Overview
Definition:
Allergic rhinitis in children is a common, IgE-mediated inflammatory condition of the nasal mucosa triggered by allergens
It manifests with characteristic symptoms of sneezing, nasal congestion, rhinorrhea, and pruritus.
Epidemiology:
Prevalence varies globally but is estimated to affect 10-40% of children worldwide
It often coexists with asthma and atopic dermatitis, forming the "atopic march." Peak incidence is typically in school-aged children.
Clinical Significance:
Undiagnosed or poorly managed allergic rhinitis significantly impacts a child's quality of life, leading to sleep disturbances, daytime fatigue, impaired school performance, and potential complications like sinusitis and otitis media
Understanding optimal intranasal steroid (INCS) delivery is crucial for effective management.
Clinical Presentation
Symptoms:
Cardinal symptoms include sneezing, typically in paroxysms
Profuse, clear rhinorrhea (often described as "dripping")
Nasal pruritus, which can be intense and lead to rubbing the nose upwards (allergic salute)
Nasal congestion, causing mouth breathing and snoring
Ocular symptoms like itchy, red, watery eyes (allergic conjunctivitis) may also be present
Throat irritation or cough can occur due to post-nasal drip.
Signs:
Nasal crease from repeated upward rubbing (allergic salute)
Pale, boggy nasal mucosa with edematous turbinates on anterior rhinoscopy
Allergic shiners (dark circles under the eyes) due to venous congestion
Pharyngeal cobblestoning may be seen due to post-nasal drip.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on characteristic symptoms and a history of allergen exposure
Allergy testing (skin prick tests or specific IgE blood tests) can confirm sensitization to specific allergens but is not always necessary for diagnosis
The ARIA (Allergic Rhinitis and its Impact on Asthma) guidelines provide a framework for classification and management.
Diagnostic Approach
History Taking:
Detailed history of symptom onset, duration, timing (seasonal vs
perennial), and triggers
Association with environmental factors (pets, dust mites, pollen)
Family history of atopy
Previous treatments and their efficacy
Impact on sleep, school, and daily activities
Red flags include recurrent epistaxis, purulent nasal discharge, facial pain, or vision changes suggestive of complications.
Physical Examination:
Thorough ENT examination focusing on the nasal passages (mucosal appearance, discharge, turbinate hypertrophy)
Ocular examination for conjunctival injection or edema
Examination of the pharynx and ears
Auscultation of lungs to assess for co-existing asthma.
Investigations:
Allergy testing: Skin prick tests (SPT) are the gold standard for identifying specific IgE-mediated sensitization
Serum specific IgE antibodies (RAST) are an alternative, particularly if SPT is contraindicated
These investigations help identify trigger allergens and guide allergen avoidance strategies
Nasal cytology may show eosinophils but is less commonly used for routine diagnosis.
Differential Diagnosis:
Common cold (viral rhinitis) – typically shorter duration, may have fever
Non-allergic rhinitis (e.g., vasomotor rhinitis, irritant rhinitis)
Sinusitis (acute or chronic) – purulent discharge, facial pain, fever
Nasal polyps
Foreign body in the nose (especially in younger children)
Adenoid hypertrophy.
Management
Initial Management:
Allergen avoidance is the cornerstone of management
Identification and avoidance of known triggers (e.g., dust mites, pet dander, pollens)
Regular cleaning of the child's environment
Nasal saline irrigation to clear allergens and mucus
Pharmacological treatment is indicated for persistent or bothersome symptoms.
