1. Allergic Rhinitis in Children
Dr. Madhavi Velpula
Consultant in Paediatrics,
Poole NHS Foundation Trust

2. 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

3. Key References
BSACI guidelines for the management of Allergic and Non- Allergic Rhinitis, Clinical and Experimental Allergy, 38, , 2015

4. 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

5. 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

6. Pathophysiology.

7. 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

8. 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

9. Impaired maxillary growth, dental problems, infections

10. Allergic triggers for Rhinitis in children

11. 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)

12. 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)

13. Other clues Personal history of other allergic conditions
Family history of allergic conditions
Specific allergen and irritant exposure

14. Signs of Atopy & Rhinitis

15. 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)

16. Diagnosis in Primary care setting

17. 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.

18. Investigations

19. 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

20. 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

21. 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

22. 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

23. Antihistamine - considerations
Child’s age
Child / parent understanding
Dosage
Effectiveness
Method of administration
Side effects

24. 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

25. 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

26. Nasal Antihistamines
Azelastine
Levocabastine
Olopatadine

27. 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

28. 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

29. 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

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

31. 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.

32. 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

33. 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%)

34. Decongestants –Alpha 2 adrenergic agonists
Oral
Pseudoephedrine
Nasal
Phenylephrine
Oxymetazoline
Xylometazoline

35. 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

36. 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.

38. 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

39. 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

40. 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