Allergic Rhinitis in Children Alfred Tam MBBS(HK), FRCP(Edin., London, Glasg.) FHKCPaed, FHKAM(Paediatrics) Department of Paediatrics and Adolescent Medicine, University of Hong Kong
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 increasingLee SL et al. Pediatr Allergy Immunol 2004; 15: 72-8.
AR prevalence varies in different citiesWong G et al. Clin Exp Allergy 2001; 31: 1225.
Atopic sensitization is not that different!Wong G et al. BMJ 2004; 329:486-9.
Allergic Rhinitis in HanoiNguyen et al. Pediatr Allergy Immunol 2003; 14:272-9.
Diagnosis of Allergic Rhinitis • Clinical symptoms of recurrent or persistent rhinitis and/or associated health effects • Signs of atopy and recurrent or persistent rhinitis • Demonstration of IgE allergy • Exclusion of other causes of rhinitis
Diagnosis of Allergic Rhinitis • 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 • Signs of atopy and recurrent or persistent rhinitis
Diagnosis of Allergic Rhinitis • Demonstration of IgE allergy
Immunoassay Not influenced by medication Not influenced by skin disease Does not require expertise Quality control possible Expensive Skin test Higher sensitivity Immediate results Requires expertise Cheaper Immunoassay vs Skin Test for Diagnosis of Allergy
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 controls (n=139) 90 allergic rhinitis (n=312) † 85 * scale: 0 to 100 80 Declininghealthstatus * 75 * 70 * * 65 60 * 55 50 Physical Role– Bodily Pain General Vitality Social Role– Mental Change in Functioning Physical 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 forAsthma (European Community Respiratory Health Survey) 25 OR=11 no rhinitis, N=5198 rhinitis, N=1412 20 15 Asthma (%) OR=17 10 5 0 Atopic Non atopic Adapted from Leynaert B et al. J Allergy Clin Immunol 1999; 104:301
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 . Š 4 days per week . or Š 4 weeks Persistent . > 4 days per week . and > 4 weeks Moderate-severe one or more items . abnormal sleep . impairment of daily activities, sport, leisure . abnormal work and school . troublesome symptoms Mild normal sleep & no impairment of daily activities, sport, leisure & normal work and school & no troublesome symptoms in untreated patients
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 ++
First generation agents Chlorpheniramine Brompheniramine Diphenydramine Promethazine Tripolidine Hydroxyzine Azatadine Newer agents Acrivastine Azelastine Cetirizine Desloratadine Fexofenadine Levocetirizine Loratadine Mizolastine Oral Antihistamines
Azelastine Levocabastine Olopatadine Nasal Antihistamines
Sneezing Rhinorrhea Pruritus Nose Pruritus Eyes Congestion * * * * 1.0 * * * * * * 0.8 * * * mean Individual symptom score improvement 0.6 0.4 0.2 1 wk 1 wk 1 wk 1 wk 1 wk 6 mo 6 mo 6 mo 6 mo 6 mo 0 4 wk 4 wk 4 wk 4 wk 4 wk * P<0.05 Baseline total symptom score: 8.95 Levocetirizine, 5 mg, N = 276 Placebo, N = 271 Efficacy of an Antihistamine over 6 Months in Persistent Allergic Rhinitis 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
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 Pseudoephedrine • Nasal Phenylephrine Oxymetazoline Xylometazoline
Decongestants: Alpha-2 Adrenergic Agonists nasal septum nasal airway lumen vasoconstriction nasal 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 mast cells basophils eosinophils macrophages CysLT1 receptor cytosolic phospholipase A2 leukotriene C4 arachidonic acid nucleus leukotriene C4 leukotriene D4 + 5-lipoxygenase activating protein leukotriene E4 leukotriene C4 synthase 5-lipoxygenase leukotriene A4
Efficacy of a CysLT1 Receptor Antagonist in Allergic Rhinitis with Seasonal Symptoms Daytime Nasal Symptoms Score (0-3 point scale) 0 Change frombaseline (mean, 95% CI) -0.2 -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
1 2 3 reduction of mucosal inflammation reduction of mucosal mast cells • suppression of • glandular activity • and vascular leakage • induction of • vasoconstriction reduction of late phase reactions priming nasal hyperresponsiveness reduction of acute allergic reactions Nasal Corticosteroids 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 0.98 SE=1.14 N=31 0.94 SE=1.15 N=29 0.8 0.6 Adjusted Geometric Mean of the Change from Baseline 0.4 0.2 0 Fluticasone Proprionate Nasal Spray 200 µg daily Placebo 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 • House dust mites • Pets • Cockroaches • Molds • Pollen 1. Allergens 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
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 Allergen Avoidance
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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