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.

Rhinitis%20-%20allergic%20(pediatric) Treatment

Principles of Therapy

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

Pharmacotherapy

Anticholinergics
  • Eg Ipratropium bromide
  • Effectively controls watery rhinorrhea, no effect on sneezing and nasal congestion
  • Onset of action is fast (15-30 minutes)
  • Adverse effects are infrequent; if present, usually localized and mild (eg nasal dryness, irritation, epistaxis)
Antihistamines
  • First-line therapy for mild to moderate intermittent and mild persistent rhinitis
  • H1-receptor antagonists reduce nasal itching, sneezing and 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 and nasal obstruction with minimal side effects
Oral Antihistamines
  • Eg Acrivastine, Cetirizine, Chlorpheniramine, Desloratadine, Diphenhydramine, Fexofenadine, Levocetirizine, Loratadine
  • Preferred route for intermittent or persistent allergic rhinitis and 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 and redness
Anti-Immunoglobulin E Antibody
  • Eg Omalizumab
  • Has been shown to be effective in seasonal allergic rhinitis
Corticosteroids
  • Have a strong anti-inflammatory capacity and reduce nasal itching, sneezing, congestion and 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 and expensive, and 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 and shortest possible time
Cromones (Nasal)
  • Recommended as an alternative treatment to antihistamines and corticosteroids
  • Less effective than antihistamines and 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 and relieves nasal congestion
  • Preparations containing Ephedrine, Oxymetazoline and 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
Leukotriene Receptor 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 and less than nasal corticosteroids
Saline Solutions
  • May be used as single or adjunctive agents in reducing the symptoms and improving the quality of life
    • Can also help clear the nose before eating and 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 and 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 and 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 and 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 and pillows
  • Wash sheets and blankets in hot water (60oC) every week
  • Reduce indoor humidity to around 50% (or 40-60%) (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 and windows closed at home and when inside vehicles
Others
  • Discourage smoking by household members and visitors
  • Minimize contact with irritants (eg perfumes, hair spray and other odors)
  • Reduce growth of molds in the home by decreasing humidity and eliminating sites for mold growth

Immunotherapy

  • Recommended for allergy testing-positive patients with inadequate response to pharmacologic therapy and 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 and IL-10, and 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 and 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, and 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 and small risk of anaphylactic reactions

Sublingual Immunotherapy (SLIT)

  • Sublingual and 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 and its treatment
  • Auto/self-injectable Epinephrine should be prescribed to all patients receiving SLIT
  • Has been associated with mild oral and GI symptoms and less risk for anaphylaxis compared to SCIT
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