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Diagnosis and Management of
Allergic Rhinitis in Children
Dina Muktiarti
Department of Child HealthFaculty of Medicine University of Indonesia/
Cipto Mangunkusumo Hospital
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Outline
Background
Diagnosis
Management Prevention
Conclusions
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Allergic Rhinitis
Rhinitis:
an inflammation of the lining of the nose and
characterized by nasal symptoms including
rhinorrhea, sneezing, nasal blockage and/or
itching of the nose.
Multifactorial disease induced by gene-
environment interaction
Bousquet J, et al. Allergy 2008; 63(S86):8-160.
Pawankar RP, et al. WAO white book on allergy.
Gentile DA, et al. In: Pediatric allergy. 2nd ed. Edinburgh, Elsevier, 2010. p. 291-300.
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Allergic Rhinitis
Allergic rhinitis is a global health problem that
affect 10-30% of all adults and about 40% of
children.
Prevalence of AR is increasing, although AR
prevalence in Indonesia (3-5%) is lower than
other western countries.
Bousquet J, et al. Allergy 2008; 63(S86):8-160.
Pawankar RP, et al. WAO white book on allergy.
Asher MI, et al. Lancet. 2006;368:73343.
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Allergic Rhinitis
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Allergic Rhinitis:
Why is it important?
Allergic rhinitis
Uncomfortable
symptoms.
Increased costs(direct and
indirect costs).
Predispose to the
development of
comorbidities
such as asthma.
Significantimpact on childs
health andquality of life
Meltzer EO. Allergy Asthma Proc. 2006;27:2-8.
Pawankar RP, et al. WAO white book on allergy.
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DIAGNOSIS
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Sign and Symptoms
Rhinorrhea
Sneezing
Nasal pruritus
Nasal congestion Cough
Halitosis
Sniff and snort
Epistaxis
Allergic shiner
(darkened lower eyelids)
Allergic crease
(a visible transverse lineabove the tip of the nosecaused by rubbing)
Allergic salute
(upward rubbing of thenose)
The gaper mouth(opened to breathe).
Bousquet J, et al. Allergy 2008; 63(S86):8-160.
Pawankar RP, et al. WAO white book on allergy.Gentile DA, et al. In: Pediatric allergy. 2nd ed. Edinburgh, Elsevier, 2010. p. 291-300.
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Sign and symptoms
http://www.pediatricsconsultant360.com/sites/default/files/images/1205CFP_Huang1_Fg.jpg
http://emedicine.medscape.com/article/834281-overview
http://www.pediatricsconsultant360.com/sites/default/files/images/1205CFP_Huang1_Fg.jpghttp://www.pediatricsconsultant360.com/sites/default/files/images/1205CFP_Huang1_Fg.jpg -
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CO-MORBIDITIES
Pawankar RP, et al. WAO white book on allergy.
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Allergy Tests
Skin prick tests
Specific IgE serum
Positive result means sensitization anddoes not always equivalent to clinical
allergy.
Interpretation of allergy tests in the
context of clinical history is important
Bousquet J, et al. Allergy 2008; 63(S86):8-160.
Pawankar RP, et al. WAO white book on allergy.
Gentile DA, et al. In: Pediatric allergy. 2nd ed. Edinburgh, Elsevier, 2010. p. 291-300.
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Trigger
Food allergen is a very rare cause of isolated rhinitis.
Role of air pollutants is probably important.Bousquet J, et al. Allergy 2008; 63(S86):8-160.Pawankar RP, et al. WAO white book on allergy.
Gentile DA, et al. In: Pediatric allergy. 2nd ed. Edinburgh, Elsevier, 2010. p. 291-300.
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Allergic Rhinitis Classification:
Allergic Rhinitis and Its Impact on Asthma (ARIA)-WHO
Moderate-severe
one or more items
Abnormal sleep
Impairment of dailyactivities, sport, leisure
Abnormal work andschool
Troublesome symptoms
Persistent
4 days per week
and 4 weeks
Mild
Normal sleep
& No impairment of daily
activities, sport, leisure& Normal work andschool
& No troublesomesymptoms
Intermittent
< 4 days per week
or < 4 weeks
in untreated patients Bousquet J, et al. Allergy 2008; 63(S86):8-160.
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Differential Diagnosis
Infectious rhinitis
Non-allergic rhinitis (vasomotor, drug induced,
etc)
Bousquet J, et al. Allergy 2008; 63(S86):8-160.
Gentile DA, et al. In: Pediatric allergy. 2nd ed. Edinburgh, Elsevier, 2010. p. 291-300.
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ManagementAllergenavoidance
indicatedwhen poss ib le
Pharmacotherapysafety
effectivenesseasi ly adm inistered
Immunotherapyeffectiveness
special is t prescr ipt io nmay alter th e naturalcou rse of the disease
Patienteducationalways indicated
costs
Bousquet J, et al. Allergy 2008; 63(S86):8-160.
