Allergic and Nonallergic Rhinitis in Pediatric Patients

Educational Objectives

The goal of this program is to improve management of allergic rhinitis (AR) and nonallergic rhinitis. After hearing and assimilating this program, the clinician will be better able to:

1. Identify known allergens which contribute to symptoms of AR.
2. Prescribe medication to manage specific symptoms of AR.
3. Appraise evidence supporting use of immunotherapy.

Summary

Allergic rhinitis (AR; ie, hay fever): nasal symptoms include rhinorrhea, congestion, sneezing, and pruritus; most patients with AR usually have allergic rhinoconjunctivitis, characterized by red, itchy, watery eyes; some patients may also experience itchy palate or ear canal; postnasal drip may also occur, leading to cough; rule out asthma as a cause for cough

Causes for allergy: aeroallergens include pollens from nonflowering plants (eg, grass, trees, weeds), mold spores, animal dander (from, eg, dogs, cats), and house dust mites (HDMs); people are not born allergic to specific allergens; however, B cells in some individuals tend to make immunoglobulin E (IgE) antibody, which sticks to receptors on mast cells in the nose and eyes; the allergens attached to the bound IgE cause release of histamine and production of allergic symptoms; AR symptoms are worse during certain times of the year; family history of atopic disease (eg, AR, asthma, eczema, food allergy) increases risk for development of AR; pollen food allergy syndrome is also associated with developing AR; patients with AR or nonallergic rhinitis (NAR) are at higher risk of developing ear and sinus infections because of occlusion of the sinus ostium or eustachian tube

Physical examination: usually normal in patients with AR, though some patients may have allergic shiners (dark circles under eyes; seen in patients with NAR or nasal congestion; nonspecific for AR); children rub their nose (ie, “allergic salute”) to relieve itching, and frequent rubbing may form a crease across the nasal bridge; examining the nose with an otoscope in a straight line reveals the inferior turbinates; angling upward shows the middle turbinates; though some patients with AR have pale, bluish turbinates, its absence does not exclude AR

Dermatologic testing: histamine is directly applied to the skin as a positive control to ensure the patient is not taking an antihistamine (which suppresses test results); a skin prick is used as a negative control, as some children have dermatographism; histamine forms a hive, wheal, or flare on the skin; record the size of the wheal and erythema

Serologic testing: look for serum-specific IgE; serologic and dermatologic testing are interchangeable for aeroallergens and food allergens; a positive skin or blood test does not equate with clinical allergy, as patients may have serum-specific IgE without any allergy symptoms; symptoms should corroborate test results; the higher the level of IgE, the more likely the patient has clinical allergy

Medication management

Oral antihistamines: effective against rhinorrhea and pruritus but not congestion; can be prescribed for regular or as-needed use; take effect in <1 hr with intermittent use; use antihistamines before, rather than after, expected allergen exposure for better effect; consider switching to nasal corticosteroid spray if one antihistamine fails to provide relief, as it is unlikely that another antihistamine would work; generic and branded antihistamines are equally effective; cetirizine and fexofenadine might be more effective than loratadine; cetirizine causes more sleepiness, compared with loratadine; fexofenadine does not cause sleepiness, as it does not reach the central nervous system; levocetirizine and desloratadine do not differ from their parent compounds

Decongestants: pseudoephedrine — an oral decongestant which alleviates nasal congestion; select states require prescription for purchase; side effects include insomnia, blood pressure elevation, and dysrhythmia (in people already prone); not recommended for long-term use; though phenylephrine is the recommended substitute drug, the US Food and Drug Administration recommend its withdrawal from the market, due to lack of efficacy; oxymetazoline and phenylephrine — though these nasal solutions provide relief from congestion in 5 min, rebound congestion is more severe vs initial congestion; the duration of efficacy decreases over time, rendering the medications inappropriate for chronic use

Nasal corticosteroid sprays: treat nearly all symptoms if AR; all nasal corticosteroid sprays are equally effective and are tolerated well by most patients; consider temporary discontinuation or dose reduction or division in cases of slight epistaxis

Nasal antihistamine sprays: can alleviate rhinorrhea, pruritus, sneezing, and congestion (not alleviated by oral antihistamines); use in combination with a nasal corticosteroid spray provides improved efficacy than either drug class alone; inexpensive

