Diagnosis and Management of Allergic Rhinitis in Children

8/13/2019 Diagnosis and Management of Allergic Rhinitis in Children

1/39

Diagnosis and Management of

Allergic Rhinitis in Children

Dina Muktiarti

Department of Child HealthFaculty of Medicine University of Indonesia/

Cipto Mangunkusumo Hospital


2/39

Outline

Background

Diagnosis

Management Prevention

Conclusions


3/39

Allergic Rhinitis

Rhinitis:

an inflammation of the lining of the nose and

characterized by nasal symptoms including

rhinorrhea, sneezing, nasal blockage and/or

itching of the nose.

Multifactorial disease induced by gene-

environment interaction

Bousquet J, et al. Allergy 2008; 63(S86):8-160.

Pawankar RP, et al. WAO white book on allergy.

Gentile DA, et al. In: Pediatric allergy. 2nd ed. Edinburgh, Elsevier, 2010. p. 291-300.


4/39

Allergic Rhinitis

Allergic rhinitis is a global health problem that

affect 10-30% of all adults and about 40% of

children.

Prevalence of AR is increasing, although AR

prevalence in Indonesia (3-5%) is lower than

other western countries.



Asher MI, et al. Lancet. 2006;368:73343.


5/39

Allergic Rhinitis


6/39

Allergic Rhinitis:

Why is it important?

Allergic rhinitis

Uncomfortable

symptoms.

Increased costs(direct and

indirect costs).

Predispose to the

development of

comorbidities

such as asthma.

Significantimpact on childs

health andquality of life

Meltzer EO. Allergy Asthma Proc. 2006;27:2-8.



7/39

DIAGNOSIS


8/39

Sign and Symptoms

Rhinorrhea

Sneezing

Nasal pruritus

Nasal congestion Cough

Halitosis

Sniff and snort

Epistaxis

Allergic shiner

(darkened lower eyelids)

Allergic crease

(a visible transverse lineabove the tip of the nosecaused by rubbing)

Allergic salute

(upward rubbing of thenose)

The gaper mouth(opened to breathe).


Pawankar RP, et al. WAO white book on allergy.Gentile DA, et al. In: Pediatric allergy. 2nd ed. Edinburgh, Elsevier, 2010. p. 291-300.


9/39

Sign and symptoms

http://www.pediatricsconsultant360.com/sites/default/files/images/1205CFP_Huang1_Fg.jpg

http://emedicine.medscape.com/article/834281-overview
http://www.pediatricsconsultant360.com/sites/default/files/images/1205CFP_Huang1_Fg.jpghttp://www.pediatricsconsultant360.com/sites/default/files/images/1205CFP_Huang1_Fg.jpg


10/39

CO-MORBIDITIES



11/39

Allergy Tests

Skin prick tests

Specific IgE serum

Positive result means sensitization anddoes not always equivalent to clinical

allergy.

Interpretation of allergy tests in the

context of clinical history is important





12/39

Trigger

Food allergen is a very rare cause of isolated rhinitis.

Role of air pollutants is probably important.Bousquet J, et al. Allergy 2008; 63(S86):8-160.Pawankar RP, et al. WAO white book on allergy.



13/39

Allergic Rhinitis Classification:

Allergic Rhinitis and Its Impact on Asthma (ARIA)-WHO

Moderate-severe

one or more items

Abnormal sleep

Impairment of dailyactivities, sport, leisure

Abnormal work andschool

Troublesome symptoms

Persistent

4 days per week

and 4 weeks

Mild

Normal sleep

& No impairment of daily

activities, sport, leisure& Normal work andschool

& No troublesomesymptoms

Intermittent

< 4 days per week

or < 4 weeks

in untreated patients Bousquet J, et al. Allergy 2008; 63(S86):8-160.


14/39

Differential Diagnosis

Infectious rhinitis

Non-allergic rhinitis (vasomotor, drug induced,

etc)




15/39

ManagementAllergenavoidance

indicatedwhen poss ib le

Pharmacotherapysafety

effectivenesseasi ly adm inistered

Immunotherapyeffectiveness

special is t prescr ipt io nmay alter th e naturalcou rse of the disease

Patienteducationalways indicated

costs



16/39

Management of allergic rhinitis(ARIA)

mildintermittent

mildpersistentmoderate

severeintermittent

moderatesevere

persistent

allergen and irritant avoidance

immunotherapy

intra-nasal decongestant (short time) or oral decongestant

local chromone

intra-nasal steroid

oral or local non-sedative H1-blocker

Bous uet J, et al. Aller 2008; 63 S86 :8-160.


