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Allergic Rhinitis in
Children
Dr. Madhavi Velpula
Consultant in Paediatrics,
Poole NHS Foundation Trust
Outline of Presentation

Epidemiology – Why Allergic Rhinitis is important

Making a correct diagnosis

Understand the therapeutic options for the management

Identify the challenges in prescribing
Key References

BSACI guidelines for the management of Allergic and NonAllergic Rhinitis, Clinical and Experimental Allergy, 38, 1942, 2015
Allergy can affect in different ways in
different ages

Atopy is the inherited tendency to develop harmful
Immune responses to harmless substances
Food Allergy
Atopic
Dermatitis
Childhood
wheeze
Allergic
Rhinitis
ATOPIC / ALLERGY MARCH
Asthma
What is AR

Inflammation of mucous membranes of Nose, Eyes,
Eustachian tubes, Sinuses, Middle ear and Pharynx

It is characterised by a complex interaction of
inflammatory mediators but ultimately is triggered by
Immunoglobulin E (IgE) mediated response to an extrinsic
protein
• Rhinorhoea
• Nasal blockage
• Postnasal drip
• Itchiness
• Sneezing
• Associated health
effects
‼IgE mediated
Epidemiology

Probably underestimated

Top 10 reasons for primary care health visits

Affects social life, sleep, school attendance, performance
& work

Substantial costs

Sex: Males > females. Prevalence equal in adulthood

Co-morbidities & health effects
Allergic triggers for Rhinitis in children
Making a Diagnosis - Symptoms


Sneezing, itchy nose, itchy palate (AR very likely)

Seasonal? (pollens or mould spores)

At home? (pets or house dust mite)

Improves on holiday?
Rhinorrhoea

Clear (AR likely)

Yellow (AR or infection)

Green, blood tinged or unilateral (other cause)
Making a diagnosis - Symptoms

Nasal obstruction





Unilateral (AR unlikely) vs bilateral
Nasal crusting

AR unlikely

Often seen with AR, especially seasonal AR

Cough may be caused by AR
Eye symptoms
LRT symptoms
Other symptoms

Snoring, sleep disturbance, mouth breathing, “nasal voice”
(not very specific for AR)
Other clues

Personal history of other allergic conditions

Family history of allergic conditions

Specific allergen and irritant exposure
Signs of Atopy & Rhinitis
Clinical examination

Depressed / widened nasal bridge (AR unlikely)

Assess nasal airflow

Anterior Rhinoscopy
? Purulent secretions (AR unlikely)
? Nasal polyps (yellow/grey and lack sensitivity)
? Nodules and crusting (AR unlikely)
Diagnosis in Primary care setting
Other causes of Rhinitis in children

Infection – Viral / Bacterial / fungal Rhinosinusitis

Foreign body in the nose

Drug, Food induced rhinitis (Rhinitis medicamentosa)

Physical, chemical factors

NARES, aspirin sensitivity

Vasomotor rhinitis
Investigations
Immunoassay versus Skin prick tests
Immunoassay
Skin Prick

Not influenced by Skin disease

Higher sensitivity

Not influenced by medication

Immediate results

Does not require expertise

Requires expertise

Quality control possible

Cheaper

Expensive
AR Classification
Intermitent
• < 4 days per week
• Or < 4 weeks
Mild
• Normal sleep
• No impairment
• Normal school and work
• No troublesome symptoms
In untreated patients
Persistent
• > 4 days per week
• > 4 weeks
Moderate & Severe
(one or more items)
• Abnormal sleep
• Abnormal school
performance & work
• Impairment of daily
activities, sport &
leisure
• Troublesome symptoms
Therapeutic Options
Allergen Avoidance
When possible
Pharmacotherapy
Safe, effective & easy
to be administered
Immunotherapy
COSTS
Parents Education
Always indicated
Specialist
treatment, may
alter the course of
the disease
Education
 Nature
of disease
 Symptoms
 Complications (eg sinusitis, otitis media, later asthma)
 Allergen avoidance
 Realistic expectations of treatment
 Drug treatment and potential issues
 Compliance and correct technique
Antihistamine - considerations

