1. Rhinitis in Childhood – Not to be sniffed at
Pediatric Update – One Airway Concept
November 2017 Philippines
Rhinitis in Childhood – Not to be sniffed at
BW Lee, Dept Paediatrics
National University of Singapore

2. How is Rhinitis in Childhood Diagnosed?
Clinical definition
Etiological classification

3. DeGroot BMJ 2007

4. Rhinitis Duration ARIA guideline (WHO):
Rhinitis lasting ≥2 weeks may have other causes than cold

5. Dairy cards of 146 children (4 to 12 yrs) with acute URI
Duration of symptoms
last for approximately 5–11 days
rarely more than 14 days
Infectious rhinitis

6. Skin
Lungs

7. Current Classification of Rhinitis
ARIA classification (Dykewicz and Hamilos, 2010):
Rhinitis
Nonallergic rhinitis
Idiopathic (non allergic without eosinophilia)
Infectious
Nares
Occupational
Other triggers
(Hormone, Drug, etc)
Allergic Rhinitis
This is the current classification of rhinitis, according to a recent paper by Dykewicz and Hamilos. Rhinitis is divided first into 4 groups.
Allergic rhinitis which is triggered by aero-allergen recognition by airway epithelia and IgE on mast cells and basophils.
Non-allergic rhinitis which is further divided to idiopathic, no eosinophil inflammation but also no infection; Nonallergic rhinitis with eosinophilia syndrome (NARES): Eosinophils in nasal smear, negative SPT and serum IgE to environemtal allergen but its quite rare in children; and infectious.
The other 2 types of rhinitis aren’t relevant in children so I won’t mention much.
ARIA Update. Allergy 2008

9. Non-allergic rhinitisvs
Non-allergic rhinitis
DeGroot BMJ 2007
La Mantia et al Int J Ped Otorhinolaryngoly 2017

10. ARIA classification of allergic rhinitis – 2007 update
INTERMITTENT
symptoms
<4 days per week; or
<4 weeks
PERSISTENT
>4 days per week; and
>4 weeks
MILD
all of the following
Normal sleep
No impairment of daily activities, sport, leisure
No impairment of work and school
No troublesome symptoms
MODERATE-SEVERE
one or more items
Abnormal sleep
Impaired daily activities, sport, leisure
Impaired work and school
Troublesome symptoms
Allergic rhinitis (AR) is traditionally classified as seasonal (SAR) or perennial (PAR) based on the time of exposure to allergens.
In 2001, the Allergic Rhinitis and its Impact on Asthma (ARIA) Guidelines proposed a new classification system for AR, dividing it into two categories: ‘intermittent’ and ‘persistent’. In this proposal, intermittent and persistent AR were further subdivided into ‘mild’ and ‘moderate/severe’.1 This slide shows the definition of each of these categories.
The ARIA Guidelines also presented treatment recommendations for the four categories of AR: mild intermittent, moderate/severe intermittent, mild persistent and moderate/severe persistent. A stepwise approach is advocated for the treatment of persistent disease.
An update to the ARIA Guidelines, which incorporates revised AR classification and management recommendations, is expected in the near future.
1. Bousquet J et al. J Allergy Clin Immunol 2001;108(Suppl 5):S147–336.
Guidelines advocate a stepwise approach to treating persistent AR
Bousquet J et al. J Allergy Clin Immunol 2001;108(Suppl 5):S147–336;
Aria: at a glance pocket reference 2007.

