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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

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allergic rhinitis in children

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 children1
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
What is allergic rhinitis?
  • Rhinorhoea
  • Nasal blockage
  • Postnasal drip
  • Itchiness
  • Sneezing
  • Associated health effects
  • IgE mediated
diagnosis of allergic rhinitis
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 rhinitis1
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 rhinitis2
Diagnosis of Allergic Rhinitis
  • Signs of atopy and recurrent or persistent rhinitis
diagnosis of allergic rhinitis3
Diagnosis of Allergic Rhinitis
  • Demonstration of IgE allergy
slide14
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
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
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
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

slide19

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
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
slide22

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

slide24

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

Chlorpheniramine

Brompheniramine Diphenydramine

Promethazine

Tripolidine

Hydroxyzine

Azatadine

Newer agents

Acrivastine

Azelastine

Cetirizine

Desloratadine Fexofenadine Levocetirizine Loratadine

Mizolastine

Oral Antihistamines
nasal antihistamines
Azelastine

Levocabastine

Olopatadine

Nasal Antihistamines
slide27

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

slide28

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
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
Decongestants: Alpha-2 Adrenergic Agonists
  • Oral

Pseudoephedrine

  • Nasal

Phenylephrine

Oxymetazoline

Xylometazoline

slide32

Decongestants: Alpha-2

Adrenergic Agonists

nasal septum

nasal airway lumen

vasoconstriction

nasal

turbinates

slide33

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
slide34

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

slide35

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

slide36

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%)
slide37

Nasal Corticosteroids

Beclomethasone dipropionate

Budesonide

Ciclesonide*

Flunisolide

Fluticasone propionate

Mometasone furoate

Triamcinolone acetonide

* Currently only approved for asthma

slide38

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

slide39

Efficacy of Nasal Corticosteroid Sprays in Children with

Allergic Rhinitis and Seasonal Symptoms

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

slide40

Comparative Efficacy of Nasal Corticosteroids

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

slide41

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
slide42

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)
slide43

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

1. Allergens

2. Pollutants and Irritants

house dust mite allergen avoidance
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

Allergen Avoidance
to conclude
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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