Allergic Rhinitis in Children: An Underestimated Disease

Abstract

Allergic rhinitis affects approximately 40% of children. This study aimed at determining the prevalence, sociodemographic features, comorbid illnesses, complications and quality of life in children referred to the outpatient clinic of “Allergic Rhinitis” in Penteli Children Hospital, Athens, Greece. We analyzed 590 pediatric patients referred to the outpatient clinic of “Allergic Rhinitis” in Penteli Children Hospital, Athens, Greece from 26/01/2012 to 20/11/2022. Allergic rhinitis was recorded as the one and only allergic disease in 59% of the children diagnosed with allergic rhinitis, concomitant asthma in 16% of them, atopic dermatitis in 8% and allergic conjunctivitis in 5%. 54% of asthmatic children was diagnosed allergic rhinitis, while 16% of allergic rhinitis children was diagnosed asthma. Skin tests were important diagnostic tools, not being necessary the measurement of total IgE in plasma. Eosinophils from nasal secretions were increased in 19% of the children with non-diagnostic cases and the diagnosis was local allergic rhinitis (LAR). Clinical presentations of allergic rhinitis were mainly nasal blockage, runny nose, recurrent sneezing and nasal itching. The most common complication was acute or chronic sinusitis 35%. Major associated comorbid illnesses among were tonsils hypertrophy, adenoid hypertrophy and inferior turbinate hypertrophy. Allergic rhinitis was reported in 78% of studied children and was frequently characterized by significant morbidity. Allergic rhinitis affected all paediatric age group and was peaked at age group 11–14 years and 5–7 years. There were associated epidemiological features, clinical manifestations, comorbid illnesses, complications and affectation of the quality of life in children.

Introduction

This study aimed at determining the prevalence, sociodemographic features, comorbid illnesses, complications and quality of life in children referred to the outpatient clinic of “Allergic Rhinitis” in Penteli Children Hospital, Athens, Greece.

Currently, allergic rhinitis affects approximately 40% of children [1]. While allergic rhinitis itself is not life-threatening, morbidity from the condition is significant, because it is associated with asthma, otitis media or eustachian tube dysfunction, acute or chronic sinusitis, nasal polyps, allergic conjunctivitis, and atopic dermatitis [2–6]. It may contribute to learning difficulties, sleep disorders, and fatigue [7–9].

Materials and Methods

We conducted a randomized retrospective study of 590 pediatric patients referred to the outpatient clinic of “Allergic Rhinitis” in Penteli Children Hospital, Athens, Greece from 26/01/2012 to 20/11/2022.

Moreover, a second retrospective study was conducted. In order to evaluate sleep and behavioural disorders in our children with allergic rhinitis, the parents of children who belonged to the age group 4–16 years old and who were diagnosed with allergic rhinitis completed two questionnaires, the Factor Structure of the Strengths and Difficulties (SDQ) and the Pittsburg Sleep Quality Index (PSQI). Exclusion criteria were immunotherapy, high degree of tonsil or adenoid hypertrophy, post-traumatic or congenital abnormalities of the nose, other diseases of the nose and sleep apnea of other etiology. This second study included two groups. The first group was 40 children diagnosed with allergic rhinitis and the second group was the control group (40 children).

A detailed history was important in the evaluation of allergic rhinitis. The diagnostic procedure included the same questionnaire used at the time of diagnosis, endoscopy with rigid fiberoptic endoscope 2,7 mm, 0° and 30° field of view, Skin Prick Test, measurement of total blood serum IgE levels and eosinophils from nasal secretions and Radioallergosorbent Test (RAST), a blood test using radioimmunoassay test to detect serum specific IgE antibodies, to determine the substances a child is allergic to in some only non-diagnostic cases.

More specifically, the first step in the diagnostic protocol was the endoscopy with rigid fiberoptic endoscope 2,7 mm, 0° and 30° field of view of all patients. The second stage included the completion of the common questionnaire that is used for the diagnosis of allergic rhinitis. From the questionnaire, basic personal demographic information and rhinitis symptoms were obtained, such as “Has your child ever had a problem with sneezing or a runny or a blocked nose when he/she did not have a cold or the flu?”, “In the past 12 months, has your child had a problem with sneezing or a runny or a blocked nose when he/she did not have a cold or the flu?”, “Has your child ever been diagnosed as AR?” and “In the past 12 months, has your child underwent or been treated for AR?”.

