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Allergic Rhinitis and co-morbidities in children Meenu Singh. MD, FCCP, FCIAAI Professor of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh 160012.
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Atopic Dermatitis Food Allergy Allergic Rhinitis Allergic Childhood Asthma Adult Asthma Atopic or Allergy March Natural sequence of allergic clinical conditions appearing during a certain age period and persisting over a number of years from childhood to adulthood Atopy is the inherited tendency to develop harmful immune responses to harmless substances Allergy can affect different children in different ways
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Allergic Rhinitis Allergic rhinitis is clinically defined as a symptomatic disorder of the nose induced by an IgE-mediated inflammation after allergen exposure of the membranes lining the nose Most prevalent in Pediatric & Adolescent population Traditionally, classified into Seasonal allergic rhinitis (SAR) and Perennial allergic rhinitis (PAR)
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Intermittent < 4 days per week or < 4 weeks Mild Normal sleep No impairment of daily activities, sport, leisure Normal work & school No troublesome symptoms in untreated patients Persistent > 4 days per week and > 4 weeks Moderate-Severe one or more items Abnormal sleep Impairment of daily activities, sport, leisure Abnormal work and school Troublesome symptoms J Allergy Clin Immunol 2001;108:S147-336. Allergic Rhinitis: Classification
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Mast Cell Chemotactic Factors Phases of allergy: PINE or MPI
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Allergic Rhinitis in children Pediatric rhinitis: Range of symptoms Cough Sneezing Nasal pruritus Nasal congestion Sore throats – recurrent infections Halitosis Respiratory distress – infant Hypernasality Behavioral problems Pediatric AR and its comorbid disorders Conjunctivitis Pharyngitis Sinusitis Asthma Eczema Otitis media Lymphoid hypertrophy/obstructive sleep apnea Speech impairment Failure to thrive Reduced quality of life Lack G. J Allergy Clin Immunol 2001;108:S9-15
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AR in children: Clinical presentation Allergic rhinitis (AR) : Multiplicity of symptoms in the child Clinical presentation depends on the duration of allergen exposure (perennial versus seasonal and episodic exposure), age of the child, and extent of co-morbid disease. AR commonly presents in childhood as recurrent sore throats and upper respiratory tract infections Diagnosis of AR is often missed in children, who are thus treated inappropriately with multiple doses of antibiotics. Chronic cough is common symptom of AR or sinusitis in children resulting from postnasal drip and irritation of the larynx. Lack G. J Allergy Clin Immunol 2001;108:S9-15
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Allergic Rhinitis and Co-morbidities “The nose is the part of the lung which can be accessed by the finger”
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Proportion of Allergic Rhinitis patients who also have selected co-morbid disorders Curr Med Res Opin 2004. 20:305-307 Allergic Rhinitis and Co-morbiditiesHow Common are the co-morbidities?
