Pediatric Nasal Obstruction

Why your child can’t breathe through the nose, sorted by age and by pattern

A stuffy nose for a few days with a cold is part of childhood. A nose that stays blocked for weeks or months is different. Children with chronic nasal obstruction breathe through their mouths, snore, sleep poorly, and sometimes struggle with eating, smell, speech, or attention. As a fellowship-trained pediatric ENT in Frisco, I evaluate blocked noses in children of every age, from newborns to teenagers. The most useful first step is to sort out three things: how old the child is, whether the blockage is on one side or both, and whether it is constant or comes and goes. Those three clues narrow the list of causes quickly.

Key takeaways

• The likely cause depends heavily on age. Newborn congestion, toddler blockage, and teenage blockage usually have different explanations.
• A blockage on one side only, especially with foul-smelling drainage, is a foreign object until proven otherwise. A button battery in the nose is an emergency.
• Enlarged adenoids are the most common cause of constant blockage on both sides in young children. Allergies become more common as children get older.
• Nasal polyps are unusual in healthy children. A child with polyps should be evaluated for cystic fibrosis.
• After a nose injury, sudden blockage on both sides needs a same-day exam to rule out a septal hematoma.
• Do not raise the head of the bed for babies under 12 months. Safe-sleep guidance is flat on the back on a firm surface.

Causes by age

Newborns and young infants

Babies breathe mainly through the nose in the first months of life, so even mild swelling can make feeding noisy and hard. Most newborn congestion is harmless and improves on its own over the first weeks to months. Saline drops and gentle suction before feeds are usually all that is needed.

A few structural problems need prompt attention. In choanal atresia, the back of the nasal passage is closed by bone or tissue. When both sides are closed, a newborn struggles to breathe and turns dusky at rest, then pinks up when crying, because crying opens the mouth. When only one side is closed, the main sign may be constant thick drainage from one nostril, and the diagnosis is sometimes made months or years later. Choanal atresia can occur with other conditions, including CHARGE syndrome. Pyriform aperture stenosis, a narrowing of the bony opening at the front of the nose, causes similar breathing and feeding problems. Both are diagnosed with an exam, a small scope or catheter, and often a CT scan, and both can be treated surgically.

Toddlers and preschoolers

Young children typically catch six to eight colds a year, more in daycare. In the fall and winter the colds can run together, so it can seem as if the nose is never clear. If the blockage continues between colds, snoring is present most nights, or your child breathes through the mouth even when well, enlarged adenoids are the usual suspect. Adenoids tend to be largest between about ages 3 and 7 and shrink in the teenage years. My posts on the adenoids and on chronic mouth breathing in young children go into more detail.

This is also the peak age for objects in the nose: beads, food, foam, toy parts.

School-age children and teenagers

Allergic rhinitis becomes much more common with age. Seasonal pollen allergies usually take a few seasons of exposure to develop, so they are uncommon in very young children, while indoor allergens such as dust mites, pets, and cockroaches can cause symptoms earlier. Allergic blockage often comes with sneezing, itching, clear drainage, dark circles under the eyes, and the “allergic salute” (rubbing the nose upward). North Texas has a long pollen season. Our Frisco pollen and allergen forecast tracks it day to day.

In older children and teens, a deviated septum (often from a fall or sports injury), enlarged turbinates (the ridges on the side walls of the nose that swell with allergies or irritation), and rebound congestion from overusing decongestant sprays such as oxymetazoline become more common.

One side or both sides?

Blockage on one side narrows the possibilities:

• An object in the nose. One-sided, foul-smelling, sometimes blood-tinged drainage in a young child is a foreign body until proven otherwise. Many children never tell their parents. A button battery in the nose is an emergency, because it can burn through the nasal septum within hours. If you think your child put a battery or magnet in the nose, go to the emergency department.
• A deviated septum, often after an injury.
• One-sided choanal atresia, which may not be diagnosed until later in childhood.
• A polyp or growth. These are uncommon. In adolescent boys, one-sided blockage with repeated heavy nosebleeds needs an ENT exam to rule out a rare benign but vascular tumor called a juvenile nasopharyngeal angiofibroma.

Blockage on both sides more often points to adenoids, allergies, infections, enlarged turbinates, or medication overuse.

Constant versus comes and goes: blockage that switches from side to side over the day is often the normal “nasal cycle” combined with allergies or swollen turbinates. Blockage that never lets up, on one or both sides, is more likely to be structural: adenoids, septum, polyps, or something in the nose.