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Management of allergic rhinitis(ARIA)
mildintermittent
mildpersistentmoderate
severeintermittent
moderatesevere
persistent
allergen and irritant avoidance
immunotherapy
intra-nasal decongestant (short time) or oral decongestant
local chromone
intra-nasal steroid
oral or local non-sedative H1-blocker
Bous uet J, et al. Aller 2008; 63 S86 :8-160.
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Steps of
allergic rhinitismanagement
Diagnosis of allergic rhinitis Check for asthmaespecially in patients with severeand/or persistent rhinitis
MILDNot in preferred order
Oral H1 blockeror intranasal H1-blockerand/ordecongestantor LTRA
Intermittentsymptoms
Persistentsymptoms
If conjunctivitis:Add: oral H1-blocker
or intraocular H1-blockeror intraocular cromone
(or saline)
Allergen and irritant avoidance may be appropriate
MODERATE- MILDSEVERE
Not in preferred order
oral H1 blockeror intranasal H1-blocker
and/or decongestantor intranasal CS
or LTRA(or cromone)
In persistent rhinitisreview the patientafter 24 weeks
If failure: step-upIf improved: continue
for 1 month
Consider specific immunotherapy
LTRA: leukotriene rece tor anta onists
MODERATE-SEVEREIn preferred order
intranasal CSH1 blocker or LTRA
Improved Failure
Step-down
and continuetreatment
for >1 month
Review the patientafter 24 weeks
Review diagnosis
Review complianceQuery infectionsor other causes
Add orincreaseintranasalCS
Rhinorrheaadd
ipratropium
Blockageadddecongestantor oral CS(short term)
Failure
referral to specialist
Bousquet J, et al. Allergy 2008; 63(S86):8-160.
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EVIDENCE BASED ON ALLERGICRHINITIS MANAGEMENT
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Strength of evidence fortreatment of rhinitis
Seasonal AR Perennial AR
Adult Children Adult Children
Oral antihistamine H1 A A A A
Intranasal antihistamine H1 A A A A
Intranasal corticosteroid A A A A
Intranasal chromones A A A A
LTRA A A
Subcutaneous immunotherapy A A A A
Sublingual immunotherapy A A A
Allergen avoidance D D D D
Bousquet J, et al. Allergy 2008; 63(S86):8-160.
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Medications of allergic rhinitisSneezing Rhinorrhea Nasal Nasal Eye
obstruction itch symptoms
H1-antihistamines
oral +++ +++ 0 to + +++ ++
intranasal ++ +++ + ++ 0
intraocular 0 0 0 0 +++
Corticosteroids +++ +++ ++ ++ +
Chromones
intranasal + + + + 0
intraocular 0 0 0 0 ++
Decongestantsintranasal 0 0 ++ 0 0
oral 0 0 + 0 0
Anti-cholinergics 0 +++ 0 0 0
Anti-leukotrienes + ++ ++ ? ++Bous uet J et al. Aller 2008 63 S86 :8-160.
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ALLERGEN AVOIDANCE
Allergen avoidance is important but sometimes it
is impractical.
House dust mite allergens: do not use currently
available single chemical or physical preventivemethods aimed at reducing exposure to house
dust mites.
multifaceted environmental control programs. Metanalysis: Isolated use of HDM impermeable
bedding is unlikely to prove effective.
Bousquet J, et al. Allergy 2008; 63(S86):8-160.Nurmatov U, et al. Allergy. 2012; 67: 15865.
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ALLERGEN AVIODANCE
Allergen Control measures
Dust mites Encase bedding in airtight covers
Wash bedding in water at temperatures >130F
Remove wall-to-wall carpeting
Remove upholstered furniture
Animal dander Avoid furred pets
Keep animals out of patient's bedroom
Cockroaches Control available food supply
Keep kitchen/bathroom surfaces dry and free of standing water
Professionally exterminate
Mold Destroy moisture-prone areasAvoid high humidity in patient's bedroom
Repair water leaks
Check basements, attics, and crawl spaces for standing water
and mold
Gentile DA, et al. In: Pediatric allergy. 2nd ed. Edinburgh, Elsevier, 2010. p. 291-300.
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ORAL ANTIHISTAMIN H1
H1-antihistamines antagonize the H1-receptor on smooth
muscle cells, nerve endings, and glandular cells, leading to a
reduction in nasal symptoms (rhinorrea, itching, sneezing),
but it only have a mild effect on nasal congestion.
Supplementary functions:
inhibition of mediator release from mast cells and
basophils
additional anti-inflammatory properties (2nd
generation):
reduction in intercellular adhesion molecule 1
expression
Greiner AN, Meltzer EO. J Allergy Clin Immunol. 2006;118:985-96.Brozek JL, et al. J Allergy Clin Immunol. 2010;126:466-76.
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ORAL ANTIHISTAMIN H1
Second-generation oral H1-antihistamines are
recommended for AR because they have
better H1-receptor selectivity and less
anticholinergic side effects.
