Intranasal corticosteroids in pediatric airway inflammation: From pharmacokinetics and evidence to optimized clinical practice.

Intranasal corticosteroids (INS) are widely recommended as first-line therapy for pediatric upper airway disorders due to their potent local anti-inflammatory effects and favorable safety profile. This narrative review evaluates current evidence regarding the pharmacologic properties, clinical efficacy, and safety of INS in children with allergic rhinitis (AR), adenoid hypertrophy (ADH), obstructive sleep apnea (OSA) or sleep-disordered breathing (SDB), otitis media with effusion (OME), and rhinosinusitis (RS). A structured literature search of PubMed, EMBASE, and Cochrane databases (2015-2025) identified randomized controlled trials, observational studies, systematic reviews, and meta-analyses assessing indications, efficacy outcomes, and adverse events. Evidence consistently supports INS as the most effective pharmacologic therapy for pediatric AR, with significant improvements in symptom scores and quality of life. In ADH and mild OSA/SDB, INS may reduce nasal obstruction and decrease adenoid size, potentially lowering the need for surgical intervention. Data for OME are inconsistent, and routine use is not universally recommended. In acute and chronic RS, INS demonstrates benefit, particularly when allergic inflammation predominates. Pharmacokinetic differences among agents influence safety. Newer molecules such as fluticasone propionate, fluticasone furoate, and mometasone furoate exhibit low systemic bioavailability and high receptor affinity, minimizing hypothalamic-pituitary-adrenal axis suppression. Local adverse effects are generally mild and comparable to placebo. Epistaxis is a recognized local adverse effect, although pediatric data do not demonstrate a significant increase compared with placebo. Available data suggest minimal, clinically insignificant effects on growth velocity when recommended doses are used. Overall, INS remain a cornerstone of AR therapy, with well-established efficacy and a favorable safety profile when appropriately used. There is also supportive and clinically meaningful evidence for their use in selected children with ADH, although the available evidence is heterogeneous. In contrast, evidence for INS in OME, OSA/SDB, and pediatric CRS remains limited or inconsistent and does not currently support their routine use solely for these pediatric upper airway conditions, particularly in the absence of concomitant nasal allergic inflammation.