Primary care management of allergic rhinitis in children

Opening Vignette Lionel, an 11-year-old boy, was brought by his mother to your clinic for longstanding nasal blockage and snoring. Lionel’s mother reported that he had been having constant nasal blockage for the past 2 years, as well as bouts of sneezing attacks. She also noticed that he ground his teeth at night, resulting in recurrent mouth ulcers. The patient reported poor night-time sleep with resultant daytime fatigue and difficulty concentrating in school. He did not have symptoms suggestive of sleep apnoea, such as loud snoring with pauses in breathing or choking in sleep, or frequent upper respiratory tract infections. He had a history of mild eczema as an infant but did not require pharmacotherapy. There was a significant family history of atopy, with both parents having had asthma. During physical examination, you noticed a transverse crease on the dorsum of the patient’s nose resulting from constant rubbing. He also had pale oedematous inferior turbinates with clear watery discharge. Examination of the oral cavity did not reveal any enlarged tonsils, and the ear examination was normal.WHAT IS ALLERGIC RHINITIS? Allergic rhinitis (AR) is a chronic symptomatic disorder of the nose that arises after exposure to allergens via immunoglobulin-E (IgE)-mediated Type 1 hypersensitivity reactions. This results in inflammation of the lining of the nose.[1] Common allergens include house dust mite, dander from animals such as cats and dogs, mould and cockroach waste. Based on the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines, AR can be classified by the temporal pattern (e.g. intermittent or persistent) and by severity (mild or moderate–severe).[2] Severity of AR is classified as mild when symptoms are present but do not interfere with quality of life. It is classified as severe when symptoms are significant enough to interfere with quality of life, for example, sleep disturbance, impairment of daily activities and impairment of school performance. Figure 1 classifies AR according to the ARIA guidelines.Figure 1: Classification of allergic rhinitis according to the Allergic Rhinitis and its Impact on Asthma guidelines. Allergic rhinitis can be categorised based on symptom duration (intermittent, persistent) and severity (mild, moderate/severe).HOW RELEVANT IS THIS TO MY PRACTICE? Allergic rhinitis is the most common chronic disease in childhood, affecting up to 25% of children,[3] with a peak prevalence in the adolescent years.[4] In Singapore, due to the tropical climate year-round, which promotes the proliferation of dust mites and mould, most people with AR have the persistent type.[5] In addition, house dust mite is the most common allergen trigger, as the majority of the local population is sensitised to it.[6] Symptoms that children with AR typically present with include nasal congestion, sneezing, rhinorrhoea and itching. However, they may also present with atypical symptoms via associated comorbidities, depending on the child’s age. Some of these atypical presentations include recurrent ear infections and reduced hearing due to eustachian tube dysfunction, cough, poorly controlled asthma, sleep problems, poor concentration at school, prolonged and frequent respiratory tract infections, and impairment of school performance.[7] In the paediatric population, the physician may also observe a phenomenon known as ‘atopic march’, which refers to the sequential development of atopic conditions over the course of infancy and childhood. The typical atopic march sequence begins with atopic dermatitis in infancy, progressing to food allergy, asthma and AR. In light of this and considering that a period of allergen exposure is required before the development of the disease, it is rare for children under 2 years of age to have AR. As such, if a very young child appears to have persistent nasal symptoms, other diagnoses should be considered. Likewise, unilateral symptoms, mucopurulent rhinorrhoea, anosmia and pain are also unlikely to be due to AR, and other diagnoses should be considered. WHAT CAN I DO IN MY PRACTICE? Clinicians should devote time to the diagnosis and management of children presenting with signs and symptoms of AR. Quick-relief medications such as decongestants, for example, oxymetazoline, provide short-term symptom relief but not lasting long-term control, and hence should be avoided. Overall, AR requires more of the physician’s time to diagnose and manage successfully. Recognising allergic rhinitis in children Diagnosing AR in the paediatric population presents unique challenges. This is because children are often unable to verbalise their symptoms, resulting in the condition remaining undiagnosed and untreated. As such, it is important for a physician to recognise the signs