2007 Annual Evidence Update on Rhinitis: Paediatric Rhinitis

< Previous | Next >

Guideline summary - paediatric rhinitis

Knowledge week contents

 

 

 

 

Contributing Author: Glenis Scadding

Children suffer between 6 and 8 viral colds per year on average, so the differentiation between viral and allergic rhinitis may be difficult. Skin prick testing is possible even in young children: in those under three food allergens may be relevant where rhinitis is accompanied by other symptoms such as atopic dermatitis or gut symptoms. Synergy between allergy and infection exists [1;2] with allergic children suffering more severely with viral colds – which in combination with allergic sensitization and exposure lead to a twenty-fold risk of hospitalization for asthma.
Rhinosinusitis is also common and may be related to underlying innate or acquired immune deficiency or to allergy, but frequently no predisposing factors are identified. It usually resolves with maturation at around 7 years of age, as does otitis media with effusion (OME). Medical treatment is needed, including saline douching and discouraging parental smoking. Surgery is reserved for those few with acute severe problems or with severe chronic symptoms not responding to medical therapy [3]. 
It is essential to explain the nature of the problem and treatment options to parents and to demonstrate correct use of sprays if prescribed [4;5].

It is essential to explain the nature of the problem and treatment options to parents and to demonstrate correct use of sprays if prescribed [4;5].

Pharmacotherapy –
Pharmacotherapy is essentially the same as for adults with the caveat that if topical corticosteroids are to be used then non–systemically bioavailable ones with good paediatric safety data (fluticasone, mometasone) should be employed. 
A long-acting antihistamine given once daily is useful if rhinorrhoea and sneezing predominate, or if there are extranasal symptoms such as a rash. Continuously as opposed to ‘as required’ administration gives optimal results [6].
During the pollen season saline nasal irrigation may improve symptoms [7].
In severe nasal obstruction brief use ( <14 days ) of corticosteroid nose drops (e.g. Betnesol or Fluticasone) or a decongestant may be helpful [8]. The best position for administration is with the child lying, head back. Oral steroids may be used for a day or two to relieve very severe nasal congestion with systemic symptoms during hay fever.
Ipratropium bromide 0.03% may be helpful for rhinorrhoea [9;10].
Leukotriene receptor antagonists can be used for seasonal rhinitis together with asthma [11].
Efficacy of allergen immunotherapy has been demonstrated by subcutaneous [12;13] and sublingual routes [14-17] but is contra-indicated in children with asthma. Immunotherapy given to children with allergic rhinitis reduces the progression to asthma [12].
Surgery is reserved for acute severe problems or for children with severe chronic symptoms uncontrolled by medical therapy [3].

 

References
1. Murray CS, Poletti G, Kebadze T, Morris J, Woodcock A, Johnston SL, Custovic A. Study of modifiable risk factors for asthma exacerbations: virus infection and allergen exposure increase the risk of asthma hospital admissions in children. Thorax 2006; 61:376-82. [Link to abstract]

2. Murray CS, Simpson A, Custovic A. Allergens, viruses, and asthma exacerbations. Proc Am Thorac Soc 2004; 1:99-104. [Link to abstract]

3. Scadding GK, Caulfield H. Paediatric Rhinosinusitis. In: Scott Brown, ed. Otorhinolaryngology. 2006.

4. Clement PA, Bluestone CD, Gordts F, Lusk RP, Otten FW, Goossens H, Scadding GK, Takahashi H, van Buchem FL, Van CP, Wald ER. Management of rhinosinusitis in children. Int J Pediatr Otorhinolaryngol 1999; 49 Suppl 1:S95-100. [Link to abstract here]

5. Gani F, Pozzi E, Crivellaro MA, Senna G, Landi M, Lombardi C, Canonica GW, Passalacqua G. The role of patient training in the management of seasonal rhinitis and asthma: clinical implications. Allergy 2001; 56:65-8. [Link to abstract]