Eye drops: necessary for patients with eye symptoms despite use of an oral or nasal antihistamine (which usually alleviate eye symptoms); eye drops may contain an antihistamine and/or a decongestant; the speaker prefers eye drops containing only an antihistamine to avoid rebound ocular erythema

Montelukast: the speaker avoids montelukast for AR, as Philip et al (2002) demonstrate greater efficacy and AR symptom reduction with loratadine, compared with montelukast or placebo; a black box warning exists for depression and suicide among patients who use montelukast

Subcutaneous allergy shots (immunotherapy): start with the minimum dose of allergens, with upward titration until a maintenance dose is achieved; patients should stay at the maintenance dose for ≈5 yr to achieve long-lasting (sometimes lifelong) improvement; patients may or may not require other medications while receiving allergy shots; allergy shots do not substitute for environmental control; side effects may include swelling at the injection site and anaphylactic reactions; though most patients never experience systemic reactions, they can be severe when they occur; allergy shots should be administered by physicians at centers with readily available resuscitation equipment; Varney et al (1991) demonstrated lower symptoms or need for medication among patients who receive immunotherapy against grass pollen, compared with placebo; following patient rerandomization, Durham et al (1999) demonstrated similar levels of symptom improvement among patients newly started on immunotherapy, compared with patients who discontinued immunotherapy after 4 yr

Sublingual immunotherapy: administered daily; pills should be taken for 3 to 5 yr for prolonged improvement; oral pruritus is common; systemic reactions are less common, compared with allergy shots; immunotherapy can be taken at home, though prescribe an epinephrine autoinjector as a precaution, due to the risk for eosinophilic esophagitis; each tablet prescription targets only one allergen, while allergy shots can be formulated to target multiple allergens; tablets are only available for treatment of allergies to grass, ragweed, or HDMs

Nonallergic rhinitis: patients have symptoms similar to AR with negative allergy testing; some people have a lower threshold for nasal symptoms from, eg, cigarette smoke, cold weather, air conditioning, perfume; patients with vasomotor rhinitis (a type of NAR) experience a watery, runny nose as the primary symptom; management of NAR is similar to AR with the caveat that the antihistamine used for NAR should possess anticholinergic activity, as NAR is driven more by the cholinergic system than the histaminergic system

Readings

Bernstein JA, Bernstein JS, Makol R, Ward S. Allergic rhinitis: a review. JAMA. 2024;331(10):866-877. doi:10.1001/jama.2024.0530; Caffarelli C, Mastrorilli C, Procaccianti M, Santoro A. Use of sublingual immunotherapy for aeroallergens in children with asthma. J Clin Med. 2020;9(10):3381. doi:10.3390/jcm9103381; Chang KL, Guarderas JC. Allergy testing: common questions and answers. Am Fam Physician. 2018;98(1):34-39; Durham SR, Walker SM, Varga EM, et al. Long-term clinical efficacy of grass-pollen immunotherapy. N Engl J Med. 1999;341(7):468-75. doi:10.1056/NEJM199908123410702; Emeryk A, Emeryk-Maksymiuk J, Janeczek K. New guidelines for the treatment of seasonal allergic rhinitis. PostepyDermatolAlergol. 2019;36(3):255-260. doi:10.5114/ada.2018.75749; Philip G, Malmstrom K, Hampel F, et al. Montelukast for treating seasonal allergic rhinitis: a randomized, double-blind, placebo-controlled trial performed in the spring. Clin Exp Allergy. 2002;32(7):1020-1028. doi:10.1046/j.1365-2222.2002.01422.x; Philpot EE. Safety of second generation antihistamines. Allergy Asthma Proc. 2000;21(1):15-20. doi:10.2500/108854100778249033; Varney VA, Gaga M, Frew AJ, et al. Usefulness of immunotherapy in patients with severe summer hay fever uncontrolled by antiallergic drugs. BMJ. 1991;302(6771):265-9. doi:10.1136/bmj.302.6771.265.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Kelso was recorded at Pediatrics in the Islands: Clinical Pearls 2024, held October 28, 2024, in Waikoloa, HI, and presented by the Children’s Hospital Los Angeles Medical Group. For information on future CME activities from this presenter, please visit https://www.chla.org/chla-medical-group/cme-conferences. Audio Digest thanks Dr. Kelso and Children’s Hospital Los Angeles Medical Group for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

PD704201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.