Allergic Rhinitis in Children

Allergic Rhinitis in Children

• What is allergic rhinitis?
• Diagnosis and differential diagnosis
• Assessment and classification of AR
• What can make AR worse or better?
• Health effects of AR
• What can we do to make AR better?
What is allergic rhinitis?
• Rhinorhoea
• Nasal blockage
• Postnasal drip
• Itchiness
• Sneezing
• Associated health
effects

‼ IgE mediated
 Allergic rhinitis is increasing
Lee SL et al. Pediatr Allergy Immunol 2004; 15: 72-8.

Prevelance R ates 1995-2001

45
40
35 E ver rhinitis
30
C urrent rhinitis
25
%
20
C urrent
15
rhinoconjunctivitis
10
E ver eczem a
5
0
1995 (3618) 2001(4448)
 Diagnosis of Allergic Rhinitis
1. Clinical symptoms of recurrent or
persistent rhinitis and/or associated
health effects
2. Signs of atopy and recurrent or
persistent rhinitis
3. Demonstration of IgE allergy
4. Exclusion of other causes of rhinitis
 Diagnosis of Allergic Rhinitis
1. Clinical symptoms of recurrent or persistent
rhinitis and/or associated health effects
– Rhinorhoea
– Nasal blockage
– Postnasal drip
– Itchiness
– Sneezing
– Others: conjunctivitis, eczema, asthma, chronic
rhinosinusitis, otitis media with effusion, sleep
obstruction…
 Diagnosis of Allergic Rhinitis
2. Signs of atopy and recurrent or
persistent rhinitis
Diagnosis in Primary Care Setting
 Diagnosis of Allergic Rhinitis
3. Demonstration of IgE allergy
 Immunoassay vs Skin Test for
Diagnosis of Allergy

Immunoassay Skin test

• Not influenced by • Higher sensitivity
medication
• Immediate results
• Not influenced by skin
disease • Requires expertise
• Does not require • Cheaper
expertise
• Quality control
possible
• Expensive
 Other Causes of Rhinitis in Children

• Infection
– Viral, bacterial,
– Rhinosinusitis
• Foreign body in the nose
• Rhinitis associated with physical or chemical
factors
• Drug, food induced rhinitis
• NARES, aspirin sensitivity
• Vasomotor rhinitis
 Health Effects of Allergic Rhinitis
• Social inconvenience
• Sleep disturbances/obstruction
• Learning difficulties
• Impaired maxillary growth
• Dental problems
• Infection: nose and sinuses
• Co-morbidities: conjunctivitis, asthma,
rhinosinusitis, otitis media
 Short Form Health Survey (SF-36)
Profiles of Patients with Allergic Rhinitis
90 controls (n=139)
allergic rhinitis (n=312)
†
85 * scale: 0 to 100
80

Declining 75
*
health *
status 70 *
65 *

60

55 *

50
Physical Role– Bodily General Vitality Social Role– Mental Change in
Functioning Physical Pain Health Emotional Health Health
Functioning
Domains

Adapted from Meltzer EO et al. J Allergy Clin Immunol.

1997;99:S815
 Perennial Rhinitis: an Independent Risk
Factor for Asthma
(European Community Respiratory Health Survey)

25

OR=11 no rhinitis, N=5198

20
rhinitis, N=1412
15

Asthma (%)
OR=17
10

0
Atopic Non atopic

Adapted from Leynaert B et al. J Allergy Clin Immunol

1999; 104:301
Looking for asthma…
 In Patients with Rhinitis:
• Routinely ask for symptoms suggestive of
asthma
• Perform chest examination
• Consider lung function testing
• Consider tests for bronchial
hyperresponsiveness in selected cases
 ARIA Classification
Intermittent Persistent
. Š 4 days per week . > 4 days per week
. or Š 4 weeks . and > 4 weeks