After a nose injury: watch for a septal hematoma

If your child hits the nose and, over the next day or two, the nose becomes blocked on both sides, a collection of blood can form under the lining of the septum. A septal hematoma needs to be drained promptly. Left alone, it can become infected and destroy the cartilage, which can lead to a collapsed “saddle” nose. Any child with significant nasal blockage after an injury should be examined the same day.

Why a blocked nose matters

• Sleep: nasal blockage contributes to snoring and, together with large tonsils, to obstructive sleep apnea in children. Poor sleep can show up as daytime behavior problems, inattention, and bedwetting rather than obvious sleepiness. See Does Your Child Snore? and our sleep and breathing disorders services.
• Ears: large adenoids sit next to the openings of the Eustachian tubes and are linked with fluid behind the eardrums and repeated ear infections.
• Eating and smell: infants struggle to feed when they cannot breathe through the nose, and older children with chronic blockage often have a poor sense of smell and taste.
• Teeth and face: long-term mouth breathing is associated with differences in palate shape and bite. The research on cause and effect is still debated, and palate expanders do not treat enlarged adenoids or tonsils, which are the usual cause of obstruction in young children. I explain the overlap in RPE vs. Tonsillectomy.

How a pediatric ENT evaluates nasal obstruction

1. History. How long, which side, how bad at night, snoring or pauses in breathing, allergy symptoms, nosebleeds, injuries, and medications used. A short phone video of your child sleeping is extremely helpful.
2. Examination. I look at the front of the nose with a light and check the septum, turbinates, and any drainage.
3. Nasal endoscopy. A thin, flexible camera, used after a numbing and decongesting spray, shows the adenoids, the back of the nose, and any polyps or objects. It takes about a minute, and most school-age children tolerate it well. In children who cannot cooperate, a side-view X-ray of the neck can estimate adenoid size, although it is less informative than endoscopy.
4. Allergy testing, by skin or blood test, when the history suggests allergies.
5. A sleep study when sleep apnea is suspected and the diagnosis or severity is unclear.
6. CT scan only for selected problems, such as suspected choanal atresia, chronic sinusitis being considered for surgery, or a growth.

Treatment options

At home

• Saline sprays, drops, or rinses are safe at any age and clear mucus. For infants, use saline drops and gentle bulb suction before feeds and sleep.
• A cool-mist humidifier can ease dryness. Clean it as the manufacturer directs to prevent mold growth.
• Safe sleep for infants: do not use pillows, wedges, or inclined sleepers to raise a baby’s head. The American Academy of Pediatrics recommends placing babies on their backs on a firm, flat surface. For older children, an extra pillow is fine if it helps.
• Avoid over-the-counter cough and cold medicines in young children (the FDA advises against them under age 2, and labels say not under age 4), and avoid medicated decongestant sprays for more than a few days at any age because of rebound congestion.

Medications

• Nasal steroid sprays reduce swelling from allergies and enlarged adenoids. Several are labeled for children as young as 2. They work over days to weeks, not hours, so a trial usually lasts several weeks. Aim the spray toward the outer wall of the nostril, away from the septum.
• Non-sedating antihistamines help sneezing, itching, and drainage from allergies, but do little for blockage on their own.
• Allergy immunotherapy (allergy shots or drops) can reduce allergy symptoms over time. See my allergy shots and immunotherapy guide.

Procedures and surgery

• Adenoidectomy removes enlarged adenoids through the mouth, with no external incisions. It is a short outpatient procedure. A 2016 systematic review and meta-analysis I co-authored found that adenoidectomy alone can improve obstructive sleep apnea in young children, although children with both large tonsils and large adenoids often need both removed. See tonsil and adenoid problems in children.
• Turbinate reduction shrinks enlarged turbinates from the inside, preserving their function. It is considered for selected older children and teens whose blockage persists despite medical treatment.
• Septoplasty straightens a deviated septum. Because the septum is a growth center for the nose and midface, surgeons are conservative in young children and usually wait until growth is largely complete unless the blockage is severe.
• Removal of a foreign body, usually in the office, occasionally under brief anesthesia.
• Repair of choanal atresia or pyriform aperture stenosis in infants, when needed.
• Nasal polyps call for evaluation of the cause, including testing for cystic fibrosis, followed by medical treatment and sometimes sinus surgery. Learn more about nasal polyps.

