Pediatric Annals

Special Issue Article 

Diagnosis and Management of Allergic Rhinitis in Children

Timothy Brown, MD

Abstract

Allergic rhinitis is one of the most common chronic diseases managed by pediatricians. It can result in a significant burden of disease for the patient and their family. This article reviews classification of this condition as well as its pathophysiology, mediated by a Th2 lymphocyte response. Methods of diagnosis via elicitation of a thorough history, focused physical examination, and testing for specific allergen sensitization are discussed. Treatment of this condition is examined, focusing on allergen avoidance and a variety of available pharmacotherapies. Finally, allergen immunotherapy modalities and their potential for disease-modifying effects as well as their potential risks and benefits are outlined. [Pediatr Ann. 2019;48(12):e485–e488.]

Abstract

Allergic rhinitis is one of the most common chronic diseases managed by pediatricians. It can result in a significant burden of disease for the patient and their family. This article reviews classification of this condition as well as its pathophysiology, mediated by a Th2 lymphocyte response. Methods of diagnosis via elicitation of a thorough history, focused physical examination, and testing for specific allergen sensitization are discussed. Treatment of this condition is examined, focusing on allergen avoidance and a variety of available pharmacotherapies. Finally, allergen immunotherapy modalities and their potential for disease-modifying effects as well as their potential risks and benefits are outlined. [Pediatr Ann. 2019;48(12):e485–e488.]

Allergic rhinitis (AR) is one of the most commonly encountered chronic diseases in children and is frequently managed by primary care providers. A recent survey has shown that this condition has a prevalence rate of 13% in children in the United States.1 Although not associated with severe morbidity and mortality the burden of this condition is significant, resulting in 2 million lost school days per year and indirect costs such as lost productivity for working parents.2 The annual direct and indirect cost of AR was calculated to be around $11 billion for 2005.3 A more recent article estimates that the annual cost to society rose to $24.8 billion in 2014.4 Sub-optimal control of AR is also associated with a significantly reduced quality of life (QOL) and with reduced control of asthma (which is found in 15%–38% of patients with AR).5

Rhinitis is an inflammatory condition that is characterized by at least one of the following: nasal congestion, rhinorrhea, itching, and sneezing. AR is present when rhinitis symptoms are caused by an immunoglobulin E (IgE)-mediated process. Often, patients do not have AR alone. Mixed rhinitis (a combination of allergic and nonallergic rhinitis) is seen in 44% to 87% of patients with AR.6

Classification schemes have been developed for AR. Some have focused on the timing of symptoms (eg, seasonal or perennial). One of the more commonly employed classification systems is the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. The ARIA scheme is based on whether the symptoms are intermittent (<4 days/week for <4 weeks) or persistent (>4 days/week and >4 weeks) and whether the symptoms are moderate/severe (with the presence of one or more of the following issues: abnormal sleep, impairment of daily activities, abnormal school or work, troublesome symptoms) or mild (lacking the symptoms associated with moderate/severe AR).7

Multiple treatment guidelines have been developed by various organizations with the purpose of improving and standardizing the treatment and evaluation of AR based on medical evidence when it is present and expert opinion when it is not.8,9 These guidelines can be a valuable tool to help primary care practitioners optimally treat their patients.

Pathophysiology

Patients with atopic conditions such as AR have a tendency to develop IgE-type antibodies to environmental allergens via an excessive T helper cell type 2 (Th2) lymphocyte response when exposed to allergen. Th2 lymphocytes produce primarily cytokines such interleukin (IL)-4, IL-5, and IL-13, which promote the creation of IgE-type antibodies and eosinophilic inflammation. The allergic response to antigen exposure can consist of early and late phases. The early phase is mediated primarily by IgE present on the surface of effector cells (eg, mast cells, eosinophils, basophils). These release preformed mediators such as histamine, prostaglandins, and leukotrienes. These mediators act upon blood vessels to cause leakage, resulting in rhinorrhea and mucosal edema. Mediators acting upon sensory nerves leads to sneezing and the sensation of itch. As these mediators are preformed, the symptoms develop within minutes of exposure. The late phase of the allergic response is mediated by chemoattractants such as IL-5, resulting in infiltration of the mucosa with eosinophils, neutrophils, and basophils. Congestion is the most prominent symptom due to the late phase response.