Many studies on 2nd generation oral H1-
antihistamine also proved clinical efficacy for
AR.
Greiner AN, Meltzer EO. J Allergy Clin Immunol. 2006;118:985-96.
Brozek JL, et al. J Allergy Clin Immunol. 2010;126:466-76.
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INTRANASAL ANTIHISTAMIN
ARIA suggests intranasal H1-antihistamines in
children with seasonal AR and for persistent
AR.
However, ARIA recommends oral
antihistamine over intranasal antihistamine
Greiner AN, Meltzer EO. J Allergy Clin Immunol. 2006;118:985-96.
Brozek JL, et al. J Allergy Clin Immunol. 2010;126:466-76.
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INTRANASAL CORTICOSTEROID
Improve all nasal symptoms of AR, including nasal
congestion, rhinorrhea, itching, and sneezing.
The comprehensive clinical effects of INSs are based on a
broad mechanism of action. Reduction of the nasal mucosa inflammatory cells and
their associated cytokines.
Cochrane (2009): not conclusive data on beneficial effect
of INS for AR in children. ARIA (2010) suggests intranasal glucocorticosteroids over
other treatment for AR in children.
Greiner AN, Meltzer EO. J Allergy Clin Immunol. 2006;118:985-96.
Al Sayyad JJ, et al. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD003163. DOI: 10.1002/14651858.CD003163.pub4.
Brozek JL, et al. J Allergy Clin Immunol. 2010;126:466-76.
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Systemic Bioavailability of INS
Sastre J, Mosges R. Investig Allergol Clin Immunol. 2012; 22: 1-12.
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INTRANASAL CORTICOSTEROID
Meltzer EO. Allergy Asthma Proc. 2006;27:2-8.
http://www.ncbi.nlm.nih.gov/pubmed/?term=Allergic+rhinitis:+Managing+the+pediatric+spectrumhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Allergic+rhinitis:+Managing+the+pediatric+spectrumhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Allergic+rhinitis:+Managing+the+pediatric+spectrum -
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Techniques of Intranasal Corticosteroid
Use1. Hold head in a neutral, upright position
2. Clear nose of any thick or excessive mucus,
if present, by gently blowing the nose
3. Insert spray nozzle into the nostril
4. Direct the spray laterally or to the side,
away from the middle of the nose
(septum) and toward the outer portion of
the eye or the top of the ear on that side.
(If possible, use the right hand to spray the
left nostril and left hand to spray the right
nostril, to direct the spray away from the
septum)
5. Activate the device as recommended bythe manufacturer, and use the number of
sprays recommended by the doctor
6. Gently breathe in or sniff during the
spraying
7. Breathe out through the nose
Sastre J, Mosges R. Investig Allergol Clin Immunol. 2012; 22: 1-12.
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Bothersome side effects of prescription nasal
allergy sprays experienced by children
Meltzer E. J Allergy Clin Immunol 2009;124:S43-7
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DECONGESTANT
Vasoconstrictors.
The reduction in blood flow to the nasal vasculature
after administration leads to increased nasal patency
in 5 to 10 minutes when applied topically or 30minutes when administered orally.
Tolerance and rebound congestion can occur when
topical decongestant are used for longer than 1
week.
Greiner AN, Meltzer EO. J Allergy Clin Immunol. 2006;118:985-96.
Brozek JL, et al. J Allergy Clin Immunol. 2010;126:466-76.
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LEUKOTRIENE RECEPTOR ANTAGONIST
Montelukast, with very limited comparator
data, does not appear to be more effective
than nonsedating antihistamines and is less
effective than INSs for AR treatment.
ARIA: LTRA for preschool children with
persistent AR (conditional recommendation)
Greiner AN, Meltzer EO. J Allergy Clin Immunol. 2006;118:985-96.
Brozek JL, et al. J Allergy Clin Immunol. 2010;126:466-76.
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IMMUNOTHERAPY
Immunotherapy is an allergen-specific therapy
that is clinically effective and induces long-
term remission of allergic rhinitis and allergic
asthma.
ARIA suggest subcutaneous immunotherapy
for AR in children and sublingual
immunotherapy for children with AR causedby pollens.
Greiner AN, Meltzer EO. J Allergy Clin Immunol. 2006;118:985-96.
Brozek JL, et al. J Allergy Clin Immunol. 2010;126:466-76.
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PREVENTIONS
Primary prevention:
Exclusive breastfeeding
No smoke exposure
Avoidance of pets or house dust mite in early
life no conclusive data
Brozek JL, et al. J Allergy Clin Immunol. 2010;126:466-76.
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CONCLUSIONS
Allergic rhinitis is one of common chronic
disease in the pediatric population.
Allergic rhinitis can affect childs health and
quality of life.
Treatment choice based on classification.
Issues of compliance and convenience are
important considerations.
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THANK YOU