Allergic rhinitis in children

Allergen avoidance measures are the first course of action in the treatment of allergic rhinitis in children.

Second-generation oral or intranasal antihistamines remain the mainstay of treatment for mild intermittent symptoms

Intranasal corticosteroids are the most effective medications for moderate to severe symptoms.

In patients who do not respond to pharmacotherapy, allergen immunotherapy may be effective.

Immunotherapy can reduce the risk of new allergic sensitizations and by preventing the progression of allergic upper airway disease to lower airway disease, such as asthma.

Allergic rhinitis has several long-term consequences in children including: increased bronchial hyperactivity, chronic otitis media with effusion, bacterial sinusitis, adenoidal hypertrophy, dental and skeletal maldevelopment.

Prevalence of allergic rhinitis increasing worldwide.

The combined approach using allergen avoidance and pharmacotherapy can usually prevent progression of the IgE-mediated inflammatory process.

Initially the treatment of allergic rhinitis requires the reduction offending allergens such as house dust mites and indoor molds.

Enclosing the mattress, box spring, and pillows in allergen-proof casings, washing bed linens and stuffed animals weekly in hot water, and reducing indoor humidity to 50% to 60% using an air conditioner or dehumidifiers , replacing carpet, when possible, and frequent vacuuming are efforts to reduce allergens.

In children’s bedrooms the use of air filters in heating/air-conditioning units, vacuums, and vent outlets and use of a portable air-cleaner unit with a high-efficiency particulate arresting (HEPA) filter is suggested.

To reduce exposure to pollens and outdoor molds, bathing a child before entering the house and before reaching the bedroom, changing outside clothing, keeping windows closed during pollen season, and keeping children away from lawns being mowed.

Pet allergens are eliminated by removing pets, and if this is not possible, prevening the pet from entering the child’s bedroom, and bathing the animal biweekly, and use an air-cleaner with a HEPA filter.

Second-generation oral antihistamines which include cetirizine, loratadine, fexofenadine, desloratadine, levocetirizine are the mainstay of treatment for allergic rhinitis, to reduce symptoms of rhinorrhea, pruritus, sneezing and watery eyes.

Oral suspensions are available and ease administration and compliance in young children.

Fexofenadine oral suspension has been shown to be effective and well-tolerated in children as young as 2 years.

The intranasal antihistamine azelastine is an effective treatment of perennial allergic rhinitis in older children.

Intranasal corticosteroids are the most potent drugs for allergic rhinitis, and the dose in children is usually limited to 1 spray in each nostril.

Growth in children should be monitored regularly in children when receiving intranasal corticosteroids.

Oral decongestants pseudoephedrine and phenylephrine have been used in combination with antihistamines for symptomatic relief, alleviating congestion caused by rhinitis.

Effectiveness of many of these agents have not been proven, and may be hazardous, therefore, they should not be given to children younger than 2 years.

Decongestant nasal sprays, such as oxymetazoline, decrease nasal congestion, without significantly improving itching, sneezing, and rhinorrhea.

Decongestant nasal sprays have a more rapid onset of action than oral decongestants.

Prolonged continuous use for 3 or more days can lead to rhinitis medicamentosa, which requires temporary suspension of the drug.

Use of intranasal decongestants should be associated with blood pressure monitoring.

Use of intranasal decongestants may be associated with the development of headache, difficulties in sleeping, or jitteriness.

Leukotriene receptor antagonist montelukast in children has an efficacy in the treatment of allergic rhinitis similar to that of oral antihistamines.

Cromolyn, is a mast cell stabilizer available as a nasal spray, and is useful for preventing rhinorrhea, pruritus, and sneezing of seasonal allergic rhinitis.

Ipratropium nasal spray, an anticholinergic agent, is most beneficial in patients with clear anterior rhinorrhea?

Use of a nasal wash with saline to flush out inhaled allergen particles that are trapped in nasal passages is considered in older children with allergic rhinitis.

Allergen immunotherapy involves the administration of allergen extracts to achieve clinical tolerance of those allergens that cause symptoms in patients with allergic conditions.

Allergen immunotherapy is indicated for children with allergic rhinoconjunctivitis, and is effective in patients with mild forms of allergic disease and in those who do not respond to pharmacotherapy.

While most immunotherapy is given by subcutaneous injection, the sublingual route is another option currently under study.

Immunotherapy reduces the risk of new allergic sensitizations and prevents the progression of allergic upper airway disease to lower airway disease.

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