The diagnostic accuracy based on the questionnaire alone was approximately 60%. Thus, as the third stage for the diagnosis of allergic rhinitis, Skin Prick Test was performed in all patients. Skin Prick tests were important diagnostic tools, not being necessary the measurement of total IgE in plasma.

Total blood serum IgE and eosinophils from nasal secretions were measured in cases of non-diagnostic/negative Skin test.

The last step was the Radioallergosorbent Test (RAST). This blood test was performed only in inadequate diagnosis or contraindication in the application of the previous methods.

Results

A total of 590 pediatric patients were examined of which 458 were children diagnosed with allergic rhinitis. Children with allergic rhinitis represented 78% of all examined peadiatric patients. The rest 132 cases included children with symptoms mimic allergic rhinitis. The possible diagnosis in those patients was adenoid hypertrophy, inferior turbinate hypertrophy, idiopathic rhinitis and vasomotor (non-allergic) rhinitis.

Allergic rhinitis was recorded as the one and only allergic disease in 59% of the children diagnosed with allergic rhinitis, concomitant asthma in 16% of them, atopic dermatitis in 8% and allergic conjunctivitis in 5%.Chronic urticaria was documented in 12% of the children diagnosed with allergic rhinitis. 54% of asthmatic children was diagnosed allergic rhinitis, while 16% of allergic rhinitis children was diagnosed asthma.

There were 60% males and 40% female among the children with allergic rhinitis with male to female ratio of approximately 3:2. Allergic rhinitis affected all pediatric age group and was peaked at the age group 11–14 years and 5–7 years accounted for 35% and 32% respectively (Fig. 1). There was positive family history of allergy in 54% of children with allergic rhinitis (Fig. 2). A total of 68% children with allergic rhinitis were living in urban setting while 32% of them were from rural setting. We received equal randomized samples from each group of children (urban group and rural group) in order to measure the real prevalence of allergic rhinitis in each group. The prevalence of urban population was 15%, with the prevalence of rural population was 11%, and the difference wasn’t statistically significant between urban and rural residents. Persistent (perennial) allergic rhinitis was recorded in 64% of children with allergic rhinitis while intermittent (seasonal) allergic rhinitis was recorded in 36% (Fig. 4). Skin tests were important diagnostic tools, not being necessary the measurement of total IgE in plasma. Total blood serum IgE were measured in cases of non-diagnostic/ negative Skin test. Immunotherapy was effective in 100% of the patients.

Fig. 1.

Demographic data of 590 children from 26/01/2012 to 20/11/2022 in the outpatient clinic of “Allergic Rhinitis” in Penteli Children Hospital, Athens, Greece

Fig. 2.

Other sociodermographic features among children with allergic rhinitis

Fig. 4.

Symptoms among children with allergic rhinitis

The most frequent aeroallergen sensitization that resulted in positive skin prick test was trees; Plantain, Arizona Cypress, Olive Tree 50% followed by Grass Mixture 33%, mites; Dermatophagoides Farina, Acarus Siro 30%; Dermatophagoides Pteronyssinus 31%; other grass pollen, weeds and flowers; Bermuda grass 25%; Timothy grass 15%; Cereal Mixture 15%; Pellitory 8%; Parietaria sp. 6%; Mugwort 5%; Groosefoot 5%; Rye 2%; fungis (molds); Penicillium Notatum 4%; Candida Albicans 2%; Cladosporium Herbarum 1%; Alternaria Alternata 1% and animal dander (cat 12%; dog 8%) (Fig. 3).

Fig. 3.

