rhinitis%20-%20allergic%20(pediatric)
RHINITIS - ALLERGIC (PEDIATRIC)
Rhinitis is the inflammation of the nasal lining membranes.
Allergic rhinitis is most prevalent in childhood and adolescence.
Careful elimination of nonallergic etiologies must be done in preschool children as allergic rhinitis is unusual in <3 years of age.

Principles of Therapy

  • A step-wise approach to treatment is recommended
  • Step-down therapy as patient’s symptoms improve & step-up when symptoms worsen
  • Combination/step-up therapy may be used in patients with inadequate response to monotherapy
    • Intranasal corticosteroids & oral antihistamines: has better symptom control than monotherapy
    • Oral antihistamines & oral decongestant or leukotriene modifiers: showed better symptom control compared to monotherapy
    • Intranasal corticosteroids & leukotriene modifiers: use should be limited if symptoms lessen or disappear with nasal steroids alone
    • Intranasal corticosteroids & intranasal antihistamines or intranasal Oxymetazoline: showed better efficacy than monotherapy

Pharmacotherapy

Anticholinergics
  • Eg Ipratropium bromide
  • Effectively controls watery rhinorrhea, no effect on sneezing & nasal congestion
  • Onset of action is fast (15-30 minutes)
  • Adverse effects are infrequent; if present, usually localized & mild (eg nasal dryness, irritation, epistaxis)
Antihistamines
  •  First-line therapy for mild to moderate intermittent & mild persistent rhinitis
  • H1-receptor antagonists reduce nasal itching, sneezing & rhinorrhea, but are less effective for nasal congestion; also relieve ocular symptoms
Nasal Antihistamines
  • Eg Azelastine, Olopatadine, Levocabastine
  • Rapid onset of action (<30 minutes) but relatively short-acting
  • May be used in children with seasonal allergic rhinitis to help reduce symptoms & nasal obstruction w/ minimal side effects
Oral Antihistamines
  • Eg Acrivastine, Cetirizine, Chlorpheniramine, Desloratadine, Diphenhydramine, Fexofenadine, Levocetirizine, Loratadine
  • Preferred route for intermittent or persistent allergic rhinitis & may be used to prevent symptoms associated with occasional allergy exposure
  • 2nd generation antihistamines are ideal as 1st-line therapy in equal preference to nasal antihistamines
  • Preferred over oral leukotriene receptor antagonists for treatment of preschool children with persistent allergic rhinitis 
  • Use of 1st generation antihistamines should be limited; may reduce academic ability in school children
  • Onset of action occurs in <1 hour
Intraocular Antihistamines
  • May be used to relieve ocular symptoms of allergic rhinitis such as pruritus & redness
Anti-Immunoglobulin E Antibody
  • Eg Omalizumab
  • Has been shown to be effective in seasonal allergic rhinitis
Corticosteroids
  • Have a strong anti-inflammatory capacity & reduce nasal itching, sneezing, congestion & rhinorrhea
Nasal Corticosteroids
  • Eg Beclomethasone, Budesonide, Ciclesonide, Flunisolide, Fluticasone, Mometasone, Triamcinolone
  • Most effective treatment for allergic rhinitis
  • Onset of action is relatively slow (12 hours), with max efficacy after a few days
    • Ciclesonide: onset of action is within 1 hour of use
    • Mometasone: onset of action is within 12 hours of use
  • Caution is needed due to the possible effect on growth; regular height measurements are advised
  • In severe cases, nasal corticosteroids should be administered before the start of allergy season as prophylaxis
Oral/Intramuscular (IM) Corticosteroids
  • IM agents are more invasive & expensive, & are less preferred
  • Oral corticosteroids are reserved for patients with refractory or severe symptoms not controlled by antihistamines or topical agents
    • Short course for 3-5 days may be helpful
  • Therapy must be limited to lowest effective dose & shortest possible time
Cromones (Nasal)
  • Recommended as an alternative treatment to antihistamines & corticosteroids
  • Less effective than antihistamines & nasal corticosteroids 
  • An option due to its excellent safety profile
  • Most efficient if used regularly prior to onset of allergic symptoms but may be considered for symptomatic treatment (nasopharyngeal itchiness, sneezing, rhinorrhea, conjunctivitis)
Decongestants
  • Sympathomimetic & relieves nasal congestion
  • Preparations containing Ephedrine, Oxymetazoline & Xylometazoline should not be used in patients <2 years of age
Nasal/topical Decongestants
  • Eg Oxymetazoline, Xylometazoline
  • Short courses may be used to immediately reduce severe nasal congestion
  • Because of the risk of rebound congestion (rhinitis medicamentosa), use should be limited to <10 days
  • Beneficial prior to instillation of nasal corticosteroids
Oral Decongestants
  • Eg Pseudoephedrine, Ephedrine
  • Not as effective as nasal decongestant; consider the benefits versus safety concerns especially in patients <6 years of age
  • Doesn’t have rebound congestion
  • May be used as additional medication with antihistamine, efficacy is increased than either medication alone but with combined side effects
LeukotrieneReceptor Antagonists (LTRA)
  • Eg Montelukast
  • A therapeutic option used either alone or in combination with oral antihistamines or nasal corticosteroids; not to be used as initial therapy
  • May be used in children with seasonal allergic rhinitis, preschool children with persistent allergic rhinitis, and those with coexisting asthma
  • Efficacy comparable to oral antihistamines & less than nasal corticosteroids
Saline Solutions
  • May be used as single or adjunctive agents in reducing the symptoms & improving the quality of life
    • Can also help clear the nose before eating & sleeping
  • There is no difference in radiologic or symptoms score when comparing isotonic with hypertonic saline, although hypertonic solutions have been shown to improve mucociliary clearance
  • Associated with mild side effects (eg burning, irritation, nausea)

