Allergic Rhinitis / Conjunctivitis in children

Scope

Diagnosis and management of allergic rhinitis and conjunctivitis in children under 18.

Allergic rhinitis affects 30% of the world's population, and 20% of the UK population. Symptoms can adversely affect work, home, and social life .

In children poorly controlled symptoms can cause learning problems and sleep disturbance.

In UK teenagers it is linked to poor national exam performance.

Often co-exists with Asthma. Symptomatic rhinitis is a major risk factor for poor asthma control and exacerbation of symptoms.

Asthma is found in 15-38% of people with allergic rhinitis.

It is categorised as 'seasonal' or 'perennial', and recently as 'intermittent' or 'persistent'.

Allergic rhinitis is mainly seen in children over 2 years old caused by outdoor allergen sensitisation.

Children under 2 years old may have clinically significant sensitisation to indoor allergens e.g. house dust mites, moulds, pets, cockroaches or outdoor allergens if they have significant exposure.

Out of scope

The scope of this pathway does not extend to acute severe rhinosinusitis (common complication of rhinitis) and the management of this condition is not considered.

​Assessment

Diagnosis

Two or more of the following for more than one hour per day on a recurrent or persistent basis:

  • Rhinorrhoea (watery, runny nose)
  • Sneezing
  • Bilateral nasal obstruction/blockage/congestion
  • Itching eyes +/- conjunctivitis

Rhinitis may be accompanied by symptoms affecting eyes, ears, sinuses, throat and chest

Ask for triggers:

  • Perennial (cat, dog, dust mite, cockroach, molds) can worsen during winter months due to long hours spent indoors
  • Seasonal (trees, grass, weeds)

Differential Diagnosis

  • Upper respiratory infection
  • Chronic sinusitis
  • Anatomical nasal obstruction
    • Adenoidal hypertrophy
    • Nasal polyps
    • Deviated nasal septum
    • Foreign body
  • Gastro Oesophageal Reflux Disease

See bsaci diagnostic algorithm

Red Flags

Refer red flags to ENT

Unilateral symptoms, polyps, persistent purulent discharge or blood staining etc.

Secondary care referral for acute severe rhinosinusitis

  • This condition that can be life threatening. It is characterised by the sudden onset of two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or thick nasal discharge. Additional symptoms include facial pain or pressure, reduction or loss of smell and/or headache. If high fever and displaced eyeball are present urgent referral is warranted.

​Investigations

Examination
  • Reduced airflow
  • Allergic shiners (dark rings under the eyes)
  • Nasal crease across the bridge of the nose
Anterior Rhinoscopy
  • Pale, oedematous nasal mucosa
  • Enlarged turbinates
  • Normal examination does not exclude the diagnosis of intermittent disease
Skin prick test or Serum specific IgE
  • Younger children
    • No test usually needed
  • Older children
    • Based on history, specific IgE for house dust mite and other aeroallergens may be helpful, but if there is a clear trigger testing is not required

​Management

Allergen avoidance where possible

Saline douche

Mild symptoms

Should be treated with oral non-sedating antihistamines at doses up to twice BNF maximum dose for effective treatment of rhinorrhoea

Note - may need doses twice BNF maximum. For optimal results should be given continuously or prophylactically (e.g. 2 weeks before the pollen season).

Formulary chapter 3.2

Moderate to severe symptoms

Add intranasal corticosteroids especially with nasal blockage (good safety data for long term use in children)

Formulary chapters 12.2

Systemic corticosteroids (in addition to intranasal corticosteroid) at doses of 15-20mg for maximum of 5 days. Can be used for severe symptoms uncontrolled on conventional therapy, or to control symptoms during important periods (e.g. exams or other major events).

Formulary chapter 12

Topical sodium cromoglicate eye drops are useful in allergic conjunctivitis. See section 11.4 Corticosteroids and other anti-inflammatory preparations

Consider a concomitant diagnosis of asthma and manage according to guidelines.

Avoid:

  • sedating antihistamines,
  • depot corticosteroids
  • chronic use of decongestants

Treatment failure should prompt a review of the diagnosis and compliance with therapy (regular therapy is more effective than "as required" treatment).

Check intranasal corticosteroid technique

How to use a Topical Nasal Corticosteroid Spray

For more information see:

North and East Devon Formulary: Allergic rhinitis

BSACI - Rhinitis management guidelines

​Referral

Referral Criteria

Refer red flags to ENT – see red flag section.

There is no need to refer patients with rhinitis due to an obvious cause e.g. grass pollens, and who are responding to regular antihistamines.

Refer if persistent allergic rhinitis of uncertain cause, and those with troublesome symptoms not responding to optimal treatment

Referral Instructions

Refer via DRSS

e-Referral Service Selection

  • Specialty: Children and adolescent
  • Clinic Type: Allergy
  • Service: DRSS - Northern - Paediatrics (Medical) - NEW Devon CCG - 99P

Referral Forms

DRSS referral form

Supporting Information

North and East Devon Formulary: Allergic rhinitis

BSACI - Rhinitis management guidelines

RCPCH Allergy Care Pathways for Children Asthma/Rhinitis

NICE Allergic rhinitis

Itchy Sneezy Wheezy website

Evidence

References

  1. Scadding, G.K., Durham, S.R., Mirakian, R. et al. (2008) BSACI guidelines for the management of allergic and non-allergic rhinitis. Clinical and Experimental Allergy 38(1), 19-42.
  2. Greiner, A.N., Hellings, P.W., Rotiroti, G. and Scadding, G.K. (2012) Allergic rhinitis. Lancet378 (9809), 2112-2122
  3. ARIA (2010) Allergic Rhinitis and its impact on Asthma (ARIA) 2010 revision. ..Allergic Rhinitis and its Impact on Asthma.www.whiar.org
  4. Walker S, Khan-Wasti S, Fletcher M, Cullinan P, Harris J, Sheikh A. (2007) Seasonal allergic rhinitis is associated with a detrimental effect on examination performance in United Kingdom teenagers: case-control study. J Allergy Clin Immunol. 2007 Aug;120(2):381-7. Epub 2007 Jun 8.
  5. Angier, E., Willington, J., Scadding, G. et al. (2010) Management of allergic and non-allergic rhinitis: a primary care summary of the BSACI guideline. Primary Care Respiratory Journal 19(3), 217-222

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

Publication date: 6 July 2016

Review date: 5 July 2018

 

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