Allergic rhinitis in children

Essentials

  • Common in school age children
  • If not adequately managed will impair quality of life.
  • Periodic treatment with an antihistamine and/or nasal glucocorticoid is a safe, and usually adequate, management option.
  • Desensitization can be considered after pre-school age in moderate to severe allergic rhinitis.
  • The management of allergic rhinitis is important in an asthmatic child.

Epidemiology

  • Allergic rhinitis usually presents after the age of 2 years, and about 15% of school age children are affected.
  • The most common allergens are pollens (deciduous trees, grasses and mugwort) as well as animal dander.
  • A doctor should be aware of the local annual appearance of pollens and mould spores.

Symptoms

  • Watery bilateral rhinorrhoea
  • Sneezing, tickly cough, congestion
  • Nose bleeds
  • Mouth breathing, snoring
  • Nocturnal awakenings, tiredness, reduced functional capacity and difficulty concentrating
  • Associated diseases: otitis media, sinusitis, asthma, conjunctivitis

Diagnosis

History

  • The type and severity of symptoms, are they bilateral, do they alter with the seasons and surroundings?
  • Previous history of allergic symptoms
  • In seasonal rhinitis, the timing of symptoms should be elicited.
  • In perennial rhinitis, the allergens of the close surroundings should be considered.
  • Environmental factors: smoking, exposure to animals, other possible exposure
  • Family history: allergies, asthma

Differential diagnosis

  • Respiratory tract infections
  • Enlarged adenoids may cause snoring and mouth breathing.
  • Glue ear
  • A foreign body in the nose (Foreign body in the nose)
  • Structural anomalies
  • Reflux

Clinical examination

  • Mode of breathing: a mouth breather?
  • The structure of the nose: is the nose straight and symmetric?
  • Anterior rhinoscopy: oedema and bluish discoloration of the inferior nasal concha, clear discharge, asymmetry?
  • Mouth and pharynx: the size of adenoids and tonsils is assessed by looking into the pharynx with the aid of a tongue depressor and a mirror. Is there mucus at the back of the throat (postnasal drip)?
  • Lung auscultation (asthma)?
  • Skin (eczema suggestive of atopy?)
  • Eyes (allergic conjunctivitis?)

Investigations

  • Allergy testing (skin prick tests or serum IgE assays) can be carried out at any age and should be done if the results would influence treatment decisions.
  • If indicated, investigations may also include blood tests, x-ray examinations and asthma investigations.

Treatment

  • Confirmed irritants (e.g. animals) should be avoided on an individual level.
  • Drug treatment in children is usually carried out in courses lasting for 1–3 weeks.
  • With antihistamines, the effect onset is within hours, with nasal glucocorticoids the start is slower, within 2 to 3 days.
  • The efficacy of the most commonly used medicines in the treatment of different symptoms: see table T1
  • Nasal irrigation with e.g. a “neti” pot
  • When administering nasal sprays, the body is leaned forward and the other nostril is pressed closed, the spray is directed off the nasal septum, and the inhalation of the spray should be avoided.

Mild symptoms

  • Antihistamines (second-generation H1 receptor blockers): tablets, solutions, drops for children ≥ 1 year of age
  • Cromoglycate or antihistamine eye drops for children ≥ 3 years of age

Moderate to severe symptoms

  • Nasal glucocorticoids for children ≥ 3 years of age (individually determined and depending on the drug)
  • Antihistamines orally for children ≥ 1 year of age and/or nasally for children ≥ 4 years of age
  • A nasal decongestant (for up to 7 days) for children ≥ 1 year of age
  • Combination of an antihistamine and a nasal glucocorticoid in the nose for children ≥ 12 years of age
  • An antihistamine-sympathomimetic combination tablet or capsule (for up to 10 days) for children ≥ 12 years of age
  • Cromoglycate or antihistamine eye drops for children ≥ 3 years of age
  • Desensitization (by injections, sublingual tablets, or solutions) (Allergen-specific immunotherapy)

Table 1. The efficacy of the most commonly used medicines in the management of allergic rhinitis and conjunctivitis. The number of pluses denotes the degree of efficacy, 0 = no effect.
Oral antihistamine Nasal antihistamine Ophthalmic antihistamine Nasal glucocorticoid Nasal decongestant Oral decongestant Nasal cromone Ocular cromone Antileukotrienes Immunotherapy
From age (in years) 1 4 3 3 1 12 2 3 0.5 5
Rhinorrhoea ++ ++ 0 +++ 0 0 + 0 + ++
Sneezing ++ ++ 0 +++ 0 0 + 0 + ++
Nasal itch +++ ++ 0 ++ 0 0 + 0 + ++
Nasal congestion + + 0 +++ ++ + + 0 ++ ++
Allergic eye symptoms ++ 0 +++ ++ 0 0 0 ++ ++ ++

Referral criteria for specialist care

  • Symptoms persist despite medication.
  • To assess the need for desensitization in moderate to severe allergic rhinitis (Allergen-specific immunotherapy)
  • Problems in diagnosis or drug treatment
  • Additional investigations are required, such as allergy testing for allergens other than the most usual ones or other clinical follow-up investigations.

References

1. Bousquet J, Anto JM, Bachert C et al. Allergic rhinitis. Nat Rev Dis Primers 2020;6(1):95.  [PMID:33273461]
2. Roberts G, Xatzipsalti M, Borrego LM et al. Paediatric rhinitis: position paper of the European Academy of Allergy and Clinical Immunology. Allergy 2013;68(9):1102-16.  [PMID:23952296]
3. Tharpe CA, Kemp SF. Pediatric allergic rhinitis. Immunol Allergy Clin North Am 2015;35(1):185-98.  [PMID:25459584]
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