ALLERGIC RHINITIS IN CHILDREN Rina

ALLERGIC RHINITIS
IN CHILDREN
Literature Reading
Rhinology
By
Rina Desdwi Utami S
Supervisor :
dr. Arif Dermawan, M.Kes, Sp.THT-KL(K)
Dept of Otorhinolaryngology - Head and Neck Surgery

Faculty of Medicine Universita Padjadjaran / Hasan Sadikin
General Hospital
Bandung
2017
INTRODUCTION
Allergic rhinitis (AR) is common in children
The prevalence has been reported to be 10-40% in

the pediatric population worldwide
AR is commonly under-diagnosed, with symptoms

frequently attributed to a recurrent common cold
Turner, Kemp. Allergic Rhinitis in Children. Journal of Paediatrics and Child Health. November 2010: 302-310
2
INTRODUCTION
Although allergic rhinitis is seldom a severe or life

threatening disease, it can have profound effects on
daily living and development of a child
AR has multiple comorbidities and is closely related

to asthma
Thomas S. Rhinitis in Children : Diagnosis of AR relles on history and physical exam; antigen testing confirms diagnosis
and directs treatment. SLU Care The Physicians of Saint Louis University. Missouri Medicine. Vol. 105. May/June 2008
3
INTRODUCTION
Often the childs parents will concentrate on

comorbid diseases only and will not mention or be
concerned by symptoms of their childs allergic
rhinitis
Diagnosis of AR is made by a combination of history

and physical exam
4
INTRODUCTION
Treatment of AR can include allergen avoidance,

pharmacotherapy and immunotherapy
All three therapies are effective and safe in children
5
INTRODUCTION
Nasal symptoms are one of the most common

complaints in the pediatric population. It is
estimated that about 50% of rhinitis is atopic in
nature
AR is the most common atopic disease and one of

the most frequent chronic conditions of children
6
INTRODUCTION
It is interesting that these figures are found

primarily in industrial nations and are less evident in
developing countries
The factors that cause these differences are not clear,

but likely involve genetic and environmental
mechanisms
7
INTRODUCTION
One possible explanation for the differences in these

respective populations is the Hygiene hypothesis
8
Patogenesis Allergic Rhinitis:
9
Scadding. Allergic Rhinitis in Children. Paediatrics and Child Health. 2008; 18:7,323-29
9
DEFINITION
Rhinitis an inflammation of the lining of the nose and is

characterized by nasal symptoms including anterior or
posterior rhinorhoea, sneezing, nasal blockage and/or itching
of the nose.
Allergic rhinitis the most common form of

noninfectious rhinitis and is associated with an IgE-mediated
immune response against allergens associated with ocular
symptoms.
Updated ARIA Recomendation 2008
10
CLASSIFICATION
Of Allergic Rhinitis
Intermittent Persistent
Symptoms Symptoms
< 4 days per week > 4 days per week
or < 4 weeks at a time and > 4 weeks at a time
Mild Moderate-severe
one or more items
normal sleep abnormal sleep
no impairment of daily activities, impairment of daily activities, sport,
sport, leisure leisure
normal work and abnormal work and school
school
troublesome symptoms
no troublesome symptoms

11
Diagnosis in Primary Care Setting

12
DIAGNOSIS
Clinical Course of Atopy and Rhinitis
One of the most common reasons for a child to

visit the physician is for chronic nasal airway
symptoms
The challenge for the physician is to find the
underlining cause and therapy for the child
Infections are the most common cause of acute
rhinitis in children
Sanford T. Rhinitis in Children : Diagnosis of AR relles on history and physical exam; antigen testing confirms diagnosis
13
DIAGNOSIS
Between the ages of 2-6 the average child has six

infections per year each lasting 7-10 days
Secondary infection occurs it can last 2-3 week
Recurrent infections can mimic the chronic
process of AR
Immunologic deficiencies can increase the
number and length of rhinology infections
14
DIAGNOSIS
Structural causes for foreign bodies

rhinitis should be choanal atresia
evaluated nasal polyps
nasal tumors
Septal deviation
15
DIAGNOSIS
ciliary dyskinesia
Physiologic causes for reflux
rhinitis in children
cystic fibrosis
Drugs can
with the most common
lead to rhinitis being topical decongestants
in children
16
DIAGNOSIS
It is useful to keep in mind the age related

manifestations of AR and atopy in children; this
is often referred to as the Allergic March.
Children with atopy will often express the

disease in a progressive manor starting with
eczema, then asthma and finally AR
17
DIAGNOSIS
Allergic March
Weinberg E.G. The Allergic March. CME Vol 8, No 2. February 2010
18
DIAGNOSIS
History
A complete history is integral to the diagnosis of

allergic rhinitis
To diagnose AR in children the physician should

evaluate the symptoms and comorbidities of the
child
19
DIAGNOSIS
History
congestion,
Nasal

itching
rhinorhea
symptoms epistaxis
micronosmia
Cough
Often present throat clearing
itching
conjunctival
Eye edema
hyperemia
20
DIAGNOSIS
History
asthma
The common eczema
comorbidities atopic dermatitis
otitis media.
21
DIAGNOSIS
History
A set of questions directed at these areas can be

used as a screening device to raise the suspicion
of AR diagnosis
Children with AR frequently miss school days,

have disruption of sleep with associated fatigue
and impaired concentration
22
DIAGNOSIS
History
Their ability to perform well in school and

extracurricular activities is also effected by AR
These challenges can cause emotional problems,

isolation and poor self-esteem.
23
DIAGNOSIS
History
Family history can also support the diagnosis of

