The Treament of Allergic Rhinitis in Children: History
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Subjects: Pediatrics
Contributor:
Ioannis Goniotakis
,
Evanthia Perikleous
,
Sotirios Fouzas
,
Paschalis Steiropoulos
,
Emmanouil Paraskakis

Although it is commonly under-diagnosed and under-treated, it causes important social and economic effects (diminished quality of life, poor academic performance, escalated medical visits, heightened medication usage, and effects in other chronic conditions, e.g., asthma). It is characterized by distinctive, easily identifiable symptoms (sneezing, nasal discharge, nasal congestion, nasal–eye–palatal itching) and indirect accompanying indicators (fatigue and decreased school performance). The classification of allergic rhinitis hinges upon its nature and chronic distribution (seasonal or perennial) and its intensity, which spans from mild to moderate and severe. The diagnostic process primarily relies upon recognizing key clinical indicators, evaluating historical records, and considering risk factors. It is supported by abnormal laboratory findings, like in vitro allergen-specific IgE tests (enzyme immunoassay—EIA, chemiluminense immunoassay—CLIA) or in vivo skin prick tests for specific allergens. In the differential diagnosis, other chronic diseases manifesting with chronic rhinitis should be excluded (e.g., rhinosinusitis, chronic non-allergic rhinitis, rhinitis triggered by medications). The treatment of allergic rhinitis in children is mainly chronic and is focused on allergen exposure prevention, drug therapy, and immunotherapy in severe cases. Locally administered intranasal corticosteroids are the cornerstone of therapy. They are safe, effective, and have a favorable safety profile even during long-term use. Choosing a suitable intranasal corticosteroid drug with low systemic bioavailability makes long-term treatment even safer. Combinations of intranasal corticosteroids and H1 antihistamines are available in several countries and are widely used in more severe cases and the presence of year-round symptoms. Adding newer-generation oral H1-antihistamines broadens the available therapeutic inventory without significant effects compared to using previous-generation, once widely available, H1-antihistamines. Treatment of allergic rhinitis is complex and multi-dimensional, requiring an effective approach by a specialized group of specialized pediatricians, and is severely affected by the concurrent presence or development of other diseases in the spectrum of allergic diseases (conjunctivitis, asthma).

  • allergic rhinitis
  • children

1. Introduction

Allergic rhinitis is one of the most prevalent medical conditions globally and typically persists throughout an individual’s lifetime. The reported frequency of allergic rhinitis by those affected ranges from 2% to 25% in children and from 1% to >40% in adults [1]. However, the prevalence of confirmed allergic rhinitis in European adults is estimated to be between 17% and 28.5% [2].
Classic symptoms of allergic rhinitis include persistent sneezing, watery nasal discharge, itching, and nasal congestion. Ocular symptoms are also common. Allergic conjunctivitis is associated with itching, eye redness, and tearing. Other potential symptoms include upper lip itching, postnasal drip, and coughing [3]. Allergic rhinitis is often linked with asthma, present in 15% to 38% of patients with allergic rhinitis. Nasal symptoms occur in 6% to 85% of patients with asthma [4]. Additionally, allergic rhinitis is a risk factor for asthma onset, and uncontrolled moderate-to-severe allergic rhinitis significantly affects asthma control [5].
Allergic rhinitis may seem innocuous compared to other medical conditions as it is not associated with high morbidity and mortality. However, the burden of the disease and its related socio-economic costs are substantial [6]. Allergic rhinitis diminishes the quality of life for many patients, disrupting their sleep quality and cognitive function and inducing irritability and fatigue. Moreover, it is associated with reduced school and work performance, especially during peak pollen periods [7]. Allergic rhinitis is a frequent reason for visits to family pediatricians, primary care facilities, and hospitals (emergency departments and routine outpatient clinics). The appropriate treatment of allergic rhinitis improves symptoms, quality of life, and performance at work and school [8].

2. Diagnosis

The clinical suspicion of allergic rhinitis is initially raised based on the symptoms, which include one or more of the following: persistent sneezing, rhinorrhea, itching, watery nasal discharge, nasal congestion, and hypogeusia. Key elements from the medical history include the timing/location of allergic rhinitis symptoms’ onset, factors that alleviate or exacerbate symptoms (e.g., exposure to chemicals or smoke at home or school), and triggers for symptoms (pollen, household dust, molds, plants/trees, mites, animals). Determining a child’s allergic sensitization pattern using skin prick testing (SPT) or
laboratory methods for the in vitro measurement of allergen-specific IgE (EIA, CLIA) is particularly valuable for completing the diagnostic assessment and determining further therapeutic options, especially if immunotherapy is a potential consideration [9]. In the context of a personalized approach to pharmaceutical treatment and appropriate medium- to long-term monitoring, accurate differential diagnosis is crucial. The measurement of local IgE in nasal lavage fluid distinguishes LAR from NAR in the pediatric population and predicts the response to classical allergic rhinitis treatment [10].