Diagnosis

The evaluation of a patient with rhinitis symptoms begins with a thorough history. The history should include (but not necessarily be limited to) specific symptoms present and their duration; treatments tried and their effectiveness; presence of related conditions (eg, asthma, sinusitis); assessment of interference with quality of life; environmental exposures (eg, carpeting, animal exposure, tobacco smoke); and family history.

The physical examination in a patient with suspected AR should include checking for the findings listed in Table 1.

Allergic Rhinitis Symptoms

Table 1.

Allergic Rhinitis Symptoms

Although physical examination findings can be suggestive of allergic disease, these findings are not sufficient to definitively diagnose a patient as having an allergic condition despite the colloquial terms (eg, allergic shiners, allergic nose).

If a patient has suspected AR, then a therapeutic trial of allergy medication may be initiated. Although a response to allergy medication does not definitively diagnose AR, it is suggestive. If the patient's symptoms are adequately controlled with allergy medication, then specialist involvement and allergy testing may not be necessary.

At times it is necessary to perform testing to detect the presence or absence of specific IgE antibodies against environmental allergens. Reasons to perform allergy testing include guidance for avoidance recommendations, assistance with diagnosis, and determination of allergens to be included in immunotherapy.

The two primary methods for the diagnosis and identification of specific IgE antibodies to environmental allergens are in vivo skin testing and in vitro serum testing. Skin testing is the preferred form of evaluation as it is less expensive, generally has a greater sensitivity, and the results are available immediately. However, certain conditions such as the inability to discontinue antihistamines, the presence of dermatographism or severe dermatitis, or patient or physician convenience/preference are all potential reasons to perform in vitro serum testing. The choice of which allergens to include in testing is dependent upon the patient's history (eg, which allergens are suspected) and environment (eg, animal exposure, predominant pollens, exposure to cockroaches). Although the presence of specific IgE implies sensitization, it does not definitively indicate causation. The diagnosis of AR requires not only a history of rhinitis and a demonstration of presence of specific IgE, but also the presence of symptoms that are consistent with exposure to the sensitized allergen.

Treatment

When a patient has been diagnosed with AR, a variety of treatment options may be employed. No matter which treatment method is chosen, the response to treatment should be evaluated and lack of a response should prompt the practitioner to review whether a change in treatment needs to be made or whether another diagnosis needs to be considered.10

Allergen avoidance should be advised in all patients with AR. Identification of specific IgE antibodies is helpful in determining precise avoidance measures. Written handouts can be helpful to guide families. Subsequent office visits should include an assessment of whether allergen avoidance measures are being followed (Table 2).

Effective Strategies to Avoid Allergens

Table 2.

Effective Strategies to Avoid Allergens

Numerous medications are available for the treatment of AR. Although certain medications have been shown to be more effective for treatment of specific symptoms, it is also important to consider a family's wishes with regard to treatment as certain therapies may be less preferable based upon cost, delivery device, and risk of side effects. Some of the most commonly used therapies for treatment of allergic rhinitis are listed in Table 3. It is important to note that these medications have different approved ages for administration.

Common Therapies Used for the Treatment of Allergic Rhinitis

Table 3.

Common Therapies Used for the Treatment of Allergic Rhinitis

Allergy immunotherapy (IT) is another possible treatment option. It has been available in subcutaneous form (SCIT) for decades and more recently has been approved in the US for sublingual treatment (SLIT) for certain allergens. Unlike the medications previously described, this form of treatment has the potential for disease-modifying effects where symptom reduction can persist for years following discontinuation of treatment. Sublingual drops for treatment of AR, although employed commonly in European countries, are not currently approved for treatment in the US. Both SLIT and SCIT can cause systemic allergic reactions, so careful monitoring is required. There are insufficient studies to directly compare these two forms of therapy, so a definitive statement for preference of one treatment over the other is not possible at this time (Table 4).

Types of Allergen Immunotherapy

Table 4.

Types of Allergen Immunotherapy

Summary

AR is a common, chronic medical condition that is often treated at a primary care provider's office. However, there may be certain indications where consultation with an allergist/immunologist should be considered. These include requirement of systemic corticosteroids, ineffective response to treatment, reduced quality of life (eg, sleep disturbance), when allergy immunotherapy is being considered, the presence of comorbid conditions (asthma, chronic sinusitis), and the need to further identify and clarify allergic triggers.