11. Pointers to Diagnosis of Allergic and Non allergic Rhinitis in Children
Clinical Diagnosis
Rhinitis or URI
AR or NAR
Other features of atopy
Assess clinical severity
Effects on quality of life
Investigations usually not needed unless there are red flag signs

12. Rhinitis or something else?
What are the red flags?
Rhinitis or something else?

13. Approach to Rhinitis in Children
specialist
Aria Update, Allergy 2008

14. Differential Diagnosis of Rhinitis in Young Children
Foreign body
Anatomical variations
Unilateral choanal atresia
Benign tumours (dermoid cyst)
Mucociliary dyskinesia
Aria Update, Allergy 2008

15. Rhinitis in very young infants
exclude congenital abnormalities

16. What is the age of onset of allergic rhinitis in children?
Infants
Preschool age
School age

17. Incidence of different types of allergic diseases by age
How often does allergic rhinitis occur in young children?
Aeroallergen sensitization

18. Rhinitis in Relation to Age
Mostly Non-allergic
Mostly Allergic
(cont) as shown in a large cross-sectional study in KK hospital here in Singapore. As shown in this figure, up to the age of 2, more than half of rhinitis cases were non-allergic in contrast to rhinitis at later age.
1Chiang WC, et al. Ped Pulm. 2012
*Atopy was defined as sensitization to house dust mites, cockroach, cat, dog, mould, and grass 18

20. Prevalence of Rhinitis in Young Children Duration of Rhinitis
32.1
≥2w
Allergen sensitization
20%
≥4w
n=733
Hardjojo A et al, Ped Allergy Immunol 2015

21. Factors Associated with Rhinitis: Multivariate Analysis
≥2 weeks (n=235) vs control (n=498)
Thus I took each factors to be adjusted with each other and with mode of delivery in the multivariate analysis. This figure shows the result of the multivariate analysis, with significant factors colored in red. As shown here, eczema, wheeze, and food sensitization remained significantly associated with rhinitis. Maternal history also remained significantly associated with rhinitis, though paternal history lost its significance.
*In reference to Chinese
Adjusted for each other and mode of delivery
Hardjojo A et al Ped Allergy Immunol 2015

22. Onset Rhinitis in the First Year
Birth cohort (n=747) Tucson Respiratory Group
Onset rhinitis ≤1yr more likely than onset >1yr:
Allergic rhinitis by 6 years (77 vs 57%) (p< )
Asthma by 6 years (23 vs 13%) (p<0.005)
Early onset rhinitis is a risk factor for allergic rhinitis in later childhood
Wright et al Pediatr 1994

23. 175 children (median age 5.7 years) with NAR, 41% developed allergen sensitization during 3 year follow up
Risk factors:
family history of atopy,
persistent nasal symptoms,
symptoms triggered by aeroallergens

24. Summary of Early Onset Rhinitis
Early onset rhinitis maybe an early manifestation of the ‘atopic’ phenotype
Phenotype may not be associated with allergen sensitization
but may occur subsequently

25. Case Study: Chinese Girl. Third child
1 month
5 months
8 months
13 months
18 months
19 months
20 months
23 months
27 months
30 months
34 months
36-48 months
Transient Nasal Congestion
URI – nasal congestion with fever, and cough
URI with cough
URI with nasal congestion
URI prolonged cough
URI fever – acute rhinosinusitis (hospitalized) (antibiotics)
URI with prolonged cough
Tonsillitis with cervical lymphadenitis (antibiotics)
First viral wheeze – prolonged. Rhinitis
Recurrent wheeze – started low dose inhaled steroids. Rhinitis
Rhinitis with recurrent otitis media. Started topical nasal steroids
Documented dust mite sensitization

26. Complications and Co-morbidities

27. THE UPPER AIRWAY AND COMORBIDITIES
Hearing/speech problems & Serous Otitis Media
Sinusitis
Obstructive sleep apnea
Rhinitis
‘sneezers and runners’
‘blockers’
Learning problems and Fatigue
Asthma

29. Acute
Subacute
Chronic (>12 weeks)
ARIA Update. Allergy 2008

30. Algorithm does not apply to preschool children
Aria Update, Allergy 2008

31. Role of Antibiotics in Children with Chronic Rhinosinusitis
Is there a role?
What is the length of antibiotics course?
Which antibiotic?