3. Treatment 

The treatment of allergic rhinitis is based on four main axes: (a) allergen avoidance; (b) systematic nasal lavage (saline nasal irrigation); (c) the administration of targeted, effective, and clinically responsive therapy; and (d) the implementation of immunotherapy [11].
For patients with seasonal allergic rhinitis, recommended first-line treatment options are (1) intranasal corticosteroid administration with or without concomitant oral H1 antihistamines or (2) intranasal corticosteroid administration combined with oral H1 antihistamines. The combination of intranasal corticosteroids and intranasal H1 antihistamines results in a faster response compared to the isolated use of intranasal corticosteroids. Response assessment is recommended after 2–4 weeks to determine the further therapeutic plan. If there is a response, treatment should be continued for at least one month. In case of exacerbation, escalation of the administered treatment is necessary. Second-line treatments can include oral H1 antihistamines or anti-leukotrienes [12].
For patients with perennial allergic rhinitis, recommended first-line treatment options, based on preferences and availability, are (1) monotherapy with intranasal corticosteroids or (2) intranasal corticosteroid administration combined with oral H1 antihistamines. In cases of perennial allergic rhinitis, oral H1 antihistamines administered orally are recommended as second-line treatment, while oral leukotriene receptor antagonists are considered third-line treatment [13][14].
Intranasal corticosteroids have a good safety profile regarding long-term adverse effects. However, choosing the appropriate type of corticosteroid is vital due to significant differences in absorption from nasal mucosa and systemic bioavailability. Fluticasone formulations (furoate, propionate) and mometasone are preferred as they exhibit minimal systemic absorption, reducing the risk of systemic corticosteroid complications [13][14]. Concerning orally administered H1 antihistamines, older-generation antihistamines (e.g., hydroxyzine) are contraindicated due to the availability of newer, safer H1 antihistamine formulations. First-generation antihistamines effectively cross the blood–brain barrier and affect brain function, inducing sedation, cognitive impairment, and psychomotor development. Their widespread over-the-counter distribution during the previous decades has highlighted the possibility of serious, even fatal, side effects during overdose and “off-label” usage as sedatives/anxiolytics (e.g., respiratory depression, seizures, coma, death) [15]. Newer-generation formulations can be safely used for an extended period, including >1 year of continuous use in preschool-aged children [15].
Saline nasal irrigation (SNI) using isotonic solution is used as an adjunctive non-pharmacologic treatment for allergic rhinitis. It has proven efficacy in acute and chronic rhinosinusitis, as well as in cases after sinus surgery. Systematic reviews of the literature suggest that it is a useful additional treatment for AR with low cost, easy application, and infrequent side effects [16].
The use of allergen immunotherapy (AIT) is an alternative solution in cases of severe non-responsive rhinitis to first- to third-line treatments or for reducing the risk of progression to asthma in children with allergic rhinitis and atopic dermatitis. This proposal is attractive based on the concept of the atopic march, where a child with eczema and food allergies develops asthma and allergic rhinitis in later childhood. However, systematic literature reviews provide limited evidence supporting the use of AIT as a preventive intervention [17][18][19]. There seems to be short-term benefit in preventing asthma in individuals with allergic rhinitis and grass and ragweed sensitization, especially when AIT is initiated in childhood using subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) [17]. Data are insufficient to support or discourage the use of AIT against other allergens (mites and others.). Evidence of the effectiveness of SCIT in children is scarce compared to adults. Despite this, AIT is the only targeted allergen tolerance-inducing treatment currently available. The decision to initiate allergen immunotherapy depends on several factors, such as the severity of the disease, the expected adherence to therapy, the child and family background, the expected results, a thorough understanding of possible side effects, the high cost and duration of treatment, and results [18]. The drawbacks of this intervention should be thoroughly discussed with the family before treatment initiation. SCIT administration is particularly challenging for children because of multiple injections. SLIT is a more friendly approach for children. Still, it is less effective in managing allergic rhinitis caused by common aeroallergens. However, it is still being determined whether this benefit persists for several years after discontinuation of AIT or if AIT is indeed a cost-effective intervention [19].

This entry is adapted from the peer-reviewed paper 10.3390/children10091571

References

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