Mild Moderate-
normal sleep severe
& no impairment of daily one or more items
activities, sport, leisure
. abnormal sleep
& normal work and school
. impairment of daily
& no troublesome activities, sport,
symptoms leisure
. abnormal work and
school
in untreated patients . troublesome
symptoms
Medications for Allergic Rhinitis -
ARIA sneezing rhinorrhea nasal nasal
eye obstruction itch
symptoms
H1-antihistamines
oral +++ +++ 0 to + +++ ++
intranasal ++ +++ + ++ 0
intraocular 0 0 0 0
+++
Corticosteroids +++ +++ ++ ++ +
Cromones
intranasal + + + + 0
intraocular 0 0 0 0 ++
Decongestants
intranasal 0 0 ++ 0 0
oral 0 0 + 0 0
Anti-cholinergics 0 +++ 0 0 0
Anti-leukotrienes 0 + ++ 0 ++
 Oral Antihistamines
• First generation agents • Newer agents
Chlorpheniramine Acrivastine

Brompheniramine Azelastine
Diphenydramine Cetirizine
Promethazine Desloratadine Fexofenadine
Tripolidine Levocetirizine Loratadine

Hydroxyzine Mizolastine

Azatadine
Nasal Antihistamines

• Azelastine

• Levocabastine

• Olopatadine
 Efficacy of an Antihistamine over 6 Months in
Persistent Allergic Rhinitis
Sneezing Rhinorrhea Pruritus Nose Pruritus Eyes Congestion

* * * *
1.0

0.8 * * * * *
* *
mean
0.6
* *
Individual
symptom
score
improvement 0.4

0.2

0
1 wk 6 mo 1 wk 6 mo 1 wk 6 mo 1 wk 6 mo 1 wk 6 mo
* P<0.05 4 wk 4 wk 4 wk 4 wk 4 wk

Baseline total symptom score: 8.95

Levocetirizine, 5 mg, N = 276
Placebo, N = 271

Bachert C et al. J Allergy Clin Immunol 2004:114:838

 Efficacy of an Antihistamine in the Treatment of
Allergic Rhinitis with Perennial Symptoms

(n= 337)
(n= 339)

Simons FER et al., J Allergy Clin Immunol 2003;111:617

Newer Generation Oral Antihistamines
Somnolence/Drowsiness
Active Placebo Data Source

Cetirizine
13.7% 6.3% www.PDR.net
10 mg qd

Desloratadine
2.1% 1.8% www.PDR.net
5 mg qd

Fexofenadine
1.3% 0.9% www.PDR.net
60 mg bid
Bachert et al
Levocetirizine
6.8% 1.8% JACI
5 mg qd 2004;114:838

Loratadine
8% 6% www.PDR.net
10 mg qd
Newer Generation Oral Antihistamines
• First line treatment for mild allergic rhinitis

• Effective for
– Rhinorrhea
– Nasal pruritus
– Sneezing

• Less effective for

– Nasal blockage

• Possible additional anti-allergic and anti-inflammatory effect

• In-vitro effect > in-vivo effect

• Minimal or no sedative effects

• Once daily administration

• Rapid onset and 24 hour duration of action

 Decongestants: Alpha-2
Adrenergic Agonists

• Oral • Nasal

Pseudoephedrine Phenylephrine

Oxymetazoline

Xylometazoline
 Decongestants: Alpha-2
Adrenergic Agonists
nasal septum
nasal airway lumen

nasal vasoconstriction
turbinates
 Decongestants
EFFICACY:
• Oral decongestants: moderate
• Nasal decongestants: high

ADVERSE EFFECTS:
• Oral decongestants: insomnia, tachycardia, hyperkinesia
tremor, increased blood pressure, stroke (?)
• Nasal decongestants: tachyphylaxis, rebound congestion, nasal
hyperresponsiveness, rhinitis medicamentosa
 Cysteinyl-Leukotriene Production and
the CysLT1 Receptor

CysLT1
receptor

cytosolic
phospholipase A2
leukotriene C4

arachidonic
nucleus acid leukotriene C4
+ leukotriene D4
5-lipoxygenase
activating leukotriene E4
protein
5-lipoxygenase leukotriene C4 mast cells
synthase basophils
leukotriene A4
eosinophils
macrophages
 Efficacy of a CysLT1 Receptor Antagonist
in Allergic Rhinitis with Seasonal Symptoms
Daytime Nasal Symptoms Score
(0-3 point scale)
0

-0.2
Change from
baseline
(mean, 95% CI) -0.4

-0.6
* *
placebo, N=149

montelukast, N=155
mean baseline=2.0 loratadine, N=301
*p<0.01 vs placebo

Adapted from Nayak, et al. Ann Allergy Asthma Immunol.

