemed to be about the age when we had to give Miralax constantly, or she was so constipated that she would go stand in a corner by herself for what seemed like an eternity while trying to “poop”. No one wants their child to poop out hard rocks, so if your toddler has constipation please talk to your primary care provider about what can be done. This is the time to try to start getting some natural fiber in their diet through cooked vegetables and fresh fruit, along with some whole grain in the form of pasta or bread. Oh, if you’re wondering how in the world constipation can impact the nose, next time you are sitting on the pot and having a bowel movement, or “bear down” and pretend to have one, this “valsalva” manuever or the act of bearing down may bring on nasal stuffiness. Once again, the body is connected in so many ways!
4)Enlarged adenoid tissue. An ENT can simply perform nasopharyngoscopy during an office visit to tell you if your child has enlarged adenoid causing blockage of airflow from the nose down to the throat, which often leads them to have snoring, and chronic mouth breathing.
Preschoolers Age 2-5.
1)Poor Diet and Dietary Habits. If you know me, my blogs, my message, and my book by now, it will not surprise you that I will once again point to excessive dairy and sugar as well as eating/drinking too close to bedtime as the culprit of many chronically stuffy noses. I have not yet proven this scientifically to convince all doctors and providers to counsel families to really pay attention to the child’s diet and dietary habits, but nontheless I have enjoyed years of helping families get their kid’s nose to “work” again simply by cleaning up their eating habits. Learning that the “Kitchen is Closed” along with not letting kids drink as much juice, juice pouches, sugary beverages, sodas, chocolate milk, etc. I definitely recommend to all families to pay close attention to their child, treat constipation, minimize dairy and sugar in the evenings, follow 5 steps to “A Healthier Wei”, minimize processed and fast foods, and try to cut out evening and bedtime snacks. Foods and beverages too high in sugar results in a constantly over-acidic stomach content and may lead to excessive reflux which can trigger nasal congestion, runny nose, and cough.
2)Excessive dryness/environmental irritants/lack of humidity in environment. After spending the past 10 years in Kansas City, I have learned that dry air often causes chronic nasal stuffiness in children when heat in the house is typically turned on from October through April. At times, families use wood burning stoves, or children are exposed to second hand smoke, but of which can cause significant nasal stuffiness. I always tell parents to make sure the child’s bed is not directly beneath the vent when forced air heat is the source of home heating. I routinely recommended that families invest in a cool mist humidifier (filter free ones which they make now) which is placed in the child’s room and used once the forced air heat is turned out. Families living in the north or northeast part of the country, where winters are long and cold, definitely are at risk of having excessive dryness in their home environment.
3)Possible allergies or as a result of true chronic sinonasal inflammation or rhinosinusitis. Not a “sinus infection” like the one that you have been told must be treated with antibiotics. Children may be born allergic to food and animals, but are rarely allergic to trees, grass, pollen, and other environmental allergens until after they have been exposed for a few years. However, a bad cold may lead to lack of reversal of mucosal thickening, resulting in chronic mucosal thickening and poor “self-cleansing” of the paranasal sinuses.
4)Enlarged adenoid tissue. An ENT can simply perform nasopharyngoscopy during an office visit to tell you if your child has enlarged adenoid causing blockage of airflow from the nose down to the throat, which often leads them to have snoring, and chronic mouth breathing. I can’t tell you how often this is something that is never checked, while a child is prescribed months of allergy medications and nasal sprays. In the past many physicians would order lateral head X-rays, but in this day and age when unnecessary radiation exposure to our children is highly recommended by national guidelines, the preferred radiation free way is to have an ENT specialist look quickly with a scope in the office setting.
School-aged Children age 5 and up.
1)True chronic rhinosinusitis, usually secondary to being a child who is allergic to multiple aeroallergens. I have found chronic stuff nose to be the number symptom in children who test positive for allergies and have an allergic nature. In my published studies, nasal congestion/stuffiness was reported in over 95% of patients who were enrolled into my clinical trial with true evidence of chronic rhinosinusitis based on their CAT scan (imaging study).
2)Allergic rhinitis. These children will often have hayfever symptoms, often rubbing eyes and itching their noses. If either parent have test-proven allergies the child may have 40-60% chance of becoming an allergic individual. Typically this condition responds to nasal steroid spray and oral antihistamines.
3)Non-allergic rhinitis/chronic inferior turbinate hypertrophy. Each human nose has 3 sets of “turbinates’ or structures in the nose covered with nasal mucosa/epithelium. Turbinates regular airflow, and is covered with the living organ/mucosa of the nose which has cells with “cilia” that beats or cleanse the air we breathe in. The inferior turbinates are the largest and most inferior pair in the nasal passage, and in many children in whom skin allergy test is negative, they continue to have compromised nasal passage for airflow due to engorgement of the mucosa covering the inferior turbinates. For these children, I have had great clinical success performing “inferior turbinoplasty”, a fairly easy and straightforward , outpatient, procedure in which ENT surgeon can gently reduce/debulk the engorged mucosa of these largest pair of turbinates. I do not ever hurt the mucosa or living tissue over the turbinates as I believe one may be made a “nasal cripple”, since if we cause the mucosa to turn into scar, then that part of the nasal ciliary clearance/epithelium would not function properly.
4)Enlarged adenoid tissue.
Summary.If your child has suffered from chronic “stuffy nose”, first think about what he/she is eating and drinking and what time are they eating and drinking. You can start by making changes to their diet and dietary habits, and if things do not improve, definitely talk to your child’s primary care provider and consider referrals to ENT specialists and/or allergists. As for a great treatment option for children (especially age 4 and older) with chronic stuffy nose, regardless of cause, read my blog on “nasal saline irrigation”.
Dr. Julie Wei is a pediatric ear, nose, and throat specialist and the author of A Healthier Wei. As a mother herself, Dr. Wei is a passionate advocate for improving children's health through better diet and dietary habits. She has been committed to helping parents learn how to eliminate their child's ear, nose, and throat problems simply by reducing excessive sugar and dairy intake, as well as minimizing habitual late night snacking. She hopes to raise awareness for the need for accountability by both medical professionals and parents to ensure that children are not prescribed or take unnecessary medications long term.
When she is not in the clinic, operating room, or conducting research, you will find her in the kitchen preparing food with love along with her daughter Claire. If you sit next to her on the plane, she will likely share with you information about how to minimize choking hazards in young children, and many other tips for improving your child's health.