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 Non- Allergic Rhinitis, Clinical and Experimental Allergy, 38, 19- 42, 2015

Allergy can affect in different ways in different ages Food Allergy Atopy is the inherited tendency to develop harmful Immune responses to harmless substances 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 Nose is invariably affected, other organs are affected in certain individuals. Types: Allergic, Non allergic and infective

Pathophysiology.

IgE mediated Rhinorhoea Nasal blockage Postnasal drip Itchiness Sneezing Associated health effects IgE mediated Other symptoms include sinusitis, middle ear problems, asthma.. Inflammation of nasal mucosa with exudate in the air way. It is a symptom complex

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

Impaired maxillary growth, dental problems, infections

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 Eye symptoms Often seen with AR, especially seasonal AR LRT symptoms Cough may be caused by AR 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 Nonallergic rhinitis with nasal eosinophilia syndrome.

Investigations

Immunoassay versus Skin prick tests Not influenced by Skin disease Not influenced by medication Does not require expertise Quality control possible Expensive Higher sensitivity Immediate results Requires expertise Cheaper

AR Classification Intermitent < 4 days per week Or < 4 weeks Persistent > 4 days per week > 4 weeks Mild Normal sleep No impairment Normal school and work No troublesome symptoms Moderate & Severe (one or more items) Abnormal sleep Abnormal school performance & work Impairment of daily activities, sport & leisure Troublesome symptoms In untreated patients

COSTS Therapeutic Options Immunotherapy Allergen Avoidance When possible Immunotherapy Specialist treatment, may alter the course of the disease Parents Education Always indicated Pharmacotherapy Safe, effective & easy to be administered

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 Brompheniramine Diphenydramine Promethazine Tripolidine Hydroxyzine Azatadine Acrivastine Azelastine Cetirizine Levocetirizine Loratadine Desloratadine Fexofenadine Mizolastine First generation agents are available over-the-counter, both as single agents and in combination with other drugs. They are similarly efficacious compared to each other, with minor differences . Adverse effects and safety — Significant sedation because they are lipophilic and easily cross the blood brain barrier. Central nervous system symptoms are reported by 20 percent or more of patients, and adverse effects on intellectual and motor function are well-documented, even in the absence of subjective awareness of sedation

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 Corticosteroids – Avamys, Nasonex, Dymista, Flixonase, Beconase

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 mast cells Reduce mucosal inflammation Suppression of flandular activity and vascular leakage Induction of vasoconstriction Reduce acute allergic reactions Reduction of late phase reactions Reduction of symptoms and exacerbations

Nasal Corticosteroids Age (in years) Drug Good safety data >4 Fluticasone Yes >5 Flunisolide Dexamethasone - >6 Mometasone Triamcinalone Beclomethasone >12 Budesonide Betamethasone

Prime the spray, blow the nose first, head position – tilted forward, position of nozzel / direction of spray – not towards septum, sniffing after spraying is not necessary.

Other therapies Oral anti-leukotrienes Topical cromones Montelukast licensed for SAR + asthma > 6 months, Zafirlukast > 12 y Topical cromones 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 Oral decongestants – Moderate Nasal decongestants - High 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 ++ + +++ Corticosteroids Chromones Decongestants ++++ Anticholinergics Anti-leukotrienes Effect of therapies on rhinitis symptoms.

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