that point to AR. These include ‘allergic shiners’ (dark circles around the eyes related to venodilation), ‘allergic salute’ (the continual habit of rubbing the nose in an upward or transverse manner) and ‘allergic crease’ (a horizontal crease across the lower half of the bridge of the nose resulting from the continual upward rubbing of the nose). The clinical history should include the symptom type, chronicity of symptoms, frequency of symptoms, exacerbating factors, severity of symptoms and family history of atopy. Nasal congestion is a prominent symptom in children and may be the only complaint. The caregiver may also bring to attention symptoms such as watery rhinorrhoea, frequent sneezing, a nasal voice, repeated throat clearing, mouth breathing, frequent snoring or chronic gaping of the mouth. Other presenting symptoms due to uncontrolled AR could be recurrent headache from sinusitis, early morning abdominal discomfort from aerophagia and mouth breathing, cough, recurrent oral ulcers and teeth enamel erosions from teeth grinding, malalignment of teeth, and inattention at school. Allergic rhinitis is usually not considered a possible cause of these symptoms; as a result, the patient often undergoes unnecessary testing and treatment without any improvement in symptoms. Physical examination findings The nose, tympanic membrane and oropharynx should be examined, as they may show findings suggestive of AR or other associated conditions. A standard office otoscopy should be used to visualise the nasal mucosa and the appearance of the turbinates. Nasal obstruction is often seen, and the turbinates may be enlarged or swollen with pale nasal mucosa and clear nasal secretions. The oral cavity should also be examined, looking out for pharyngeal cobblestoning and enlarged tonsils. However, it is pertinent to note that negative examination findings do not eliminate the possibility of AR. COMMON PITFALLS IN MANAGEMENT The control of AR is often suboptimal due to poor adherence to medications on the patient’s or caregiver’s part, poor understanding of disease and inadequate follow-up.[8] Sufficient emphasis should be placed on patient and/or caregiver education to empower them for chronic management. Common parental misconceptions It is important to correct misconceptions about AR through parental education; this will help to prevent trivialising of symptoms or nonadherence to treatment. Common myths include views that AR is harmless and that all children will outgrow their allergies. It must be noted that although the nature of the symptoms of AR is non-life-threatening, they can have a major effect on quality of life, sleep, academic performance, emotional well-being and productivity when poorly controlled. In addition, untreated AR can contribute to potentially serious sequelae, including asthma, sinusitis and recurrent otitis media. Majority of children diagnosed with AR will have symptoms 10 years later, and 40% of young adults will have them even 20 years later.[9] Another misconception is that physicians may prescribe inappropriate or ineffective doses of medications and may not provide adequate follow-up to assess response to treatment. Parents may also have the belief that testing for allergen-specific IgE with blood tests or skin testing before making the presumptive diagnosis of AR and initiating treatment is unnecessary. Indeed, the identification of possible triggers through a good clinical history and initiation of empirical treatment are sufficient for most patients. However, the caveat is that there should be adequate follow-up to assess the patient’s response to treatment. Patients who have refractory symptoms should be referred to a paediatric allergist for further evaluation, or an alternative diagnosis should be considered. MANAGING ALLERGIC RHINITIS IN CHILDREN The management strategies of AR in children include avoidance of allergens, pharmacotherapy and use of specific immunotherapy (IT). Partnership between patients, caregivers and the medical team is also essential for the effective treatment of AR. The World Health Organization developed the ARIA guidelines to provide clinicians with an evidence-based resource for the management of both adults and children with AR. The guidelines, which suggest a stepwise approach to treatment to maximise the benefits of treatment while minimising adverse side effects, have been adapted and illustrated in Figure 2.Figure 2: Care pathway for the management of allergic rhinitis. Adapted from the Allergic Rhinitis and its Impact on Asthma 2008 guidelines.Allergen avoidance Avoidance of allergen triggers is recommended where possible. However, a more realistic goal would be to decrease allergen exposure as much as possible. The physician should also be mindful that major environmental modifications, such