Allergic rhinitis in children Dr Gulamabbas Khakoo Consultant in Paediatrics, Hillingdon Hospital...
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Allergic rhinitis in children
Dr Gulamabbas Khakoo
Consultant in Paediatrics, Hillingdon Hospital NHS Trust
Consultant in Paediatric AllergySt Mary’s Hospital, Paddington
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Scope of presentation
• Epidemiology - why allergic rhinitis is important• Making a correct diagnosis• Treatment• Link with asthma – ? One airway, one disease
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Key references
• BSACI guidelines for the management of allergic and non-allergic rhinitis. Clin Exp Allergy 2007; 38: 19-42
• Allergic rhinitis and its impact on asthma (ARIA guidelines). J Allergy Clin Immunol 2001; 108: S147-334
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The allergic march
• Distinction between sensitisation and allergy• Food allergies in early childhood tend to resolve,
although food sensitisation predicts aeroallergen sensitisation
• Allergic rhinitis and aeroallergen sensitisation starting earlier in childhood and recent data that it is more persistentBAMSE birth cohort Clin Exp Allergy 2008; 38: 1507-13
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Rhinitis
• Inflammation of the nasal mucosa• Often involves sinuses hence term rhinosinusitis
(more severe disease)• Classification
– Allergic– Non-allergic– Infective
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Allergic triggers for rhinitis in children
Mites House dust mite, allergen in mite faeces
Major cause of perennial rhinitis
Pollens Trees, grasses, shrubs, weeds
Main causes of seasonal rhinitis
Animals Cats, dogs, horses Allergen in sebaceous glands and saliva
Fungi / moulds Alternaria, Aspergillus, Cladosporium
Seasonal and / or perennial symptoms
Environmental aggravated
(Adults occupational)
Smoke, cold air, glues, solvents, sulphur dioxide
May aggravate pre-existing rhinitis
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Prevalence of seasonal and perennial allergic rhinitis
SAR20%
PAR40%
Combination of SAR and
PAR
40%
Percentage of allergic rhinitis cases
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Making a diagnosis of allergic rhinitis (AR) - 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)
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Making a diagnosis of allergic rhinitis (AR) - 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 v. specific for AR)
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Other clues in history taking
• Personal history of other allergic conditions• Family history of allergic conditions• Specific allergen and irritant exposure
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Examination
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Visual examination
• Depressed / widened nasal bridge (AR unlikely)• Assess nasal airflow
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Anterior rhinoscopy
• ? Purulent secretions (AR unlikely)• ? Nasal polyps (yellow/grey and lack sensitivity)• ? Nodules and crusting (AR unlikely)
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Investigations
• Peak nasal inspiratory flow• Acoustic rhinometry• Rhinomanometry• Nasal endoscopy• Total IgE generally unhelpful• Specific IgE (RAST) helpful• Skin prick testing
– Very safe– Some contraindications
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Treatment of AR
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ARIA guidelines: classification of allergic rhinitis
Intermittent symptoms <4 days per week or <4 weeks
Persistent symptoms >4 days per week and >4 weeks
Mild symptoms Normal sleep Normal daily activities Normal work and school No troublesome symptoms
Moderate-severe symptoms >1 items
Abnormal sleep Impairment of daily activities,
sport, leisure Problems caused at school
or work Troublesome symptoms
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Nasal congestion is the symptom most patients want to prevent
63
19
8
50
1711
0
10
20
30
40
50
60
70
Nasal congestion Runny nose Sneezing
Respondents (%) Children
Adults
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Treatment
• Education– Nature of disease– Symptoms– Complications (eg sinusitis, otitis media, later
asthma)– Allergen avoidance– Realistic expectations of treatment– Drug treatment and potential s/es– Compliance and correct technique