6. Ciprandi G, Ricca V, Passalacqua G, Truffelli T, Bertolini C, Fiorino N, Riccio AM, Bagnasco M, Canonica GW. Seasonal rhinitis and azelastine: long- or short-term treatment? J Allergy Clin Immunol 1997; 99:301-7. [Link to abstract]

7. Garavello W, Romagnoli M, Sordo L, Gaini RM, Di BC, Angrisano A. Hypersaline nasal irrigation in children with symptomatic seasonal allergic rhinitis: a randomized study. Pediatr Allergy Immunol 2003; 14:140-3. [Link to abstract]

8. Serra HA, Alves O, Rizzo LF, Devoto FM, Ascierto H. Loratadine-pseudoephedrine in children with allergic rhinitis, a controlled double-blind trial. Br J Clin Pharmacol 1998; 45:147-50. [Link to abstract]

9. Bonadonna P, Senna G, Zanon P, Cocco G, Dorizzi R, Gani F, Landi M, Restuccia M, Feliciello A, Passalacqua G. Cold-induced rhinitis in skiers--clinical aspects and treatment with ipratropium bromide nasal spray: a randomized controlled trial. Am J Rhinol 2001; 15:297-301. [Link to abstract]

10. Meltzer EO, Orgel HA, Biondi R, Georgitis J, Milgrom H, Munk Z, Van BJ, Wood CC, Drda K. Ipratropium nasal spray in children with perennial rhinitis. Ann Allergy Asthma Immunol 1997; 78:485-91. [Link to abstract]

11. Philip G, Malmstrom K, Hampel FC, Weinstein SF, LaForce CF, Ratner PH, Malice MP, Reiss TF. Montelukast for treating seasonal allergic rhinitis: a randomized, double-blind, placebo-controlled trial performed in the spring. Clin Exp Allergy 2002; 32:1020-8. [Link to abstract]

12. Moller C, Dreborg S, Ferdousi HA, Halken S, Host A, Jacobsen L, Koivikko A, Koller DY, Niggemann B, Norberg LA, Urbanek R, Valovirta E, Wahn U. Pollen immunotherapy reduces the development of asthma in children with seasonal rhinoconjunctivitis (the PAT-study). J Allergy Clin Immunol 2002; 109:251-6. [Link to abstract]

13. Kuehr J, Brauburger J, Zielen S, Schauer U, Kamin W, Von BA, Leupold W, Bergmann KC, Rolinck-Werninghaus C, Grave M, Hultsch T, Wahn U. Efficacy of combination treatment with anti-IgE plus specific immunotherapy in polysensitized children and adolescents with seasonal allergic rhinitis. J Allergy Clin Immunol 2002; 109:274-80. [Link to abstract]

14. Moller C, Dreborg S, Lanner A, Bjorksten B. Oral immunotherapy of children with rhinoconjunctivitis due to birch pollen allergy. A double blind study. Allergy 1986; 41:271-9. [Link to abstract]

15. Vourdas D, Syrigou E, Potamianou P, Carat F, Batard T, Andre C, Papageorgiou PS. Double-blind, placebo-controlled evaluation of sublingual immunotherapy with standardized olive pollen extract in pediatric patients with allergic rhinoconjunctivitis and mild asthma due to olive pollen sensitization. Allergy 1998; 53:662-72. [Link to abstract] 

16. LaRosa M., Ranno C, Andre C, Carat F, Tosca MA, Canonica GW. Double-blind placebo-controlled evaluation of sublingual-swallow immunotherapy with standardized Parietaria judaica extract in children with allergic rhinoconjunctivitis. J Allergy Clin Immunol 1999; 104:425-32. [Link to abstract]

17. Yuksel H, Tanac R, Gousseinov A, Demir E. Sublingual immunotherapy and influence on urinary leukotrienes in seasonal pediatric allergy. J Investig Allergol Clin Immunol 1999; 9:305-13. [Link to abstract]