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Allergic rhinitis in children

Allergic rhinitis in children. Dr Gulamabbas Khakoo Consultant in Paediatrics, Hillingdon Hospital NHS Trust Consultant in Paediatric Allergy St Mary’s Hospital, Paddington. Scope of presentation. Epidemiology - why allergic rhinitis is important Making a correct diagnosis Treatment

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Allergic rhinitis in children

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  1. Allergic rhinitis in children Dr Gulamabbas Khakoo Consultant in Paediatrics, Hillingdon Hospital NHS Trust Consultant in Paediatric Allergy St Mary’s Hospital, Paddington

  2. Scope of presentation • Epidemiology - why allergic rhinitis is important • Making a correct diagnosis • Treatment • Link with asthma – ? One airway, one disease

  3. 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

  4. 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 persistent BAMSE birth cohort Clin Exp Allergy 2008; 38: 1507-13

  5. Rhinitis • Inflammation of the nasal mucosa • Often involves sinuses hence term rhinosinusitis (more severe disease) • Classification • Allergic • Non-allergic • Infective

  6. Allergic triggers for rhinitis in children

  7. Prevalence of seasonal and perennial allergic rhinitis Percentage of allergic rhinitis cases

  8. 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)

  9. 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)

  10. Other clues in history taking • Personal history of other allergic conditions • Family history of allergic conditions • Specific allergen and irritant exposure

  11. Examination

  12. Visual examination • Depressed / widened nasal bridge (AR unlikely) • Assess nasal airflow

  13. Anterior rhinoscopy • ? Purulent secretions (AR unlikely) • ? Nasal polyps (yellow/grey and lack sensitivity) • ? Nodules and crusting (AR unlikely)

  14. 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

  15. Treatment of AR

  16. ARIA guidelines: classification of allergic rhinitis • Intermittent symptoms • <4 days per week or • <4 weeks • Persistent symptoms • >4 days per week and • >4 weeks • Moderate-severe symptoms >1 items • Abnormal sleep • Impairment of daily activities, sport, leisure • Problems caused at school or work • Troublesome symptoms • Mild symptoms • Normal sleep • Normal daily activities • Normal work and school • No troublesome symptoms

  17. Nasal congestion is the symptom most patients want to prevent Respondents (%) ChildrenAdults Nasal congestion Runny nose Sneezing

  18. 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

  19. 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

  20. Allergic rhinitis: ARIA treatment guidelines

  21. Oral (H1) antihistamines

  22. 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

  23. Nasal corticosteroids

  24. 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%

  25. 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

  26. One airway, one disease?

  27. Approximately 80% of patients with asthma have rhinitis Most patients with asthmahave rhinitis Rhinitis alone Rhinitis + asthma Asthmaalone Leynaert et al 2000

  28. Allergic rhinitis increases the risk of asthma ~3-fold Allergic rhinitis is a risk factor for asthma Subjects with asthma at 23-year follow-up (%) 12 p<0.002 10 10.5 8 6 4 3.6 2 0 No AR at baseline (n=528) AR at baseline (n=162)

  29. 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

  30. 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?

  31. 61% fewer hospitalisations in treated patients Treating allergic rhinitis cuts asthma costs Patientshospitalised over 1-year period (%) 2.5 p<0.01 2.3 2.0 1.5 0.9 1.0 0.5 0.0 Patients untreatedfor AR (n=1357) Patients treated for AR(n=3587)

  32. 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

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