as removing carpeting and replacing upholstered furniture, are expensive and might not be affordable for all families. To enhance patient and caregiver cooperation, initial emphasis should be placed on low-cost interventions. Practical strategies to reduce exposure to common allergens in Singapore are outlined in Box 1.Box 1: Practical strategies to reduce exposure to common allergens in Singapore.Pharmacological treatment Medications for AR are generally necessary, as complete allergen avoidance is not always feasible. Pharmacotherapy aims at safe and effective symptom relief with prevention of complications. Oral antihistamines Oral antihistamines help to reduce symptoms of rhinorrhoea and nasal itch but do not help with nasal congestion.[10] Second-generation antihistamines are preferred because they are comparable in efficacy with an improved side effect profile and longer duration of action. First-generation antihistamines can be useful at night to help with sleep. However, they are generally not recommended due to their ability to cross the blood–brain barrier, which results in side effects such as sedation and difficulty with learning.[10] Oral and nasal decongestants Both oral and nasal decongestants are available in Singapore. They alleviate nasal congestion but do not help with nasal itch and rhinorrhoea.[11] They are also ineffective in providing durable long-term control of AR. When used in combination with oral antihistamines for short-duration therapy, they offer some short-term symptom control. If used longer than 3–5 days, topical decongestants run the risk of causing rebound congestion and ‘stuffiness’. They should not be used for control of chronic symptoms. Table 1 shows the common antihistamines and decongestants available in Singapore that are safe for use in the paediatric population.Table 1: Antihistamines and decongestants that are safe for use in the paediatric population.aIntranasal antihistamines Intranasal antihistamines such as azelastine and olopatadine have been shown to be effective in rapidly improving nasal congestion in children.[11] However, intranasal sprays are generally not actively marketed in Singapore. Azelastine is registered for use in Singapore as a combination nasal spray with fluticasone propionate for children 12 years and older, while olopatadine as an intranasal spray is currently not available. Intranasal corticosteroids Intranasal corticosteroids are effective in relieving nasal congestion, rhinorrhoea and nasal itch, and are recommended for patients with moderate to severe symptoms.[12] They do not work instantly, as the maximal effect may require several days or weeks of regular use to be apparent. Treatment should be started at the maximal dose appropriate for age, and the dose can be tapered down gradually to the lowest effective dose. Subsequently, patients can reduce the frequency of dose gradually and maintain symptom control with use as needed. Studies show that intranasal corticosteroids are relatively safe in children and do not influence long-term growth velocity due to the relatively low doses used in nasal sprays.[12] However, physicians should still monitor the growth of any child on long-term corticosteroid-containing medications. Other potential side effects include epistaxis and nasal septum perforation, and hence, the proper technique of administration needs to be taught to patients and/or their caregivers. Intranasal corticosteroids of any type should be tapered to the lowest effective dose in all patients once symptoms are controlled. Commonly used intranasal steroids in Singapore that are safe for use in the paediatric population are listed in Table 2.Table 2: Common intranasal steroids in Singapore that are safe for use in the paediatric population.aBest recommendations for administration are as follows: begin by blowing the nose gently, lean the head forward and ensure that the nasal spray is almost vertical. Patients are advised to use the hand opposite the nostril being treated, aim the nozzle upwards and outwards pointing towards the ear of the nostril being treated, and spray without sniffing. Following administration, patients should be advised to rinse the mouth and throat. For younger children who need help, caregivers could get the child to sit down while they stand or squat in front of them. The child should be instructed to look down like they are reading a book, while the caregiver aims the nozzle upwards and outwards.[13] A common cause of treatment failure is poor technique when administering intranasal corticosteroids. Hence, it is important for physicians to spend time explaining the appropriate use of these devices. Intranasal decongestants Intranasal decongestants, such as oxymetazoline, are commonly prescribed for relief of nasal congestion. However, they only offer some improved symptom control in the short term. In addition, they carry the risk of systemic side effects, including hypertension, cardiac arrhythmias, palpitations and central nervous system excitation.