17/39

Steps of

allergic rhinitismanagement

Diagnosis of allergic rhinitis Check for asthmaespecially in patients with severeand/or persistent rhinitis

MILDNot in preferred order

Oral H1 blockeror intranasal H1-blockerand/ordecongestantor LTRA

Intermittentsymptoms

Persistentsymptoms

If conjunctivitis:Add: oral H1-blocker

or intraocular H1-blockeror intraocular cromone

(or saline)

Allergen and irritant avoidance may be appropriate

MODERATE- MILDSEVERE

Not in preferred order

oral H1 blockeror intranasal H1-blocker

and/or decongestantor intranasal CS

or LTRA(or cromone)

In persistent rhinitisreview the patientafter 24 weeks

If failure: step-upIf improved: continue

for 1 month

Consider specific immunotherapy

LTRA: leukotriene rece tor anta onists

MODERATE-SEVEREIn preferred order

intranasal CSH1 blocker or LTRA

Improved Failure

Step-down

and continuetreatment

for >1 month

Review the patientafter 24 weeks

Review diagnosis

Review complianceQuery infectionsor other causes

Add orincreaseintranasalCS

Rhinorrheaadd

ipratropium

Blockageadddecongestantor oral CS(short term)

Failure

referral to specialist



18/39

EVIDENCE BASED ON ALLERGICRHINITIS MANAGEMENT


19/39


20/39

Strength of evidence fortreatment of rhinitis

Seasonal AR Perennial AR

Adult Children Adult Children

Oral antihistamine H1 A A A A

Intranasal antihistamine H1 A A A A

Intranasal corticosteroid A A A A

Intranasal chromones A A A A

LTRA A A

Subcutaneous immunotherapy A A A A

Sublingual immunotherapy A A A

Allergen avoidance D D D D



21/39

Medications of allergic rhinitisSneezing Rhinorrhea Nasal Nasal Eye

obstruction itch symptoms

H1-antihistamines

oral +++ +++ 0 to + +++ ++

intranasal ++ +++ + ++ 0

intraocular 0 0 0 0 +++

Corticosteroids +++ +++ ++ ++ +

Chromones

intranasal + + + + 0

intraocular 0 0 0 0 ++

Decongestantsintranasal 0 0 ++ 0 0

oral 0 0 + 0 0

Anti-cholinergics 0 +++ 0 0 0

Anti-leukotrienes + ++ ++ ? ++Bous uet J et al. Aller 2008 63 S86 :8-160.


22/39

ALLERGEN AVOIDANCE

Allergen avoidance is important but sometimes it

is impractical.

House dust mite allergens: do not use currently

available single chemical or physical preventivemethods aimed at reducing exposure to house

dust mites.

multifaceted environmental control programs. Metanalysis: Isolated use of HDM impermeable

bedding is unlikely to prove effective.

Bousquet J, et al. Allergy 2008; 63(S86):8-160.Nurmatov U, et al. Allergy. 2012; 67: 15865.


23/39

ALLERGEN AVIODANCE

Allergen Control measures

Dust mites Encase bedding in airtight covers

Wash bedding in water at temperatures >130F

Remove wall-to-wall carpeting

Remove upholstered furniture

Animal dander Avoid furred pets

Keep animals out of patient's bedroom

Cockroaches Control available food supply

Keep kitchen/bathroom surfaces dry and free of standing water

Professionally exterminate

Mold Destroy moisture-prone areasAvoid high humidity in patient's bedroom

Repair water leaks

Check basements, attics, and crawl spaces for standing water

and mold



24/39

ORAL ANTIHISTAMIN H1

H1-antihistamines antagonize the H1-receptor on smooth

muscle cells, nerve endings, and glandular cells, leading to a

reduction in nasal symptoms (rhinorrea, itching, sneezing),

but it only have a mild effect on nasal congestion.

Supplementary functions:

inhibition of mediator release from mast cells and

basophils

additional anti-inflammatory properties (2nd

generation):

reduction in intercellular adhesion molecule 1

expression

Greiner AN, Meltzer EO. J Allergy Clin Immunol. 2006;118:985-96.Brozek JL, et al. J Allergy Clin Immunol. 2010;126:466-76.


