Allergic Rhinitis in Children: Symptoms, Causes, Diagnosis & Treatment

What is Allergic Rhinitis?

Allergic rhinitis is an allergic (or atopic) disorder. It is a chronic inflammatory disorder of the nasal mucosa with an underlying atopic basis and is clinically characterized by a group of common features like nasal congestion, rhinorrhea (i.e., nasal discharge), sneezing, and itching in the nose and is often associated with conjunctival inflammation.

This whole spectrum with an allergic basis is called allergic rhinitis.

Keywords to Remember

• It is chronic inflammation with acute exacerbations, but overall it is considered a chronic inflammation or disorder with acute exacerbations.
• There is nasal mucosa inflammation, and
• There is an underlying atopic, i.e., allergic, basis. It often tends to run in families, and then you will find an atopic basis, similar to those seen in patients with food allergies, atopic dermatitis, allergy conjunctivitis, and bronchospasm.
• Clinically, it is characterized by a common group of features that includes nasal congestion, rhinorrhea, sneezing, and itching in the nose, and almost 70–80% of children are associated with conjunctival inflammation.

Epidemiology of Allergic Rhinitis

• The onset of allergic rhinitis tends to occur very early in life. 
• Onset is mostly seen in children's first 6 years of life.
  • Peak prevalence seen in the second part of childhood, i.e., 6–12 years.
  • The onset can be seen as early as infancy.
  • The majority of children will reach 2, 3, and 4 years of age; this is the time of life during which they will be seen.
• Allergic rhinitis is a very common disorder.
  • The overall incidence of allergic rhinitis worldwide is 20–30% for children up to 12 years of age, and the prevalence can be as high as 40% in some populations.
  • The pattern of allergens responsible for allergic rhinitis is very complex, and for multiple reasons:
  • Raising economic standards
  • Less exposure of children to dirt and allergens in their early lives; this increases the chance of a child getting sensitized whenever there is exposure and can lead to allergic rhinitis.
  • Resolution of the symptoms in adolescence can be seen, and there can be a recurrence of symptoms.
  • Complete resolution of the disease occurs by the fifth decade of life.
  • If the children are always getting infections, having a runny nose, open mouth breathing, and snoring at night. confirm, does the child have fever in all of them?
  • If no and confirm only a minimal fever, he will always be allergic, sneezing.
  • So, children have atopic allergies. Diagnose as a case of allergic rhinitis.
  • The differential diagnosis is upper respiratory infection.

• So, AR is a very common entity in childhood that is under diagnosis in the majority of the pediatric period.

Also read: Abdominal Tuberculosis in Children: Symptoms, Diagnosis & Treatment 

Risk Factors for Allergic Rhinitis

• Family history of atopy
• Children with serum IgE total levels greater than (>) 100 IU/ml before the age of six
• Maternal smoking is a strong determinant of allergic rhinitis.
  • In the Western population, maternal smoking is more prevalent, and allergic rhinitis is more commonly seen.
  • Maternal smoking during pregnancy as well as postpartum both increase the risk of allergic rhinitis.
  • The risk is greatest during postpartum. A child is exposed to smoke during the first six months of life.

• Exposure to indoor allergies: Spores, mites, and dust.
• Delivery by cesarean section
• The vaginal route has some degree of exposure to the maternal genital flora, and these maternal genital floras may produce asymptomatic infections, which tend to protect the child from allergic rhinitis.
• Three or more episodes of rhinorrhea, which may not be of allergic origin, in the first year of life.
• Children aged 2-3 years who have anti-cockroach and anti-mouse IgE-specific antibodies.
• Reduced diversity of intestinal microbiota.
• Hygiene Hypothesis
  • The prevalence of allergic rhinitis is increasing globally due to increased cleanliness.
  • Exposure to indoor allergens is a risk factor.
  • It is called the hygiene hypothesis. It is not related directly, but similar things can be attributed to allergic rhinitis as well.
  • For example, children born in the 1960s or 1970s. At that time, children were not protected as they are today.
  • They were not overly pampered as today when they would go out; they had no mobile phones, video games, and things like that.
  • So, they will go out whenever they want, between the ages of one and one-and-a-half and two years old, and will be exposed to allergens, dirt, and low-grade infection.
  • But at the same time, exposure will not be happening in the critical period of infancy; it will happen in the post-infancy period when the child goes out.
  • All the low-grade infections that will be happening and all the exposure to allergens that will be happening have been shown to reinforce the immune mechanism of the child, which in turn protects against allergy.
  • So that child at an earlier time would not get as much; the disease was there earlier also, but one of the theories says why the prevalence is rising is because children are going out less, the hygiene standards are improving, and they are not getting asymptomatic infections, allergies, or post-infancy periods. As a result, I am more susceptible to these allergies.