References

  1. Meltzer EO, Blaiss MS, Naclerio RM, et al. Burden of allergic rhinitis: allergies in America, Latin America, and Asia-Pacific adult surveys. Allergy Asthma Proc. 2012;33(5)(suppl 1):S113–S141. https://doi.org/10.2500/aap.2012.33.3603 PMID: doi:10.2500/aap.2012.33.3603 [CrossRef]22981425
  2. Bhattacharyya N. Incremental healthcare utilization and expenditures for allergic rhinitis in the United States. Laryngoscope. 2011;121(9):1830–1833. https://doi.org/10.1002/lary.22034 PMID:21997726
  3. Meltzer EO, Bukstein DA. The economic impact of allergic rhinitis and current guidelines for treatment. Ann Allergy Asthma Immunol. 2011;106(suppl 2):S12–S16. https://doi.org/10.1016/j.anai.2010.10.014 PMID: doi:10.1016/j.anai.2010.10.014 [CrossRef]21277528
  4. Mudarri DH. Valuing the economic costs of allergic rhinitis, acute bronchitis, and asthma from exposure to indoor dampness and mold in the US. J Environ Public Health. 2016;2016:2386596. https://doi.org/10.1155/2016/2386596. PMID: doi:10.1155/2016/2386596 [CrossRef]27313630
  5. Brozek JL, Bousquet J, Agache I, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines-2016 revision. J Allergy Clin Immunol. 2017;140(4):950–958. https://doi.org/10.1016/j.jaci.2017.03.050 PMID: doi:10.1016/j.jaci.2017.03.050 [CrossRef]28602936
  6. Wallace DV, Dykewicz MS, Bernstein DI, et al. Joint Task Force on PracticeAmerican Academy of AllergyAsthma & ImmunologyAmerican College of AllergyAsthma and ImmunologyJoint Council of Allergy, Asthma and Immunology.The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008;122(suppl 2):S1–S84. https://doi.org/10.1016/j.jaci.2008.06.003 PMID: doi:10.1016/j.jaci.2008.06.003 [CrossRef]18662584
  7. Bousquet J, Van Cauwenberge P, Khaltaev NAria Workshop GroupWorld Health Organization. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. 2001;108(suppl 5):S147–S334. https://doi.org/10.1067/mai.2001.118891 PMID: doi:10.1067/mai.2001.118891 [CrossRef]11707753
  8. Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis executive summary. Otolaryngol Head Neck Surg. 2015;152(2):197–206. https://doi.org/10.1177/0194599814562166 PMID: doi:10.1177/0194599814562166 [CrossRef]25645524
  9. Dykewicz MS, Wallace DV, Baroody F, et al. Workgroup Chair and Cochair.Treatment of seasonal allergic rhinitis: an evidence-based focused 2017 guideline update. Ann Allergy Asthma Immunol. 2017;119(6):489–511. https://doi.org/10.1016/j.anai.2017.08.012 PMID: doi:10.1016/j.anai.2017.08.012 [CrossRef]29103802
  10. Dilley MA, Phipatanakul W. Environmental control measures for the management of atopy. Ann Allergy Asthma Immunol. 2017;118(2):154–160. https://doi.org/10.1016/j.anai.2015.12.029 PMID: doi:10.1016/j.anai.2015.12.029 [CrossRef]28153081

Allergic Rhinitis Symptoms

Nose   Presence of mucosal edema and/or nasal discharge   Evaluation for polyps   Presence of transverse nasal crease (from allergic salute) Eyes   Injection of the ocular sclera or conjunctiva   Infraorbital shiners   Dennie-Morgan folds (a fold or line in the skin below the lower eyelid) Throat   Tonsil presence and size   Presence or absence of postnasal drip and “cobblestoning” of the oropharynx

Effective Strategies to Avoid Allergens

Pollens   Close windows during pollen season   Reduce time outdoors when pollen levels are high   Shower or bathe and change clothes after being outdoors Mold   Outdoor mold avoidance similar to pollen recommendations   Keep indoor humidity less than 50%   Use air conditioner on warm, humid days   Fix leaks, remove standing water   Carpet removal, frequent vacuuming   Removal or cleaning of mold-contaminated areas (depends upon surface type) Dust mites   Elimination of reservoirs (carpeting, stuffed animals, general clutter)   Encasement of pillows, mattress, box spring with plastic or allergy covers   Keep indoor humidity less than 50%   Wash bedding frequently (hot water preferable) with detergent Animal dander   Removal from home is most effective (although many families do not elect this option)   Keep animals out of patient's bedroom   Removal of carpeting   HEPA air purifier in patient's bedroom   Frequent vacuuming   Frequent washing (cats once per week, dogs twice a week – rarely done by families)   There is no specific breed of dog that has been scientifically proven to be “hypoallergenic” Pests (rodents, cockroaches)   Elimination of food sources   Sealing entry routes into the home   Removal of carpeting/frequent vacuuming   Rodenticides, pest removal service