Prevalence of common aeroallergen sensitization in the outpatient clinic of “Allergic Rhinitis” in Penteli Children Hospital, Athens, Greece

Measurement of total blood serum IgE levels, eosinophils from nasal secretions and Radioallergosorbent Test (RAST) were performed in cases of non-diagnostic / or negative Skin Test (in 28% of the examined children). Total blood serum IgE levels were increased in 25% of the children with non-diagnostic or negative Skin test. Eosinophils from nasal secretions were increased in 19% of the children with non-diagnostic or negative Skin test and thus in these cases the diagnosis was local allergic rhinitis (LAR). Radioallergosorbent Test (RAST) was diagnostic to the specific allergens a child is allergic to in 33% of the children with non-diagnostic or negative Skin test. In 55% of children with chronic urticaria demonstrated positive skin prick test to common aeroallergens. Clinical presentations of allergic rhinitis in this study were mainly 79% nasal blockage, 66% runny nose, 13% recurrent sneezing sneezing and 11% nasal itching (Fig. 4). The most common complication was acute or chronic sinusitis 35%. The definition of acute rhinosinusitis is up to four weeks of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction; facial pain, pressure, or fullness; or both. The diagnostic criteria are based on both clinical symptoms and endoscopic findings.

Other common complications of allergic rhinitis were otitis media or eustachian tube dysfunction 33%, 16% asthma, 10% sleep disturbance or apnea and 6% dental problems (Fig. 5). Major associated comorbid illnesses among the children were tonsils hypertrophy, adenoid hypertrophy and inferior turbinate hypertrophy which accounted for 53%, 42% and 59% respectively.

Fig. 5.

Complications of allergic rhinitis

The results of the second study were also analyzed.

The Odds Ratio (OR) for SDQ questionnaire was 1, 15 (Table 1) and for PSQI questionnaire 6 (Table 2).

Table 1.

Results of the factor structure of the strengths and difficulties (SDQ) questionnaire

	Allergic rhinitis group	Control group
Index of overall difficulties within normal values (< 14)	31	32
Index of overall difficulties except normal values (≥ 14)	9	8
Total	40	40

Table 2.

Results of the pittsburg sleep quality index (PSQI) questionnaire

	Allergic rhinitis group	Control group
PSQI < 5	24	36
PSQ I ≥ 5	16	4
Total	40	40

Thus, there was a significant affectation of the quality of life in children diagnosed.

Despite of high percentage rate of morbidity in our patients, there was no associated mortality to allergic rhinitis in children in our study. Treatment of allergic rhinitis leads to improvement on the clinical features in 91% patients. No significant improvement in clinical features were noticed in 9% patients. None of the studied patients reported worse clinical condition after treatment of allergic rhinitis. No mortality was recorded from allergic rhinitis in our study.

Discussion

The prevalence of allergic rhinitis that is recorded in children world widely is low. A majority of parents and children underestimate this condition. Thus, they are treated occasionally by their family pediatrician for upper respiratory tract infection. Moreover, many parents do not seek medical intervention. Early referral to the specialist is highly recommended to avoid further complications.

In this study the prevalence of allergic rhinitis in children was high, similar to prevalence rate in other previous studies. Allergic rhinitis was peaked at the age group 11 to 14 years and 5 to 7 years accounted for 35% and 32% respectively; however majority of the pediatric patients in previous studies were preschool children. This may be due to increased number of associated comorbid illnesses such as adenoid with tonsillar hypertrophy of allergic rhinitis at this age group which prompted parent to attend a specialist. Allergic rhinitis is also associated with severe symptoms which are exacerbated by acute viral infections forcing parents to seek specialist medical cares.

The management of allergic rhinitis consists of environmental allergen avoidance and pharmacologic management (oral antihistamines, decongestants, or both and an intranasal steroid spray for nasal congestion, difficult to treat allergic rhinitis or failure of previous treatment) (Fig. 6).

Fig. 6.

The EUROFEA Management Algorithm for Pediatric Allergic Rhinitis (2021)

The treatment of allergic rhinitis in our study was allergen avoidance, medical intervention and surgical treatment of comorbid illnesses, complications and refractory to medical therapy cases as referred in European Guidelines.

Immunotherapy desensitization is used in our study only for a few cases (10%) with severe disease, poor response to pharmacotherapy and environmental control, and the presence of comorbid conditions or /and complications, as recommended. Sublingual immunotherapy (SLIT) was indicated for the treatment of allergic rhinitis (with or without conjunctivitis) induced by the allergen contained in the product and most appropriate for patients in whom one allergen seemed to account for the majority of their symptoms.

The decision to initiate allergen immunotherapy was based upon a clinical evaluation and physical examination of the patient, complemented by appropriate in vivo testing (SPT/ RAST) to identify specific allergen sensitivity to the relevant allergen(s), and a detailed discussion with the patient of goals, risks versus benefits, and long-term commitment to the treatment plan.

