Resources and Support for AllergySA Patients - Allergy Society of South Africa (ALLSA)

Allergy Conditions

Allergic Rhinitis in Children

Written by Prof. E.G Weinberg MB ChB, FCP

INTRODUCTION

Allergic rhinitis is an important condition in South Africa. It is the commonest allergic condition encountered in most communities affecting anywhere from 20 to 30 percent of the population.

Children are particularly affected by the consequences of this illness especially because nasal obstruction often leads to disturbed sleep patterns, poor concentration, hearing difficulty, poor appetite and poor growth. In addition because they are still growing disorders of dentition often occur associated with the features of the so-called long-face syndrome.

Rhinitis is defined as an inflammation of the mucus membrane lining the nose. Allergic reactions in the nose are frequent as inhaled allergens are trapped by the nasal filtration system. Allergic inflammation is characterized by the accumulation of mast cells, TH2 cells and eosinophils. Allergens interact with mast cell attached IgE resulting in the release of histamine. Histamine in turn causes symptoms by a direct effect on vascular histamine receptors which results in local swelling and oedema.

It also stimulates sensory nerves which result in the induction of reflex-mediated sneezing and increased watery nasal secretion. Histamine accounts for the immediate allergic symptoms in the nose, but not for the later inflammatory reaction or the increase in nasal reactivity. Continued exposure to allergen alters nasal sensitivity to the extent that lesser quantities of the same allergens and non-specific irritants cause ongoing symptoms.

In allergic rhinitis sneezing is a prominent feature and nasal symptoms may be accompanied by itchy watery eyes and intense itching of the nose and soft palate.

Patterns of Allergic Rhinitis

Allergic rhinitis may occur as a seasonal problem when it is known as hayfever or seasonal allergic rhinitis. Then there is the condition where symptoms are year-round in nature which is known as perennial allergic rhinitis. A third form is the so-called non-allergic rhinitis which is very rare in children and will not be discussed here.

Grass pollens and some tree pollens are the predominant cause of seasonal allergic rhinitis. In South Africa there is an enormous variety of indigenous and exotic grass species. Another feature of grass allergenicity is the very long grass season which occurs here – in many regions the grass season may last for as long as 9 months of the year.

Occasionally weed pollen or even some species of fungal spores may also be responsible for seasonal allergic rhinitis symptoms.

In general allergens which occur in the environment throughout the year, especially in the indoor environment are associated with perennial symptoms. These allergens include housedust mites, animals such as cat and dog danders, fungi and work, school or hobby-related allergens.

A. Seasonal Allergic Rhinitis (Hayfever)

Seasonal allergic rhinitis is often more commonly known as hayfever in the community. In this condition both the nose and the eyes are affected and essentially the patient suffers from a rhino-conjunctivitis. Most cases result from allergy to pollens. Hayfever is said to be the commonest allergic disorder on a world-wide basis.

The frequency of hayfever varies a great deal from place to place depending on the degree of exposure to grass or tree pollens.

During the first season when symptoms initially appear they may be interpreted as being due to a prolonged common cold. In subsequent seasons with the intense nasal itching, sneezing and profuse watery nasal discharge the diagnosis soon becomes apparent. Other troublesome symptoms include itching of the palate especially of the soft palate and intense itching in the auditory canals. Hayfever sufferers often develop headaches and are usually quite irritable. A profuse post-nasal mucus drip is often present. Allergic conjunctivitis with itchy, watery eyes and photophobia usually accompanies the nasal symptoms.

A.1. Diagnosis

The diagnosis of hay fever is not difficult and is often made by the parents of the child. A careful history is most helpful and usually reveals the seasonal nature of the complaint and the suspected role of seasonal allergens. Physical examination usually reveals a rather puffy-eyes individual with reddened watery eyes and red granular palpable conjunctivae. The nostrils are filled with excessive amounts of clear watery mucus and the turbinates appear pale and swollen. The throat may be reddened with prominent follicles on the posterior pharyngeal wall.