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Proportion of co-morbidities patients who also have Allergic Rhinitis Co-morbidities and Allergic Rhinitis How Common is the association? Curr Med Res Opin 2004. 20:305-307
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AR and Sinusitis in children AR and Sinusitis frequently co-exist and are definitely linked Sinusitis is one of the most underreported diagnoses in young children Pediatric sinus disease is characterized histologically by marked tissue eosinophilia, with mast cells expressing the activation marker There has been an  in association between AR, positive skin tests, and sinusitis Lack G. J Allergy Clin Immunol 2001;108:S9-15
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AR and Sinusitis: Pathophysiology Swelling of the mucous membranes, whether due to allergy, infection or other causes, may obstruct the drainage and aeration of the sinuses and one might therefore expect allergy to increase the risk of developing acute and chronic sinusitis.** During acute sinusitis there is swelling of mucous membranes, infiltration of eosinophils, and resulting ciliostasis and pooling of secretions that probably contribute to the subsequent infection Chronic rhino-sinusitis may be associated with a similar inflammatory process to that observed in AR
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Frontal, Ethmoidal & Maxillary sinuses drain into middle meatus through an opening called ostium (osteomeatal complex) Nasal inflammation Allergic Rhinitis Viral URTI Obstruction of sinus passage Impedes normal movement of air and secretions Accumulation of thickened secretions & impaired ciliary movements Environment for infections Mucosal swelling Chronic Sinusitis AR and Sinusitis: Pathophysiology
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Adolescent subjects with AR: 3-fold greater risk of developing de novo asthma as compared with subjects without AR Exposure to allergens and sensitization are important risk factors for childhood asthma AR and Asthma frequently co-exist and are considered as twin expressions of the same disease Possible relations exist between AR and asthma: AR may confound the diagnosis of asthma AR may be statistical associated with asthma AR may exacerbate coexisting asthma AR may have a causal role in the pathogenesis of asthma AR and Asthma in children Lack G. J Allergy Clin Immunol 2001;108:S9-15
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Cough-Variant Asthma Noctural cough in poorly controlled asthma No history of wheezing Responsive to brochodilator therapy Cough Variant Rhinitis Cough esp. nocturnal and post nasal drip Responsive to allergen avoidance; non-sedating long acting antihistamines; and/or intranasal steroids Misdiagnosis may lead to overtreatment inhaled steroids, 2 agonists and oral steroides Children with chronic cough When Asthma & Rhinitis co-exists Asthma may appear to be worse than it is Cough may be misattributed to asthma This may lead to over-treatment with high dose inhaled steroids Correct diagnosis and treatment of AR has a steroid sparing effect Lack G. J Allergy Clin Immunol 2001;108:S9-15
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AR with Asthma: Pathophysiology Inflammation in the nose lower airway hyperresponsive. Possible mechanisms include Nasobronchial reflex: Nasal allergic response altering bronchial responsiveness through. Rhinovirus adhesion theory: Allergen induced ICAM-1 serves as receptor for rhinovirus infection leading to infection and asthma exacerbation. Mouth breathing caused by nasal obstruction resulting in bronchospasm to cool dry air. Pulmonary aspiration of nasal contents transferring mediators J Allergy Clin Immunol 2001;108:S147-336.
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Common Triggers and Pathophysiology Anatomy/ Physiology Upper and lower airways are contiguous Functional linkage – nose vs mouth breathing Similar histology(epithelial, neural, vascular) Same triggers HDM, pollen, pet dander, moulds, fungi Same cells Mast cells Eosinophils Same mediators IgE Histamine Cytokines Leukotrienes Same drugs Anti IgE ? Steroids(ICS/ INS) Antihistamines ? Antileukotrienes ? Asthma Allergic Rhinitis Sinusitis AR, Sinusitis, Asthma: The link J Allergy Clin Immunol 2001;108:S147-336.
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AR and Otitis media in children OME refers to a non infectious condition of the middle ear, usually accompanied by Eustachian tube dysfunction with accumulation of serous fluid Allergy as a risk factor for OM* Atopic children more susceptible to both symptomatic AOM & asymptomatic OME* 40-50 % of children > 3 years with chronic OM have confirmed AR** Presence of higher levels of IgE or ECP in the middle ear of allergic children than levels found in the serum at the same time*** *Doyle et al. Curr Opin All Clin Immunol 2002 **Fireman et a., JACI 1997 ***Bernstein et al. Otolaryngol Head Neck Surg 1985
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AR and Otitis Media: Pathophysiology Relationship between nasal allergic inflammation and otitis media is caused by a dysfunction of the Eustachian tube There is anatomic continuity in the form of Eustachian tubes connecting Pharynx and Middle ear Inflammation Allergic Rhinitis Viral URTI Obstruction of Eustachian tubes Increased negative pressure and impaired ventilation in middle ear Aspiration of fluids in middle ear during transient openings Acute Otitis media Mucosal swelling Chronic OME
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Complications of AR with Chronic OME Lack G. J Allergy Clin Immunol 2001;108:S9-15 Chronic middle ear effusions may lead to hearing deficit and speech impairment in children 519 children with Chronic MEE attending a pediatric allergy clinic reported that 98% had associated nasal allergy A study of children with seasonal ragweed pollen allergy found an increase in the rate of ETO and clinically significant hearing loss compared with pre-seasonal assessment in the same group of children Children with AR, in addition to having MEE and hearing impairment may have a characteristic hypernasal quality to their voice and has potential to affect speech development.