Medical Management:
Intranasal corticosteroids (INCS) are the first-line therapy for persistent allergic rhinitis
They reduce inflammation in the nasal passages
Key considerations for INCS in children include:
1
**Technique is Paramount**: Proper administration ensures the medication reaches the nasal mucosa effectively
2
**Spraying Technique**:
* Shake the bottle well before use
* Prime the pump if it's a new bottle or hasn't been used for a while
* Tilt the child's head slightly forward
* Insert the spray nozzle gently into one nostril, aiming away from the nasal septum towards the outer wall of the nostril
* Close the opposite nostril with a finger
* While the child inhales gently through the nose, squeeze the pump once
* Avoid spraying directly onto the nasal septum, as this can cause irritation, dryness, and epistaxis
* Repeat in the other nostril
* Instruct the child to exhale through their mouth after spraying to avoid sucking the medication down their throat
3
**Consistency**: Daily use is crucial for optimal benefit
Symptoms often improve significantly after a few days to a week of consistent use
4
**Dosage and Potency**: Use the lowest effective dose
Potent INCS may be required for severe symptoms, but milder formulations are preferred for long-term use
Common pediatric INCS include fluticasone propionate, mometasone furoate, budesonide, and ciclesonide
5
**Duration**: Therapy is often lifelong or seasonal, depending on the pattern of rhinitis
Other medications may include oral antihistamines (second-generation preferred for fewer sedating effects), leukotriene receptor antagonists, and, in severe cases, short courses of oral corticosteroids or allergen immunotherapy.
Surgical Management:
Surgery is rarely indicated for allergic rhinitis itself
It may be considered for complications like chronic sinusitis refractory to medical management, adenoid hypertrophy causing significant obstruction, or nasal polyps
Procedures might include adenoidectomy, tonsillectomy, or endoscopic sinus surgery.
Supportive Care:
Education of parents and children about the condition, triggers, and treatment adherence
Ensuring adequate hydration and promoting nasal saline rinses
Monitoring for side effects of medications and assessing treatment efficacy
Managing co-existing conditions like asthma.
Complications
Early Complications:
Acute bacterial sinusitis: Inflammation and infection of the paranasal sinuses
Otitis media with effusion (glue ear): Fluid accumulation in the middle ear, potentially leading to hearing impairment.
Late Complications:
Chronic sinusitis
Nasal polyps
Worsening of asthma control
Sleep-disordered breathing
Impact on psychosocial development and academic performance.
Prevention Strategies:
Strict allergen avoidance
Consistent and correct use of prescribed intranasal steroids
Prompt treatment of infections
Regular follow-up to monitor for complications and adjust management.
Prognosis
Factors Affecting Prognosis:
Severity and duration of symptoms
Adherence to treatment
Control of co-existing atopic conditions (asthma, eczema)
Allergen exposure levels
The presence of complications.
Outcomes:
With appropriate management, including correct INCS technique and allergen avoidance, most children achieve significant symptom control, leading to improved quality of life, better sleep, and enhanced academic performance
However, allergic rhinitis is often a chronic condition requiring long-term management.
Follow Up:
Regular follow-up appointments with a pediatrician or allergist are essential to assess symptom control, monitor for side effects, review adherence to therapy, and re-evaluate the management plan
Annual assessment of asthma control is also crucial in children with co-existing asthma.
Key Points
Exam Focus:
Intranasal steroids (INCS) are first-line for persistent allergic rhinitis in children
Proper administration technique is crucial for efficacy and minimizing side effects
Aim spray away from the septum
Daily use is key
Identify and avoid triggers
Complications include sinusitis and otitis media
Link between allergic rhinitis and asthma (atopic march).
Clinical Pearls:
Educate parents on the "how-to" of INCS spraying
demonstration is often more effective than explanation alone
Emphasize that INCS are not "as needed" but require consistent daily use for several days to achieve full effect
Rule out structural issues or infections if symptoms are refractory to INCS
Consider allergy testing to personalize management.
Common Mistakes:
Incorrect spray technique leading to poor drug delivery or septal irritation/epistaxis
Underestimating the impact of allergic rhinitis on a child's well-being and academic performance
Inadequate allergen avoidance measures
Over-reliance on oral antihistamines for severe congestion
Not linking allergic rhinitis management with asthma control.