When surgery is recommended, I perform outpatient procedures at Stonebridge Surgery Center, which is my primary surgical venue for children who are good candidates for an outpatient setting.

From my research and practice

Several of my publications bear on nasal obstruction. A 2016 systematic review and meta-analysis in the Journal of Laryngology & Otology (Reckley, Song, Chang, Cable, Certal, Camacho) pooled the published studies of adenoidectomy alone for obstructive sleep apnea in children. Breathing interruptions during sleep fell substantially, with the largest improvement in the youngest children, although the number of studies was small. A 2016 study I co-authored in Plastic Surgery International, in 240 adults, found that allergic rhinitis and the shape of the outer nose predicted how blocked patients felt, while turbinate size on examination did not. That finding was in adults, but the lesson carries over to children: treatment decisions should follow the child’s symptoms and the whole picture, not a single exam finding. And because objects in the nose and airway are a pediatric specialty in their own right, I co-wrote the chapter on aerodigestive foreign bodies and caustic ingestion in Sataloff’s Comprehensive Textbook of Otolaryngology and co-authored research on emergency management of button batteries. You can find these on my publications and research page.

When to see a pediatric ENT

• Nasal blockage that lasts more than a few weeks or continues between colds
• Snoring most nights, pauses in breathing, or restless sleep
• Constant mouth breathing, even when your child is well
• Blockage or thick drainage on one side only
• A newborn with noisy breathing and trouble feeding, or color changes that improve with crying (seek care immediately)
• Repeated ear infections or fluid behind the eardrums along with nasal blockage
• Nasal polyps, repeated heavy nosebleeds, or blockage after an injury

Frequently asked questions

My baby sounds congested all the time but is feeding and growing well. Should I worry?

Usually not. Newborn congestion is very common and tends to improve over the first months. Saline and gentle suction before feeds are often enough. If your baby struggles to feed, has pauses in breathing, turns blue or dusky, or is not gaining weight, see your pediatrician promptly.

How do I know if my child has enlarged adenoids?

Clues include mouth breathing, snoring, a nasal-sounding voice, constant congestion that does not clear between colds, and frequent ear infections. The adenoids cannot be seen by looking in the mouth. A quick endoscopic look through the nose in the office shows their size directly.

Will my child outgrow nasal obstruction?

Adenoids shrink with age, and children get fewer colds as they grow, so some problems improve on their own. Structural causes such as a deviated septum or choanal atresia, and allergies, generally need treatment.

Are nasal steroid sprays safe for children?

Nasal steroid sprays used at labeled doses act mainly in the nose and have a long safety record in children. Your child’s doctor will recommend a specific product for your child’s age and monitor growth with long-term use.

Does my child need surgery?

Most children do not. Many improve with time, saline, and allergy treatment. Surgery is considered when a structural cause is clear and is affecting sleep, breathing, ears, or quality of life despite medical treatment.

References

1. Reckley LK, Song SA, Chang ET, Cable BB, Certal V, Camacho M. Adenoidectomy can improve obstructive sleep apnoea in young children: systematic review and meta-analysis. J Laryngol Otol. 2016;130(11):990–994. doi:10.1017/S0022215116008938
2. Camacho M, Zaghi S, Certal V, et al. Predictors of nasal obstruction: quantification and assessment using multiple grading scales. Plast Surg Int. 2016;2016:6945297. doi:10.1155/2016/6945297
3. Ruhl DS, Cable BB, Rieth KK. Emergent treatment of button batteries in the esophagus: evolution of management and need for close second-look esophagoscopy. Ann Otol Rhinol Laryngol. 2014;123(3):206–213. doi:10.1177/0003489414522969
4. Cable BB, Ruhl D. Foreign bodies and caustic ingestion of the aerodigestive tract. In: Sataloff’s Comprehensive Textbook of Otolaryngology. JP Brothers Medical Publishers; 2015.
5. Moon RY; Task Force on Sudden Infant Death Syndrome. Sleep-related infant deaths: updated 2022 recommendations for reducing infant deaths in the sleep environment. Pediatrics. 2022;150(1):e2022057990. doi:10.1542/peds.2022-057990

If your child’s nose seems blocked more often than not, I’m happy to take a look. You can contact my office to schedule a visit in Frisco or at the McKinney office of ENT and Allergy Centers of Texas.