Staining of the nasal mucus with Hansel’s stain (Table I) reveals sheets of eosinophils. Skin tests are particularly useful in identifying the offending pollen allergens.

A.2. Treatment

Seasonal allergic rhinitis responds well to treatment. Ideally antigen avoidance would be the first approach to managing any allergic disorder. However, in this situation it is obviously impossible to avoid the offending pollen allergens. For this reason symptomatic treatment is used in all patients with seasonal allergic rhinitis.

A.2.a. Antihistamines:

The new non-sedating H1 receptor antagonists have been a great advance in this form of treatment in recent years. The various preparations available in South Africa are all effective, especially in terms of dealing with nasal itching and the watery nasal discharge. Unfortunately, they are relatively ineffective in treating nasal blockage. Most patients find the once daily recommended dose for most of these antihistamines a great advantage.:

Cetirizine (Zyntec) 10 mg
Loratidine (Clarityne) 10 mg
Astemizole (Hismanal) 10 mg

The other non-sedating antihistamine available is Terfenidine (Triludan) 30 mg twice daily.

A.2.b. Topical antihistamines:

Levocabastine (Livostin) and Azelastine (Rhinolast) may be very effective in seasonal allergic rhinitis sufferers producing rapid symptomatic relief of itching, sneezing and nasal discharge. They do not have any effect on nasal blockage.

A.2.c. Sodium cromoglycate:

Sodium cromoglycate (Rynacrom, Vividrin) may be administered as nose drops or as a nasal spray. This preparation is effective in children with seasonal allergic rhinitis. For best results it should be administered four times a day, but many patients find it effective if used two to three times daily. Sodium cromoglycate is very safe and no side-effects have ever been reported with intranasal use.

A.2.d. Topical steroids:

The use of intranasal topical steroid nasal sprays has been a significant advance in the treatment of allergic rhinitis. Some preparations are available as both metered-dose aerosol sprays or as aqueous suspensions in pump-action sprays. The latter is often the most acceptable form for use in children.

Examples of products available are:

Beclomethasone dipropionate (Beconase, Viarox, Beclate, Ventnaze)
Budesonide (Rhinocort)
Flunisolide (Syntaris)
Flucticasone propionate (Flixonase)
Triamcinolone acetonide (Nasacor)

Rhinocort, Flixonase and Nasacor have the advantage of being used only once daily which considerably improves medication compliance.

Immunotherapy:

Immunotherapy which is often commonly called desensitisation, is a very successful and often under used form of therapy in allergic rhinitis. It is most successful in seasonal allergic rhinitis especially in grass sensitive individuals. Courses of immunotherapy injections are usually given for a period of at least 3 years. Success is related to achieving a high commulative dose over the treatment period. Courses of grass desensitisation should be commenced before the onset of the pollen season. Doses may need to be adjusted downward during the pollen season if the patient is made increasingly symptomatic. A knowledge of local grass pollens and whether the patient is also sensitive to the Bermuda grass species occurring in this country is helpful when choosing the ideal grass vaccine for an individual patient.

Other nasal sprays and drops:

Great care should be exercised in the use of decongestant nasal sprays and drops. There is always the danger of causing rhinitis medicamentosa which is refractory to treatment. If decongestant nose drops or sprays are required these should only be given for short periods of 7-10 days. Oxymetazoline (Iliadin) and Xylometazoline (Otrivin) are considered the safest preparations in this group.

B. Perennial Allergic Rhinitis

Perennial allergic rhinitis may be more common than the seasonal form in South Africa. Patients are invariably allergic to allergens present in the environment throughout the year e.g. house dust mites, animal danders or fungal spores. It should again be noted that prolonged grass season may acount for perennial symptoms in many patients especially in those who show peak season flare-ups of symptoms.

Although perennial allergic rhinitis resembles the seasonal form in some ways, there are important differences in symptoms, diagnosis and treatment options.