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Children with AR usually have lymphoid hypertrophy, particularly evident in the cervical lymph node chain & adenoids One study from an otolaryngology department found an association between tonsillar hypertrophy and AR. Only 8% of children in 6th grade without tonsillar hypertrophy had AR, whereas AR was apparent in 29.7% of children with tonsillar hypertrophy Children with AR often become mouth-breathers and snore at night as a result of nasal obstruction and adenoidal hypertrophy The pediatrician must consider the possibility of AR in the assessment of snoring children AR & obstructive sleep apnea Lack G. J Allergy Clin Immunol 2001;108:S9-15
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ARIA workshop and children The prevalence of seasonal allergic rhinitis is higher in children and adolescents than in adults Varied prevalence of rhinitis across the world 0.8% to 14.9% (6-7 years ) & from 1.4% to 39.7% (13-14 years) Significant correlation between asthma & rhinitis in school going children During the ragweed pollen season, 60% of children developed Eustachian tube obstruction Gastro esophageal reflux can be associated with rhinitis, especially in children J Allergy Clin Immunol 2001;108:S147-336.
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Oral H1 antihistamines are the mainstay for management of Mild Intermittent Mild Persistent AR Moderate to severe Intermittent AR ARIA workshop: Recommendations Patients with persistent rhinitis should be evaluated for asthma Patients with persistent asthma should be evaluated for rhinitis A strategy should combine the treatment of upper and lower airways in terms of efficacy and safety Long term treatment is more effective than on demand treatment
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Allergen avoidance indicated when possible Pharmacotherapy Safety, effectiveness easy to be administered Patient's education always indicated costs Immunotherapy Specialist Rx, may alter the natural course of the disease ARIA workshop: Therapeutic options
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Therapeutic options for AR Hadley JA. Med Clin North Am. 1999;83:13-25. 16. Busse WW. Clin Exp Allergy. 1996;26:868-879.
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Step ladder treatment of AR: ARIA J Allergy Clin Immunol 2001;108:S147-336.
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Management of Allergic Rhinitis: ARIA
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ARIA : Treatment in children Long-term continuous treatment with H1-antihistamines may improve lower respiratory symptoms and may exert a prophylactic effect on asthma onset in children Seasonal allergic rhinitis per se may affect learning ability and concentration. Treatment with classical antihistamines often had a further reducing effect upon cognitive function. Use of TRULY non-impairing H1-antihistamines may improve learning ability in allergic rhinitis
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Direct Medical Costs Physician Visits Procedures Hospitalization Medication Intangible Medical Costs Quality Of Life Issues Psycho-social aspect of the disease Impairment at work / school Side effects of OTC Indirect Medical Costs Lost days of work Decreased productivity School days missed Impact of AR on socio-economic costs Fergussan B. OCNA Suppl. Feb 1998
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School absences & poor performance due to distraction, fatigue & irritability Poor interaction & labeling by peers and embarrassment, isolation and low self esteem Adverse effects of most of antihistamines and decongestants Adverse impact on parents QOL Anxious, overprotective, work absences, family social life, etc. Effect of AR on pediatric QOL
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Urticaria A transient erythematous skin eruptions due to oedema of the dermis, associated with itching. (Wheal & Flare rashes) or Hive Urticarial rash & Angio-oedema Angioedema Transient swellings of deeper dermal, subcutaneous and submucosal tissues. Angioedema accompanies urticaria in approximately 50% of adults and 80% or more of children