In our selected patients the daily use of sublingual immunotherapy (SLIT) sol Sublivac FL × 24 mL was utilized. Sublivac contains allergen extracts prepared on the basis of SPT/RAST results. The most common substance in our study was mixed grasses. It is indicated for the treatment of allergic disorders of immediate type, such as allergic rhinitis, allergic conjunctivitis and allergic bronchial asthma. Treatment starts with one drop on the first day. The dose is increased by one drop daily, until the maximum dose of five drops is reached. Treatment continues with five drops daily. The drops should remain under the tongue for at least 1 min (preferably 2–3 min) before swallowing. It is recommended to carry out the treatment for a period of 3–5 consecutive years. Contraindications are acute infection of the eyes, the respiratory system or organs involved in the immune system, irreversible damage to the lungs (e.g., emphysema, bronchiectasis), severe autoimmune disorders and malignancies (e.g. kidney, thyroid, nervous system, rheumatic diseases, tuberculosis and HIV), immunodeficiencies (e.g. caused by immunosuppressants), severe uncontrolled asthma (especially with FEV 1 consistently below 70% of predicted values) and hypersensitivity to any of the excipients.

The results of immunotherapy were evident in the first six months after the onset of SLIT. Effective was the therapy if the child remained asymptomatic for six months, after the immunotherapy discontinuation. The effectiveness was measured by clinical and laboratory response (decrease of total blood serum IgE levels). If not, reevaluation of the allergens with new Skin Prick Test is needed, but in our ten year study no reevaluation was needed to perform. Thus we conducted that the SLIT was effective in all children so far.

The association of allergic diseases with psychological problems and behavioral disorders in children is existing. In order to evaluate sleep and behavioral disorders in our children with allergic rhinitis, the parents of children who belonged to the age group 4 to 16 years old and who were diagnosed with allergic rhinitis completed two questionnaires, the Factor Structure of the Strengths’ and Difficulties (SDQ) and the Pittsburg Sleep Quality Index (PSQI).

The Factor Structure of the Strengths and Difficulties (SDQ) questionnaire is short and easy to use for early control of emotional and behavioural problems in children. It is an indicator of which patients will need further evaluation and intervention from an expert. It has been translated into 40 languages. There is an official, standard Greek translation. It detects emotional symptoms, conduct problems, hyperactivity, peer problems, prosocial behaviour, impact and total difficulties.

The Pittsburg Sleep Quality Index (PSQI) questionnaire is a standard sleep quality self-assessment questionnaire during the previous month. It has been translated into 52 languages. There is an official, standard Greek translation. It studies seven clinically distinct subcategories of sleep difficulties, which are the subjective quality of sleep, sleep delay, the duration of sleep, sleep efficiency, sleep disorders, the use of hypnotics and the daily dysfunction.

The above second study included two groups. The first group was 40 children diagnosed with allergic rhinitis and the second group was the control group (40 children).

Despite of high percentage rate of morbidity in our patients, there was no associated mortality to allergic rhinitis in children in our study.

Conclusion

Allergic rhinitis was reported in 78% of studied children and was frequently characterized by significant morbidity. Allergic rhinitis affected all pediatric age group and was peaked at age group 11–14 years and 5–7 years. There were associated epidemiological features, clinical manifestations, comorbid illnesses, complications and affectation of the quality of life in children.

Abbreviations

IgE

Immunoglobulin-E

LAR

Local allergic rhinitis

OR

Odds ratio

PSQI

Pittsburg sleep quality index questionnaire

RAST

Radioallergosorbent test

SPT

Skin prick test

SDQ

Structure of the strengths and difficulties questionnaire

Author Contributions

All authors read, critiqued and approved the manuscript revisions as well as the final version of the manuscript. Also, all authors participated in a session to discuss the results and consider strategies for analysis and interpretation of the data before the final data analysis was performed and the manuscript written. All authors are part of the team managing the cases and approved the final version of the document.

Funding

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Declarations

Conflict of interest

The author(s) declare that they have no competing interests.

Ethics Approval

Ethical approval was waived by the local Ethics Committee of University of Athens and Penteli Children Hospital in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.

Consent to Participate

All patient’s parents consent for participation.

Consent for Publication

All patient’s parents consent for publication.