33. Treatment regimes:
Amoxicillin+ decongestants
Drainage of maxillary sinus
(1) +(2)
Placebo
6 months follow up

34. Management of Allergic Rhinosinusitis
Environment control
Non-pharmacological approaches
Pharmacotherapy
Allergen Immunotherapy

36. No evidence that regular/daily SNI has adverse effects
A systematic search of Medline, Embase, Cochrane Central Register of Controlled Trials, and ISI Web of Science databases for literature published from 1994 to 2010 on SNI in AR.
SNI using isotonic solution can be recommended as complementary therapy in AR.
It is well tolerated
No evidence that regular/daily SNI has adverse effects
Am J Rhinol Allergy 2012

37. Precautions Low cost adjunctive therapy Cleansing property,
Improves mucociliary clearance
Reduce medication use
Tolerability depends on:
Child’s age
Delivery system and method
Tonicity
Precautions

38. Pharmacotherapeutic options for allergic rhinitis: Efficacy on nasal and ocular symptoms
Effects on symptoms
Drug
Sneezing
Rhinorrhoea
Nasal obstruction
Nasal itching
Ocular symptoms
INS
+++ ++ +
Oral antihistamine
0 to +
Intranasal decongestant
Intranasal chromone
Anticholinergic
LTRAs ?
First line
Key message:
Pharmacotherapy remains the most effective treatment strategy for allergic rhinitis, although different drug classes have varying therapeutic efficacy against the various nasal and ocular symptoms of allergic rhinitis.1,2
Key points of information:
The prescribing physician needs to carefully evaluate the patient to match medication with the individual’s symptom profile, in terms of frequency and severity.
Oral antihistamines are recognised for their efficacy against the ocular symptoms of allergic rhinitis, but show poor efficacy for treating nasal congestion.2
Topical decongestants, on the other hand, are primarily recognised for their role in relieving nasal congestion, and intranasal chromones for their efficacy against ocular symptoms.2
Intranasal corticosteroids (INS) have proven efficacy against the nasal symptoms of allergic rhinitis and appear effective against ocular symptoms, although this has been inconsistent for any one INS.
As a result, patients with allergic rhinitis often require more than one treatment regimen for all their symptoms.
References:
Bousquet J et al Last accessed 14/04/08.
Scadding GK. J Allergy Clin Immunol 2001;108:S59–S64.
0 = no effect, +++ = maximum effect
INS, intranasal corticosteroid; LTRA; leukotriene receptor antagonist
ARIA Teaching Slides. Last accessed 30/04/08.

39. Approved Age Indication 2nd Generation H1-antihistamines
Singapore
USA
CIU AR
≥6m 2y 2y 1y -
CIU AR
≥6m 2y 2y
6m 2y
6m y 6y
Fexofenadine
Loratidine
Desloratidine
Cetirizine
Levocetirizine
Individual product inserts

40. CNS Histamine Receptors
Histamine on H1-receptors in the brain responsible for:
arousal,
reinforcement of learning/memory
H1-antihistamines
markedly alter the circadian sleep/wake cycle
daytime somnolence, sedation, drowsiness, fatigue, impaired concentration, memory
Histamine 1 receptors in the brain

41. Approved Age Indication of Intranasal Corticosteroids
Singapore
USA 2y 4y 6y
Mometasone furoate 2y 6y
12y 4y
Fluticasone furoate
Fluticasone propionate
Trimacinalone acetonide
Budesonide
Ciclesonide
Individual product inserts

42. Scadding GK, et al. BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy. 2008;38:19-42.

43. Combination or Single Drug
Antihistamine + Intra-nasal steroid
Antihistamine + Leukotriene inhibitor
Brozek J et al Aria Guidelines 2016 Revision. J Allergy Clin Immunol

44. Immunotherapy in Children with Rhinitis
What’s the role?

45. Conclusions
Recognition of rhinitis in childhood and it’s comorbidities
Impact on quality of life
Therapeutic algorithm
Unmet needs

46. ……..Thank you