25/39

ORAL ANTIHISTAMIN H1

Second-generation oral H1-antihistamines are

recommended for AR because they have

better H1-receptor selectivity and less

anticholinergic side effects.

Many studies on 2nd generation oral H1-

antihistamine also proved clinical efficacy for

AR.

Greiner AN, Meltzer EO. J Allergy Clin Immunol. 2006;118:985-96.

Brozek JL, et al. J Allergy Clin Immunol. 2010;126:466-76.


26/39


27/39

INTRANASAL ANTIHISTAMIN

ARIA suggests intranasal H1-antihistamines in

children with seasonal AR and for persistent

AR.

However, ARIA recommends oral

antihistamine over intranasal antihistamine




28/39

INTRANASAL CORTICOSTEROID

Improve all nasal symptoms of AR, including nasal

congestion, rhinorrhea, itching, and sneezing.

The comprehensive clinical effects of INSs are based on a

broad mechanism of action. Reduction of the nasal mucosa inflammatory cells and

their associated cytokines.

Cochrane (2009): not conclusive data on beneficial effect

of INS for AR in children. ARIA (2010) suggests intranasal glucocorticosteroids over

other treatment for AR in children.


Al Sayyad JJ, et al. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD003163. DOI: 10.1002/14651858.CD003163.pub4.



29/39

Systemic Bioavailability of INS

Sastre J, Mosges R. Investig Allergol Clin Immunol. 2012; 22: 1-12.


30/39

INTRANASAL CORTICOSTEROID

Meltzer EO. Allergy Asthma Proc. 2006;27:2-8.
http://www.ncbi.nlm.nih.gov/pubmed/?term=Allergic+rhinitis:+Managing+the+pediatric+spectrumhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Allergic+rhinitis:+Managing+the+pediatric+spectrumhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Allergic+rhinitis:+Managing+the+pediatric+spectrum


31/39

Techniques of Intranasal Corticosteroid

Use1. Hold head in a neutral, upright position

2. Clear nose of any thick or excessive mucus,

if present, by gently blowing the nose

3. Insert spray nozzle into the nostril

4. Direct the spray laterally or to the side,

away from the middle of the nose

(septum) and toward the outer portion of

the eye or the top of the ear on that side.

(If possible, use the right hand to spray the

left nostril and left hand to spray the right

nostril, to direct the spray away from the

septum)

5. Activate the device as recommended bythe manufacturer, and use the number of

sprays recommended by the doctor

6. Gently breathe in or sniff during the

spraying

7. Breathe out through the nose

Sastre J, Mosges R. Investig Allergol Clin Immunol. 2012; 22: 1-12.


32/39

Bothersome side effects of prescription nasal

allergy sprays experienced by children

Meltzer E. J Allergy Clin Immunol 2009;124:S43-7


33/39

DECONGESTANT

Vasoconstrictors.

The reduction in blood flow to the nasal vasculature

after administration leads to increased nasal patency

in 5 to 10 minutes when applied topically or 30minutes when administered orally.

Tolerance and rebound congestion can occur when

topical decongestant are used for longer than 1

week.




34/39

LEUKOTRIENE RECEPTOR ANTAGONIST

Montelukast, with very limited comparator

data, does not appear to be more effective

than nonsedating antihistamines and is less

effective than INSs for AR treatment.

ARIA: LTRA for preschool children with

persistent AR (conditional recommendation)




35/39


36/39

IMMUNOTHERAPY

Immunotherapy is an allergen-specific therapy

that is clinically effective and induces long-

term remission of allergic rhinitis and allergic

asthma.

ARIA suggest subcutaneous immunotherapy

for AR in children and sublingual

immunotherapy for children with AR causedby pollens.




37/39

PREVENTIONS

Primary prevention:

Exclusive breastfeeding

No smoke exposure

Avoidance of pets or house dust mite in early

life no conclusive data



38/39

CONCLUSIONS

Allergic rhinitis is one of common chronic

disease in the pediatric population.

Allergic rhinitis can affect childs health and

quality of life.

Treatment choice based on classification.

Issues of compliance and convenience are

important considerations.


39/39

THANK YOU

Documents

Diagnosis and Management of Allergic Rhinitis in Children