Overview
Definition:
Allergic rhinitis (AR) is a chronic inflammatory disorder of the nasal mucosa, triggered by re-exposure to allergens in sensitized individuals
It is characterized by symptoms such as sneezing, rhinorrhea, nasal pruritus, and nasal congestion.
Epidemiology:
AR is highly prevalent in children, affecting an estimated 10-40% globally
The incidence varies by geographic location, age, and allergen exposure
In India, studies suggest a significant burden, particularly in urban areas.
Clinical Significance:
Allergic rhinitis in children can significantly impact their quality of life, leading to sleep disturbances, impaired concentration, reduced academic performance, and increased susceptibility to other conditions like otitis media and sinusitis
Effective management is crucial for optimal child development and well-being.
Age Considerations
Infants:
AR is less common in infants under one year but can occur, often presenting with irritant-like symptoms due to difficulty distinguishing from other causes of nasal congestion
Allergen exposure through maternal diet or environment is considered.
Toddlers And Preschoolers:
Symptoms can be attributed to frequent viral infections
Diagnosis relies on a high index of suspicion and careful history
Common triggers include dust mites, pet dander, and pollens.
School Aged Children:
AR becomes more prevalent and symptomatic
It can significantly interfere with school attendance and performance
Identification and management of triggers are key.
Adolescents:
Symptoms may persist or evolve
Hormonal changes can sometimes influence rhinitis
Co-morbid conditions like asthma and eczema are common.
Clinical Presentation
Symptoms:
Episodic sneezing
Profuse watery rhinorrhea
Nasal pruritus
Nasal congestion
Post-nasal drip
Itchy, watery eyes (allergic conjunctivitis)
Sore throat
Cough (due to post-nasal drip)
Fatigue and irritability.
Signs:
Allergic shiners (infraorbital edema and discoloration)
Allergic salute (transverse nasal crease from upward rubbing)
Cobblestoning of the posterior pharyngeal wall
Pale, boggy nasal mucosa with edema
Nasal polyps (less common in children).
Diagnostic Criteria:
Diagnosis is primarily clinical, based on characteristic symptoms and history of allergen exposure
International guidelines (e.g., ARIA - Allergic Rhinitis and its Impact on Asthma) define intermittent vs
persistent and mild vs
moderate-to-severe AR based on symptom frequency, duration, and impact on daily activities
Allergy testing (skin prick tests or specific IgE) confirms sensitization.
Diagnostic Approach
History Taking:
Detailed history of symptom onset, duration, frequency, and seasonality
Identification of potential triggers (pets, dust, pollens, foods)
Associated symptoms (asthma, eczema)
Family history of atopy
Impact on sleep and daily activities
Previous treatments and their efficacy.
Physical Examination:
Thorough examination of the head and neck: nasal mucosa for pallor and edema
pharynx for cobblestoning
eyes for conjunctival injection and edema
ears for signs of otitis media
Auscultation of lungs to assess for wheezing (asthma).
Investigations:
Allergy testing is crucial for identifying specific allergens: Skin Prick Tests (SPT) using common aeroallergens (dust mites, pollens, molds, dander)
Serum specific IgE antibodies (RAST or ImmunoCAP)
Nasal cytology can reveal eosinophils, but is less commonly used for routine diagnosis
Blood eosinophil counts are often elevated but non-specific.
Differential Diagnosis:
Non-allergic rhinitis (vasomotor rhinitis, irritant rhinitis, hormonal rhinitis)
Infectious rhinitis (viral, bacterial)
Foreign body in the nose
Adenoid hypertrophy
Nasal polyps
Structural nasal abnormalities.
Management
Allergen Avoidance:
Primary strategy: Minimize exposure to identified allergens
For dust mites: use allergen-impermeable mattress and pillow covers, reduce humidity, vacuum frequently with HEPA filter, remove carpets and stuffed toys
For pets: keep pets out of the bedroom, frequent grooming, consider rehoming if severe
For pollens: keep windows closed during high pollen counts, use air purifiers with HEPA filters, rinse nasal passages
For molds: control humidity, repair leaks, clean visible mold.
Pharmacotherapy:
First-line: Intranasal corticosteroids (e.g., fluticasone propionate, mometasone furoate, budesonide)
Effective for congestion, rhinorrhea, sneezing, and itching
Start treatment before peak allergen season if possible
Second-line/adjunctive: Oral antihistamines (e.g., cetirizine, loratadine, fexofenadine) – less effective for congestion but good for itching and sneezing
Antihistamine nasal sprays (e.g., azelastine)
Leukotriene receptor antagonists (e.g., montelukast) – particularly useful if co-existing asthma
Decongestants (oral or nasal) – for short-term relief of severe congestion, use nasal decongestants cautiously due to rebound rhinitis.
Allergy Immunotherapy:
For children with severe, persistent AR refractory to maximal pharmacotherapy, or with significant side effects
Can be subcutaneous (SCIT) or sublingual (SLIT)
Aims to desensitize the immune system to specific allergens
Requires careful monitoring and assessment by a specialist.
Patient Education:
Crucial for compliance and successful management
Educate on triggers, avoidance strategies, correct inhaler technique for nasal sprays, medication side effects, and when to seek medical advice.
Comparative Effectiveness
Allergen Avoidance Vs Pharmacotherapy:
Allergen avoidance is fundamental and aims to remove the cause
Pharmacotherapy manages symptoms by reducing inflammation and histamine release
Often, a combination of both is most effective
Avoidance alone may not suffice if exposure is unavoidable or widespread.
Pharmacotherapy Options:
Intranasal corticosteroids are generally considered the most effective single therapy for moderate-to-severe AR, addressing all major symptoms
Antihistamines are effective for itching and sneezing but less so for congestion
Combination therapy may offer superior symptom control.
Long Term Impact:
Consistent allergen avoidance and appropriate pharmacotherapy can lead to sustained symptom control, improved quality of life, and potentially reduce the risk of developing or exacerbating asthma.
Complications
Nasal:
Chronic sinusitis, nasal polyps (rare in children).
Otologic:
Otitis media with effusion, Eustachian tube dysfunction.
Ocular:
Allergic conjunctivitis, eye rubbing leading to vision changes.
Respiratory:
Asthma exacerbations, increased susceptibility to viral upper respiratory infections.
Sleep Disturbance:
Poor sleep quality due to nasal congestion and pruritus, impacting daytime functioning and learning.
Key Points
Exam Focus:
The cornerstone of AR management in children is a multi-modal approach
Differentiate between intermittent and persistent AR
Recognize the role and mechanism of intranasal corticosteroids as first-line therapy
Understand the indications for allergy immunotherapy.
Clinical Pearls:
Always consider allergic rhinitis in children with recurrent nasal congestion, sneezing, or rhinorrhea, especially if seasonal or related to specific exposures
Educate parents on proper nasal spray technique to maximize efficacy and minimize side effects
Start intranasal corticosteroids before allergy season for optimal symptom control.
Common Mistakes:
Over-reliance on oral decongestants or antihistamines alone, especially for significant congestion
Failure to educate patients and parents on allergen avoidance strategies
Delaying diagnosis and management of co-existing asthma
Inadequate follow-up to assess treatment efficacy and adherence.