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Allergen avoidance
• Good evidence for pets (but takes time for cats), horses and certain occupational allergens
• Weak evidence for house dust mite avoidance, most benefit with multiple interventions
• Some evidence for pollen filters and nasal air filters
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Allergic rhinitis: ARIA treatment guidelines
Congestion RhinorrhoeaItching /sneezing Duration
Intranasal steroids +++ +++ ++/+++ 12-48 h
Oral antihistamines + ++ +++/++ 12-24 h
Oral decongestants + - -/- 3-6 h
Intranasal cromones + + +/+ 2-6 h
Anticholinergics - ++ -/- 4-12 h
Antileukotrienes ++ + -/- Not reported
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Oral (H1) antihistamines
Age
> 6 months
Non-sedating Sedating
Trimeprazine
> 1 year Desloratidine Hydroxyzine
Chlorphenamine
> 2 years Cetirizine (SAR only)
Loratidine
Levocetirizine
Promethazine
Ketotifen
> 6 years Fexofenadine (SAR only)
Cetirizine
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Oral antihistamines
• Effect mainly on itch, sneeze and rhinorrhoea, less on congestion
• Effects on other sites eg eyes, palate• Acts within 2-4 hours• Sedation, otherwise few adverse events• Also available topically, azelastine, which has
quick onset of action, but local irritation and taste disturbance a problem
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Nasal corticosteroids
Age (years)
>4
Drug
Fluticasone
Good safety data
Yes
>5 Flunisolide
Dexamethasone
-
-
>6 Mometasone
Triamcinolone
Beclomethasone
Yes
-
-
> 12 Budesonide
Betamethasone
Yes
-
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Nasal corticosteroids
• Acts on all symptoms of AR• Often improves eye symptoms• Onset of action within 6-8h, maximal effect may
not be seen for 2 weeks• Once or twice daily dosing• Systemic absorption least for mometasone and
fluticasone with reassuring safety data• Local irritation (worse with alcohol containing
preparations), sore throat and epistaxis affect about 10%
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Other therapies
• Oral anti-leukotrienes– 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
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One airway, one disease?
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Most patients with asthma
have rhinitis • Approximately 80% of patients with asthma have rhinitis
Leynaert et al 2000
Asthmaalone
Rhinitis alone
Rhinitis +
asthma
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Allergic rhinitis is a risk factor for asthma
• Allergic rhinitis increases the risk of asthma ~3-fold
Subjects with asthma at 23-year follow-up (%)
10.5
3.6
p<0.002
No ARat baseline (n=528)
ARat baseline (n=162)
12
10
8
6
4
2
0
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Link between allergic rhinitis and asthma
• Some patients with allergic rhinitis report increased asthma symptoms during the pollen season
• Rhinitis and asthma involve a common respiratory mucosa
• Inflammation is involved in the pathogenesis of both allergic rhinitis and asthma
• Allergic reactions in the nasal mucosa can potentially worsen asthmatic inflammatory processes in the lower airways
• Allergen specific immunotherapy for rhinitis reduces development of asthma in children
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How can rhinitis worsen asthma?
• Nasal blockage leads to mouth breathing and exposure to cold, dry air, and an increase in allergens in the lower respiratory tract
• Nasal challenge induces release of bone marrow eosinophils into the systemic circulation, which in turn can result in an inflammatory response within the entire respiratory tract
• Rhinitis causes bronchial hyperreactivity• Neurogenic reflexes?• Nitric oxide changes?
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0.9
2.3
p<0.01
Treating allergic rhinitis cuts asthma costs
• 61% fewer hospitalisations in treated patients
Patientshospitalised over 1-year period (%)
Patients untreatedfor AR
(n=1357)
Patients treated for AR
(n=3587)
2.5
2.0
1.5
1.0
0.5
0.0
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Summary
• Allergic rhinitis is common and often persistent, but often overlooked
• Diagnosis is relatively straightforward if the right questions are asked
• AR may be seasonal and / or perennial• Mainstays of treatment are allergen
avoidance, oral antihistamines and intranasal corticosteroids
• Strong link with asthma