AR. If both parents are affected by atopic disease
there is a 50% chance that the child will have AR
The percentage risk increases to 70% if the

parents symptoms are of the same type and
greater severity
24
DIAGNOSIS
History
Medical history The progression

A family history
is extremely of atopy in the
of atopy
important child
25
DIAGNOSIS
Physical Exam
The physical exam of the AR child can be

variable but often some of the following are
identified
Children with AR often clear their throats and

develop a habit of rubbing their nose and eyes
26
DIAGNOSIS
Physical Exam
Their voice is often hyponasal and mildly hoarse.
Allergic salute
Dennies-lines
Allergic shiners
27
DIAGNOSIS
Physical Exam
Allergic Allergic
Nasal crease /
shiners/
salute Linea nasalis
Dennies line
28
DIAGNOSIS
Diagnostic Tests
The causative allergens are identified by allergy

testing. Allergy testing is done in vivo (skin
testing ) or in vitro (Rast testing)
29
DIAGNOSIS
Diagnostic Tests
Skin testing Serum testing
Prick/Intradermal IgE (Rast)
Multiple needle sticks Single needle stick
Results Immediate Delay
Anaphylaxis possible No Anaphylaxis
Works on complex Less Sensitive to complex
antigens antigens
Not affected by skin Affected by skin
conditions conditions
Affected by Not affected by
Antihistamines Antihistamine
30
THERAPY
Environmental Therapy
Avoidance of allergens is a first line therapy for

children with AR
The common allergens (pollen, mold, danders

and dust mites) are often ubiquitous and
therefore hard to avoid
32
THERAPY
Environmental Therapy
The general approach to avoidance is to establish

a safe zone within the childs home
This room should have minimal cloth and

carpeting to decrease collection of antigens and
minimize habitat for dust mites
33
THERAPY
Pharmacotherapy
The drug therapy of AR can be quite effective
antihistamines, intranasal steroids, leukotriene

inhibitors, decongestants.
34
THERAPY
Pharmacotherapy
35
THERAPY
Pharmacotherapy
36
THERAPY
Pharmacotherapy
37
THERAPY
Immunotherapy
Immunotherapy in non asthmatic children relatively

Classical safe
Has been reported reducing progression from allergic
Immunotherapy rhinitis to asthma and reducing new allergic
sensitization
Oral, Nasal, Sublingual, Swallow Immunotherapy

Sublingual immunotherapy proved positive in several
Other Form of trial
Immunotherapy Far Safer, can be given at home
Side effect : sore throat
expensive
KKrouse J., Derebery J., Chadwick S., Managing the allergic patient, Elsevier,
2008
38
HIGHLIGHT
Allergic rhinitis is common in children; it affects as many as 40% of
the pediatric population
There is an apparent rise in the incidence of AR in industrial nations,

the reasons for this increase are not completely understood
Diagnosis of AR relies on history and physical exam
Treatment of AR are involve environmental control,

pharmacotherapy, and immunotherapy
There are multiple drugs available for treatment of AR, the

newer generation antihistamines and topical nasal steroids are
the first line choice for children
39
Thank You
40

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ALLERGIC RHINITIS

Dept of Otorhinolaryngology - Head and Neck Surgery

Allergic rhinitis (AR) is common in children

The prevalence has been reported to be 10-40% in

AR is commonly under-diagnosed, with symptoms

Although allergic rhinitis is seldom a severe or life

AR has multiple comorbidities and is closely related

Often the childs parents will concentrate on

Diagnosis of AR is made by a combination of history

Treatment of AR can include allergen avoidance,

All three therapies are effective and safe in children

Nasal symptoms are one of the most common

AR is the most common atopic disease and one of

It is interesting that these figures are found

The factors that cause these differences are not clear,

One possible explanation for the differences in these

Rhinitis an inflammation of the lining of the nose and is

Allergic rhinitis the most common form of

Updated ARIA Recomendation 2008

Updated ARIA Recomendation 2008

Updated ARIA Recomendation 2008

Clinical Course of Atopy and Rhinitis

One of the most common reasons for a child to

Clinical Course of Atopy and Rhinitis

Between the ages of 2-6 the average child has six

Clinical Course of Atopy and Rhinitis

Structural causes for foreign bodies

Clinical Course of Atopy and Rhinitis

Clinical Course of Atopy and Rhinitis

It is useful to keep in mind the age related

Children with atopy will often express the

Weinberg E.G. The Allergic March. CME Vol 8, No 2. February 2010

A complete history is integral to the diagnosis of

To diagnose AR in children the physician should

A set of questions directed at these areas can be

Children with AR frequently miss school days,

Their ability to perform well in school and

These challenges can cause emotional problems,

Family history can also support the diagnosis of

The percentage risk increases to 70% if the

Medical history The progression

Updated ARIA Recomendation 2008

The physical exam of the AR child can be

Children with AR often clear their throats and

Their voice is often hyponasal and mildly hoarse.

The causative allergens are identified by allergy

Avoidance of allergens is a first line therapy for

The common allergens (pollen, mold, danders

The general approach to avoidance is to establish

This room should have minimal cloth and

The drug therapy of AR can be quite effective

antihistamines, intranasal steroids, leukotriene

Immunotherapy in non asthmatic children relatively

Oral, Nasal, Sublingual, Swallow Immunotherapy

There is an apparent rise in the incidence of AR in industrial nations,

Diagnosis of AR relies on history and physical exam

Treatment of AR are involve environmental control,

There are multiple drugs available for treatment of AR, the

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