Now, due to improved environmental conditions, children are not going outside; most deliveries are happening in the caesarian section. So, the exposure to the maternal or external microbiomes is not happening, and their immune system is not getting enough in the fetus to activate the anti-inflammatory mechanism.

There are factors like:

• Maternal smoking
• Environmental pollution
• Inside the house are more effluents and heavy carpenters; whenever they will be cleaning heavy carpets, they will have a lot of dust; the dust might get roaming around.
• Air conditioners

Protective Factor against AR

• Prolonged breast feeding up to 1 and a half or 2 years of age.
• Exposure to dogs, cats, or endotoxins in early childhood. Whereas exposure to similar things except for dirt and pollen-like things in the post-infancy stage of the childhood period will find it to protect against allergic rhinitis.
• Early introduction to wheat, rye, barley, oats, eggs, and fish.
• If the child starts exposure too early, around 3 or 4 months, they will increase the risk of food allergy. So balance needs to be maintained.

Also read: Childhood Pneumonia- Causes, Symptoms, and Treatment 

Classification of AR-ARIA Classification

Intermittent Symptoms

• <4 days / week or <4 consecutive weeks

Persistent Symptoms

• ≥4 days / week and or
• ≥4 consecutive weeks 

Mild

• Normal sleep
• Normal daily activities
• Normal work and school
• No troublesome symptoms

Moderate-to-severe

• Abnormal sleep
• Impairment of daily activities, sports and leisure
• Difficulties Caused At Work And School
• Troublesome symptoms
• Earlier, the classification used to be seasonal versus perennial.
• Four categories of allergic rhinitis:
  • Mild intermittent
  • Mild persistent
  • Moderate to severe intermittent
  • Moderate to severe persistent

Also read: Anatomy And Basics Of Pediatric Pulmonology 

What Is Allergy Sensitization? 

Initially or after the first exposure to an allergen, which leads to the production of IgE antibodies, these antibodies coat the mast cells and basophils.

Antigen Exposure

↓

APCs process antigens into peptides

↓

Peptides presented by APCs to Helper T-Cells

↓

Helper T – cells Release IL-3 and IL-4

↓

Stimulate B-cell transformation to IgE-producing plasma cells

↓

IgE Coats Mast cells in nasal mucosa and basophils in the plasma

Clinical Features of AR

• There can be known or unknown exposure to an allergen that leads to the onset of acute symptoms.
  • Nasal congestion is more prominent at night.
  • Sneezing
  • Rhinorrhea: bilateral, clear, and watery.
  • Nasal itching
  • Nose picking
  • Epistaxis as a sequel to allergic rhinitis.
  • Ocular symptoms: watering from the eyes, redness, and photophobia.
• There is no fever, or if one is present, it is incidental.

Also read: Complete Guide To Understanding Cystic Fibrosis 

Physical Findings of AR

There are three important physical findings.

Allergic Salute

• In nasal congestion, children subconsciously pull up their nose using the palm, index, and middle fingers. This maneuver is called an allergic salute.
• Repeated movements form a transverse line on the bridge of the nose, known as the transverse nasal crease.
• Allergic salute is a maneuver that produces a line called the transverse line on the nasal bridge.

Allergic Shiners

• Blackish discoloration or erythematous to blackish discoloration around both eyes, called as allergic shiners.
• Around the eyes, there will be some degree of hyperpigmentation.
• In older children, it is blackish in nature.
• In younger children, around 5 or 6 years of age, it will be more pink-red than the blackish nature.

Allergic Gape

• Open-mouth breathing due to allergic rhinitis and its long-term complications.
• They develop some degree of adenoid hypertrophy and tonsillar hypertrophy. Due to chronic nasal congestion and habitually breathing from the mouth.
• In chronic mouth breathing, some degree of remodeling of the lower part of the face is present.
• The lower jaw will be slightly backward or receding compared to the front of the jaw.
• Due to chronic breathing, nasal crust and dry lips will be present.

Also read: Fetal Assessment: Key Evaluations & Prenatal Diagnosis 

Complications of Allergic Rhinitis in Children

• Associated allergic conjunctivitis is seen in >70% of patients.
  • More commonly seen in older children and adults. 
• Chronic sinusitis, often with marked eosinophilia.
• Persistent or recurrent cough due to post-nasal drip in AR. Because of the cleared nasal asthma secretion, the children will have some of the secretion go backwards, causing throat irritation.
• Eustachian tube obstruction and middle ear effusion; they can lead to acute otitis media (AOM) and acute serous otitis media (ASOM).
• Hypertrophy of the adenoids or tonsils causes open-mouth breathing.
• Obstructive sleep apnea
• Adverse effects on the quality of life.
  • Fatigue
  • Social issues (8, 10, and 12 years old) will have a lower quality of life.
  • When children start teasing their siblings, his or her nose is always rubbing.  
  • So, children start making fun of them, and that starts affecting their mental and social development.
    • Lack of sleep
    • Declines in scholastic performance.

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