B.1. Symptoms:

The symptoms of perennial allergic rhinitis oftern commence in young children, even as young as 2-3 years of age, yet the peak incidence occurs in adolescents and young adults. Nasal itching and associated eye symptoms are not usually complaints found in perennial rhinitis patients. The most common symptoms are intense nasal obstruction, bouts of sneezing especially in the early morning and profuse and troublesome watery nasal discharge.

Associated maxillary sinusitis and serous otitis media are common. Nasal obstruction may be associated with malaise, frequent headaches, disturbed sleep patterns and persistent mouth breathing. Mouth breathing often leads to dryness and cracking of the lips and children are often very thirsty and may wake at night for a drink of water.

Post-nasal mucus drip is a frequent complaint. In children this often causes them to cough continuously soon after they have got into bed at night.

Characteristic mannerisms occur in many patients such as the ‘allergic salute’. Here the nose is constantly pushed upwards with the palm of the hand in an attempt to reduce nasal obstruction. After some time an obvious transverse crease is produced across the nose where the bony and cartilaginous portions meet. This crease is known as the ‘allergic crease’. Other mannerisms often encountered include twitching of the nose and pulling of the face in some ways similar to rabbits. This is also done in an attempt to clear nasal obstruction.

Nasal obstruction is usually associated with a bluish discolouration of the lower eyelids which is known as ‘allergic shiners’. The lower eyelids may also be rather puffy and multiple skin creases known as ‘Dennies lines’ may occur in this area.

B.2. Diagnosis:

Once again the same diagnostic approach as for seasonal allergic rhinitis is employed. It is important to exclude conditions which may closely mimic perennial allergic rhinitis (see Table II) and the condition may not be as simple to diagnose as is often thought.

It is important to take a very careful history. This is usually helpful in disclosing the perennial nature of the complaint and the role of possible allergens.

Careful examination of the patient is essential. A typical pale so-called ‘allergic facies’ will be noted in many cases. The allergic shiners and nasal crease are helpful pointers to the diagnosis.

In children with chronic allergic rhinitis the palate is often high-arched and has a V-shape. As a result dental crowding and malocclusion occurs. The face may appear to be elongated and this is one of the causes of the ‘long-face syndrome’. In many cases associated serous otitis media may develop as a result of eustachian tube obstruction.

Skin tests or CAP-RAST are helpful in confirming diagnosis by identifying sensitivity to the usual perennial allergens. Nasal smears stained with Hansel’s stain are useful where the diagnosis is difficult as clumps of eosinophils are characteristic of an allergic rhinitis

B.3. Treatment:

Mild cases of rhinitis do not require intensive treatment which should be reserved for those patients with troublesome symptoms..

B.3.a. Environmental control:

Adequate environmental control measures are an important component of any treatment plan. In most patients house dust mites or pets are the principal allergens. House dust mite reduction programmes are useful in the patients bedroom,. The best measures appear to be the use of effective mattress covers which can be washed in hot water, washing of bedding also in hot water and the removal of fitted carpets.

Most people are reluctant to get rid of pets. They should be advised not to allow cats or dogs to sleep on their beds and to wash their animals at least once a week. In the case of cats this is easier said than done.

Other irritants such as cigarette smoke, deodorants, hair sprays, sawdust and chalk dust need to be avoided. Many patients also react to high chlorine concentrations in swimming pools.

B.3.b. Medication:

Recommendations for the treatment of perennial allergic rhinitis follow the same guidelines as for the seasonal form. However, steroid nasal sprays have become the main recommended treatment in perennial allergic rhinitis. The once-daily preparations tend to be the most popular and effective forms used these days.

In resistant cases a short course of topical betamethasone (Betnesol) drops given intra-nasally for no more than 10 days may be helpful in reducing nasal mucosal inflammation and swelling.

In many cases immunotherapy is an additional treatment option worthy of consideration. It should be reserved only for those allergens which are less easily avoidable such as house dust mites.

Immunotherapy should be continued for at least 3 years and is best used in those rhinitis sufferers whose symptoms are inadequately controlled in spite of appropriate environmental control measure and symptomatic treatment.