Child’s age

Child / parent understanding

Dosage

Effectiveness

Method of administration

Side effects
Oral Antihistamines
First generation
Newer agents

Chlorpheniramine

Acrivastine

Brompheniramine

Azelastine

Diphenydramine

Cetirizine

Promethazine

Levocetirizine

Tripolidine

Loratadine

Desloratadine

Fexofenadine

Mizolastine

Hydroxyzine

Azatadine
New Generation Oral Antihistamines

First line of choice for Mild AR

Effective for
– Rhinorrhoea
- Nasal pruritis
- Sneezing

Less effective for
– Nasal blockage

Possible additional anti-allergic & anti-inflammatory effect

Minimal or no sedative effect

Once daily administration

Rapid onset & 24 hour duration of action
Nasal Antihistamines

Azelastine

Levocabastine

Olopatadine
Nasal Corticosteroids

Most potent anti-inflammatory agents

Effective with all nasal symptoms including nasal obstruction

Superior to Nasal AH & anti-Leukotriene

First line Pharmacotherapy for Moderate to severe AR

Good technique is essential
Continued..

Good safety profile

Onset of action within 6-8hrs, maximal effect in 2 weeks

Once or twice daily dosage

Systemic absorption least with Mometasone and Fluticasone
Adverse effects:

Nasal irritation (worse with alcohol containing preparations)

Epistaxis 10%

Septal perforation

HPA axis suppression

Suppressed growth
Nasal corticosteroids
Reduce mucosal
inflammation
Reduction of late
phase reactions
Reduce mucosal mast
cells
Reduce acute allergic
reactions
Reduction of symptoms and
exacerbations
• Suppression of
flandular activity
and vascular
leakage
• Induction of
vasoconstriction
Nasal Corticosteroids
Age (in years)
Drug
Good safety data
>4
Fluticasone
Yes
>5
Flunisolide
Dexamethasone
-
>6
Mometasone
Triamcinalone
Beclomethasone
Yes
-
>12
Budesonide
Betamethasone
Yes
-
Other therapies

Oral anti-leukotrienes


Topical cromones


Montelukast licensed for SAR + asthma > 6 months, Zafirlukast > 12 y
Sodium cromoglicate (qds)
Topical anti-cholinergics

Ipratropium given tds may help rhinorrhoea
Nasal saline douches
 Intranasal decongestants


Short term only (useful at start of therapy), rebound symptoms
Allergen immunotherapy
 Anti-IgE therapy

Anti-Leukotriene treatment in AR
Efficacy

Equipotent to H1 receptor antagonists, but onset of action is after 2
days

Reduce nasal and systemic eosinophilia

May be used for simultaneous treatment of AR & Asthma
Safety

Dyspepsia (up to 2%)
Decongestants –Alpha 2 adrenergic
agonists
Oral

Pseudoephedrine
Nasal

Phenylephrine

Oxymetazoline

Xylometazoline
Decongestants
Efficacy

Oral decongestants – Moderate

Nasal decongestants - High
Adverse effects

Oral: insomnia,
tachycardia,hyperkinesia,
tremor,raised BP, ?stroke

Nasal: tachyphylaxis, rebound
congestion, nasal
hyperresponsiveness, rhinitis
medicamentosa
Sneezing
Rhinorrhoea Nasal
obstruction
Nasal itch
Eye
symptoms
Antihistamine
Oral
Intranasal
Eye drops
++
++
0
++
++
0
+
+
0
+++
++
0
++
0
+++
Corticosteroids
Intranasal
+++
+++
+++
++
++
Chromones
Intranasal
Eye drops
+
0
+
0
+
0
+
0
0
++
Decongestants
Intranasal
Oral
0
0
0
0
++++
+
0
0
0
0
Anticholinergics 0
++
0
0
0
Antileukotrienes
+
++
0
++
0
HDM allergen avoidance

Provide adequate ventilation to improve humidity

Wash bedding regularly at 60*C

Allergen impermeable covers

Vacuum cleaner with HEPA filter

No Carpets & feather bedding, curtains & stuffed toys




Pets

Remove pets from bedrooms

Vacuum carpets, mattresses and upholstery regularly

Wash pets regularly (±)
Molds

Ensure dry indoor conditions

Use ammonia to remove mold from bathrooms and other wet spaces
Cockroaches

Eradicate cockroaches with appropriate gel-type, non-volatile,
insecticides

Eliminate dampness, cracks in floors, ceilings, cover food; wash
surfaces, fabrics to remove allergen
Pollen

Remain indoors with windows closed at peak pollen times

Wear sunglasses

Use air-conditioning, where possible

Install car pollen filter
Summary
AR is common, persistent, often overlooked
 Diagnosis is relatively straightforward if the right
questions are asked
 Adequate treatment improves quality of life significantly
 Mainstays of treatment are allergen avoidance, oral
antihistamines and intranasal corticosteroids
 Co-morbid conditions: special attention