Non-Pharmacological Therapy

Allergen Avoidance
  • Identification & avoidance of trigger allergens should be an integral part of allergic rhinitis management strategy
  • Removal of the allergen may result in diminished severity of the disease & decreased requirement for medications
  • Identifying specific causal allergens by lab testing may encourage patients to comply with allergen avoidance instructions
  • Effectiveness of avoidance will be measured by relief of the patient’s symptoms & by a decrease in the need for medications
  • In the majority of cases, it is not possible to completely avoid allergens but these measures should be considered where appropriate
Pets
  • Do not allow animals in the house
  • If this is not possible, keep pets out of patient’s bedroom, bathe pets once or twice daily
House dust mites
  • Major allergen found in houses
  • Use allergen-impermeable covers for mattresses & pillows
  • Wash sheets & blankets in hot water (60oC) every week
  • Reduce indoor humidity to <50% (an air conditioner may reduce humidity in the summer)
  • Use high efficiency particulate air filter when vacuuming or dust weekly with mask
Pollen
  • Avoid outdoor exposure on days when pollen counts are high
  • Use of air conditioning is advisable
  • Keep doors & windows closed at home & when inside vehicles
Others
  • Discourage smoking by household members & visitors
  • Minimize contact with irritants (eg perfumes, hair spray & other odors)
  • Reduce growth of molds in the home by decreasing humidity & eliminating sites for mold growth

Immunotherapy

  • Recommended for allergy testing-positive patients with inadequate response to pharmacologic therapy & allergen avoidance measures 

Principles of Therapy

  • Repeated administration of specific allergens in patients with IgE-mediated conditions to provide protection against allergic symptoms associated with exposure to these allergens
  • Only intervention that alters the natural history of allergic rhinitis
  • Activates regulatory T cells, thereby altering humoral response to allergens by increasing CD8+ T cells & IL-10, & reducing IL-13 production
  • Indicated for patients with the following:
    • Evidence of specific IgE antibody to allergen (positive allergy test results)
    • Any of the following:
      • Clinically diagnosed with both allergic rhinitis & asthma
      • Required medication
      • Poor response to avoidance measures
      • Adverse effects to medications
      • Prevention of asthma in allergic rhinitis patients
    • Initial dose should be performed in a medical facility by a trained personnel
    • Recommended course is usually 4-5 years

Subcutaneous Immunotherapy (SCIT)

  • May be considered in children whose seasonal allergic rhinitis is triggered by pollen exposure, & perennial rhinitis due to house dust mite 
  • Efficacy for allergic rhinitis is comparable to that of nasal glucocorticoids
  • Limited by frequent injection on regular basis & small risk of anaphylactic reactions

Sublingual immunotherapy (SLIT)

  • Sublingual & intranasal allergen-specific immunotherapy may be considered in children with allergic rhinitis due to pollen exposure 
  • A more viable treatment compared to SCIT as self-administration is encouraged with this form
  • Use should be limited to those who can tolerate systemic reactions & its treatment
  • Auto/self-injectable Epinephrine should be prescribed to all patients receiving SLIT
  • Has been associated with mild oral & GI symptoms & less risk for anaphylaxis compared to SCIT
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