2002;88: 592
 Anti-Leukotriene Treatment in
Allergic Rhinitis
Efficacy

• Equipotent to H1 receptor antagonists but with onset of

action after 2 days
• Reduce nasal and systemic eosinophilia
• May be used for simultaneous treatment of allergic
rhinitis and asthma

Safety

• Dyspepsia (approx. 2%)

 Nasal Corticosteroids
Beclomethasone dipropionate
Budesonide
Ciclesonide*
Flunisolide
Fluticasone propionate
Mometasone furoate
Triamcinolone acetonide

* Currently only approved for asthma

 Nasal Corticosteroids
1 2
3

reduction of
mucosal inflammation
reduction of
late phase reactions acute allergic reactions
priming
nasal hyperresponsiveness
reduction of
mucosal mast cells
• suppression of
glandular activity
and vascular leakage
• induction of
reduction of vasoconstriction

reduction of
symptoms and exacerbations
Efficacy of Nasal Corticosteroid Sprays in Children with
Allergic Rhinitis and Seasonal Symptoms

Meltzer E. et al. J Allergy Clin Immunol. 1999;104:107.

 Comparative Efficacy of Nasal
Corticosteroids

Mandl M. et al. Ann Allergy Asthma Immunol 1997;79:370

 Nasal Corticosteroids
• Most potent anti-inflammatory agents

• Effective in treatment of all nasal symptoms

including obstruction

• Superior to anti-histamines and anti-leukotienes

• First line pharmacotherapy for persistent allergic

rhinitis
 Nasal Corticosteroids
• Overall safe to use
• Adverse Effects
– Nasal irritation
– Epistaxis
– Septal perforation (extremely rare)
– HPA axis suppression (inconsistent and not
clinically
significant)
– Suppressed growth (only in one study with
beclomethasone)
 Nasal Corticosteroid vs Placebo: Effects on 12-Hour
Urinary Free Cortisol in 2-3 Year-Old Children
6-week treatment
Value of 1 indicates
no change from baseline

1.0

0.8
0.98 0.94
Adjusted Geometric Mean 0.6 SE=1.14 SE=1.15
of the Change from Baseline 0.4
N=31 N=29
0.2

0
Fluticasone Placebo
Proprionate
Nasal Spray
200 µg daily

Adapted from Galant, S. P. et al. Pediatrics 2003;112:96

 Other Management Aspects
• Manage other co-morbidities:
– Allergic conjunctivitis
– Asthma
– Sinusitis…
• Environmental manipulations:
– allergen avoidance
– Pollution treatment
• Nutritional support
• Activities and sports
 Environmental Control
1. Allergens
• House dust mites
• Pets
• Cockroaches
• Molds
• Pollen

2. Pollutants and Irritants

House dust mite allergen avoidance
– Provide adequate ventilation to decrease humidity

– Wash bedding regularly at 60°C

– Encase pillow, mattress and quilt in allergen

impermeable covers

– Use vacuum cleaner with HEPA filter

– Dispose of feather bedding

– Remove carpets

– Remove curtains, pets and stuffed toys from

bedroom
 Allergen Avoidance
• Pets
• Remove pets from bedrooms and, even better, from the entire home
• 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
 To Conclude…
• Allergic rhinitis is very common and
causes considerable morbidity
• Adequate and appropriate treatment leads
to significant improvement in quality of life
• Co-morbid conditions are common and
warrants special attention and treatment
for optimal results
• Environmental manipulations is also
important in the control of disease
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