[12] Also, if used for longer than 3–5 days, intranasal decongestants may cause rebound congestion and stuffiness. They should not be used for control of chronic symptoms. Leukotriene receptor antagonists Montelukast should not be used as a primary treatment therapy for AR due to concerns about the risk–benefit profile. Neuropsychiatric effects, such as serious behaviour and mood-related changes, have been reported in association with the use of montelukast. However, they are uncommon. Nevertheless, its use should be restricted as an add-on therapy for patients with inadequate response or intolerance to alternative therapies.[12] Other measures: saline douching Nasal saline irrigation, also known as nasal douche, is a procedure that rinses the nasal cavity with saline solutions. Some patients may find it helpful to reduce symptoms and improve the effect of nasal steroids. It has been shown to be effective and tolerable in the majority of children and can be considered along with pharmacotherapy.[14] If saline douching is done, it should be done before intranasal corticosteroid use to avoid rinsing out the intranasal corticosteroid and rendering it ineffective. Cost considerations Due to the chronic nature of AR requiring medium- to long-term usage of medications, it is important to keep health affordable for patients. In Singapore, mometasone furoate (Nasonex™) and triamcinolone acetonide (Nasacort®) have recently been added to the subsidised drug list. This lowers retail price from over SGD 20 to about SGD 10 per bottle (140 metered actuations). Fluticasone furoate (Avamys™) remains unsubsidised. When selecting medications, physicians should keep in mind that choosing a cheaper drug may improve access and long-term adherence for patients with financial constraints. Specific immunotherapy Specific allergy IT is a treatment option for children with AR. Subcutaneous IT and sublingual IT can be considered for children aged >5 years. Indications include uncontrolled significant rhinitis symptoms despite appropriate pharmacological management, intolerance to medications or a desire to decrease long-term medication use. When administered appropriately, IT has been shown to successfully decrease symptoms of AR during the treatment period. However, patients need to be committed to a minimum treatment period of 3 years. This duration is generally recommended to ensure lasting benefits after cessation of IT and to reduce relapse rates.[15] WHEN SHOULD I REFER TO A SPECIALIST? Referral to an allergist should be considered in children with moderate to severe AR and prolonged or severe symptoms of rhinitis despite adequate pharmacotherapy and allergen avoidance. Patients with significant complications of AR, such as recurrent sinusitis or recurrent otitis media, should also be referred to an allergist. Referral should also be considered for patients who are interested to discuss IT as a treatment option. TAKE HOME MESSAGES Allergic rhinitis is a chronic atopic condition commonly encountered in the primary care setting. Physicians should be aware and recognise the various ways that AR can present in children. Management strategies of AR include allergen avoidance, pharmacotherapy and specific allergy IT. A stepwise approach should be taken in the pharmacological management of patients. Adequate follow-up is essential to assess treatment response and to ensure that the dose of intranasal steroids is tapered to the lowest effective dose once symptoms are controlled. Effective partnership between patients, caregivers and physicians is crucial for the successful treatment of AR. Referral to a specialist should be considered in children with severe symptoms of AR despite adequate pharmacotherapy and allergen avoidance, those with significant complications of AR and those who are keen to consider IT as a treatment option. Closing Vignette Lionel was diagnosed with moderate–persistent AR based on the clinical history and physical examination. Lionel and his mother were educated about AR, and the patient was started on a 4-week trial of intranasal corticosteroids. After 4 weeks of adequate treatment, his symptoms improved. The dose of intranasal corticosteroids was tapered down and continued for two more months. A further follow-up was arranged subsequently.Acknowledgement We greatly appreciate the support of the Department of Family Medicine, National University Health Systems, Singapore. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. SMC CATEGORY 3B CME PROGRAMME Online Quiz: https://www.sma.org.sg/cme-programme Deadline for submission: 6 pm, 04 October 2024