Nasal steroids reduce hospitalisation risk

VIENNA – Allergic rhinitis in children is not only very common but is strongly associated with asthma. Moreover, asthmatic children suffering from allergic rhinitis seem to be prone to more severe disease. “Two thirds of asthmatic children also suffer from allergic rhinitis, the number one chronic disease,” according to Dr. Paul Brand of Princess Amalia Children’s Hospital, Isala Klinieken, Zwolle, Netherlands.

Children with both asthma and rhinitis have higher levels of FeNo (Exhaled Nitric Oxide Fraction, a noninvasive means of measuring asthmatic airway inflammation) indicating significant ongoing inflammation. “These children have poorer asthma control and are at a higher risk of hospital admissions,” says Dr. Brand.

A study presented at the 19th ERS Annual Congress suggests that only every second child with allergic rhinitis gets diagnosed correctly. In the view of Dr. Brand, “Whenever a supposed common cold lasts longer than 10 days, we should rethink the diagnosis”. It is safe to assume we are dealing with an allergic rhinitis after excluding other causes for the nasal obstruction such as adenoidal hypertrophy or an upper respiratory tract infection.”

Not an easy diagnosis

When children present with the typical symptoms of a runny nose, along with the characteristic allergic crease caused by nasal rubbing - the so called Morgan-Denny Fold - diagnosing allergic rhinitis seems easy enough. But a large number of kids presents with general symptoms such as fatigue, sore throat or bad breath (halitosis). The diagnosis proves more difficult when the symptoms of rhinitis are intermittent and can be mistaken for an upper respiratory tract infection.

While allergic rhinitis is not in itself dangerous, it may be associated with a number of comorbidities, including asthma, atopic dermatitis and nasal polyps. Evidence now suggests that uncontrolled allergic rhinitis can worsen the inflammation associated with asthma and increase hospitalisation rates. According to recent studies, allergic rhinitis sometimes is a precursor to asthma and therefore must be taken seriously.
When symptoms are severe, allergic rhinitis may impact heavily on the daily lives of children, manifesting through disturbed sleep and reduced daytime quality of life.

Although the diagnosis is mainly clinical, skin-prick-testing or the demonstration of increased immunoglobulin E levels in the blood may provide additional useful information, says Dr. Brand.

Education and information are essential to treatment success

As with any chronic disease, non- pharmacological measures such as avoiding exposure to tobacco smoke are essential, as is the education of parents and caregivers, points out Dr. Brand. For children with perennial allergic rhinitis, avoiding of house dust mite may reduce symptoms - and it goes without saying, that when the allergic symptoms are animal-related, the family pet will have to be removed.
In mild and intermittent disease, there is a choice of treatments: oral or nasal antihistamines with nasal saline or cromoglycate as additional options. In severe, persistent cases a nasal corticosteroid and, sometimes, a short-term vasoconstrictor are currently viewed as the treatments of choice.
Not only are sleep and daytime symptoms improved by a treatment with nasal corticosteroids, but the risk of hospital admissions due to asthma is significantly reduced.

These treatments will only be effective given the cooperation of patients and their carers, however. Parents must be reassured that no side-effects such as growth retardation are to be feared from nasal steroids.

week 43, 2009