Common Therapies Used for the Treatment of Allergic Rhinitis

Intranasal corticosteroids   Most effective medication for control of symptoms of AR   Reduce congestion, rhinorrhea, sneezing, and itch   Onset of symptom relief can occur between 3 and 12 hours   Most effective if used regularly, but “as needed” use is also effective   Proper use needs to be taught to avoid epistaxis, nasal irritation   Nasal septal perforation is a rare side effect   Watch linear growth in children, particularly those also receiving inhaled corticosteroids   Recently published guideline9 showed no benefit to adding an oral antihistamine to an INCS if INCS monotherapy failed in patients with AR age 12 years or older Oral antihistamines   Relieve sneezing, itch, and rhinorrhea but has little to no effect on congestion   Quick onset of action, within 1 to 2 hours   Available as tablet or liquid, and many are available over the counter   First-generation drugs (eg, diphenhydramine, hydroxyzine) have significant sedative effects   Newer drugs (eg, loratadine, cetirizine, fexofenadine) have comparatively fewer side effects due to more specific binding to the histamine receptor and reduced crossing of the blood-brain barrier Intranasal antihistamines   Not as effective as INCS but do reduce nasal congestion and other symptoms of AR   Proper use needed to reduce side effects   Can cause mucosal irritation and epistaxis   Side effects also include sedation and bitter taste Leukotriene receptor antagonists   Montelukast has been approved for treatment of seasonal AR as well as asthma   Can be as effective as OAH but not as effective as INCS   Potential side effects include headache and neuropsychiatric events such as depression, suicidal thinking/behavior, and aggression Intranasal anticholinergics   Ipratropium bromide at the 0.03% strength has been approved to treat AR-related rhinorrhea, but it is not helpful for other symptoms of AR Nasal saline irrigation   Felt to work possibly due to improved mucus clearance and removal of antigen   Shown to reduce allergic rhinosinusitis symptoms and improve quality of life   Side effects are minimal (burning, irritation, nausea)

Types of Allergen Immunotherapy

Subcutaneous immunotherapy1   Extracts available for pollens, mold, dust mites, animal danders, and other allergens   Administration should be performed in a physician's office where personnel are trained to treat systemic allergic reactions   Although systemic allergic reactions are rare, they can be severe and fatalities have been reported   Total length of treatment is generally 3–5 years   No specific age limitation for treatment   Initiating allergen immunotherapy may help prevent future allergen sensitization   Potential contraindications: severe/uncontrolled asthma, heart disease, and use of beta blockers Sublingual immunotherapy2   Available in the US as dissolvable tablets   Limited allergens approved: two preparations of grass pollen, one preparation of ragweed pollen, and one preparation of dust mite allergen   Each of these treatments has a different age range for which it is approved (some not approved until age 18 years)   Although systemic reactions can occur, they are very rare (less than subcutaneous allergen immunotherapy)   Local, oral reactions are common (eg, oral itching)   No deaths have been reported but a prescription for an injectable epinephrine is recommended for patients who receive sublingual immunotherapy   First dose of treatment is given at a physician's office because systemic reactions are more likely to occur with the first dose. Subsequent doses may be administered at home   May either be given continuously or started 12 weeks prior to the allergen season and continued until the specific allergen season has ended   Contraindications include severe/uncontrolled asthma, history of systemic reaction to immunotherapy, and a history of eosinophilic esophagitis
Authors

Timothy Brown, MD, is an Attending Physician, Allergy and Immunology, Ann & Robert H. Lurie Children's Hospital of Chicago; and an Instructor in Pediatrics, Northwestern University Feinberg School of Medicine.

Address correspondence to Timothy Brown, MD, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL 60611; email: Tibrown@luriechildrens.org.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20191111-01

Sign up to receive

Journal E-contents