Doc talks: Runny nose in your child

Article by Dr Kenneth Oo Kian Kwan

Doc talks: Runny nose in your child

Dr Kenneth Oo Kian Kwan

ENT Surgeon / Otorhinolaryngologist
National University of Singapore, Faculty of Medicine
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Allergic rhinitis: Pointers in the Paediatric age group

Allergic rhinitis is a very common condition seen in both general practice and in most ENT practices. For those of us managing patients with allergic rhinitis, especially in the paediatric age group, it can be both frustrating and rewarding. Children present to us a unique set of issues and I will allude to a few pertinent points that have emerged after having had to deal with this issue for several years now.

The definition and management recommendations for allergic rhinitis are well known given the well-established ARIA as well as local guidelines. Despite environmental control and avoiding triggers, many of our patients continue to have moderate to severe symptoms. It is with this group of patients that we need to focus our energy on to help reduce the morbidity and discomfort of allergic rhinitis. Immunotherapy is often not an option for a lot of these patients due to cost and compliance issues and therefore pharmacotherapy remains a mainstay in most of our practices.


Compliance

Compliance is often an issue with children. Administration of medication to a child involves “two parties”, the child (or patient) and the person administering the drug. If either one is non-compliant, the result will be that the child does not receive his or her medication. As clinicians we can help improve compliance by choosing drugs that are administered at fewer frequencies. Once a day administration would be far easier to remember as well as tolerated than something that requires three doses a day.  Intranasal steroids for example, are conveniently dosed once a day in the morning in the paediatric age group. Since many children cannot swallow tablets, whether an antihistamine is available in a tasty syrup form is also an important factor. Some children may also be put off by the smell of the nasal spray and having a scentless and odourless preparation can help improve compliance.
 

Efficacy versus Safety

As parents and clinicians, we always want to choose the most effective medication with the least side effects. INS (Intranasal steroid) and antihistamines have been well studied in this respect. For example, a 20094 study focused on children aged 2 to 5 years with allergic rhinitis, confirmed the efficacy of triamcinolone acetonide aqueous nasal spray at a dose of 110mcg once daily for up to 6 months. Long term studies on children also confirmed the safety of INS in terms of its effect on stature growth and suppression of the Hypothalamus-Pituitary-Adrenal axis. In this respect, we can rest assure that prescribing well studied INS from age 2 onwards would be both effective and safe. When it comes to antihistamines, it is well known that the newer “Second generation” antihistamines cause less sedation than the “first generation” antihistamines. This is perhaps too simplistic a view, rather it is more important to divide antihistamines into those that cross the blood brain barrier and therefore cause CNS side effects versus those that do not. In that respect, there is a huge volume of data to support the fact that antihistamines like fexofenadine do not cross the blood brain barrier7,8,9 at all even at supra-normal doses. Studies using PET scans of the brain as well as cognitive function testing did not show any effect of consuming fexofenadine on the CNS10. I therefore take this into consideration when I prescribe an antihistamine to a child especially if it is for a longer period of time as we do not want to jeopardize a child’s academic or psychomotor performance.

In summary, when we manage patients with allergic rhinitis in the paediatric age group, it is important to not only follow the well established guidelines but also consider the unique qualities and properties of the respective pharmacological agents we prescribe to help us address the specific issues that this age group presents to us.

  1. Brozek JL, et al; Global Allergy and Asthma European Network; Grading of Recommendations Assessment, Development and Evaluation Working Group. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision.  J Allergy Clin Immunol. 2010 Sep;126(3):466-76.

  2. Siow JK, Chao SS, Wang DY et al. Singapore Ministry of Health. Ministry of Health clinical practice guidelines: Management of Rhinosinusitis and allergic rhinitis. Singapore Medical Journal 2010 Mar; 51(3):190-7.

  3. Blaiss M. Current concepts and therapeutic strategies for allergic rhinitis in school-age children. Clin Ther. 2004 Nov;26(11):1876-89.

  4. Weinstein S, Qaqundah P, Georges G, Nayak A. Efficacy and safety of triamcinolone acetonide aqueous nasal spray in children aged 2 to 5 years with perennial allergic rhinitis: a randomized, double-blind, placebo-controlled study with an open-label extension. Ann Allergy Asthma Immunol. 2009 Apr;102(4):339-47.

  5. Skoner DP, Gentile DA, Doyle WJ. Effect on growth of long-term treatment with intranasal triamcinolone acetonide aqueous in children with allergic rhinitis. Ann Allergy Asthma Immunol. 2008 Oct;101(4):431-6.

  6. https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/020468s024lbl.pdf

  7. Compalati E, Baena-Cagnani CE et al. Systematic review on the efficacy of fexofenadine in seasonal allergic rhinitis: a meta-analysis of randomized, double-blind, placebo-controlled clinical trials. Int Arch Allergy Immunol. 2011;156(1):1-15.

  8. Milgrom H, Kittner B, Lanier R, Hampel FC. Safety and tolerability of fexofenadine for the treatment of allergic rhinitis in children 2 to 5 years old. Ann Allergy Asthma Immunol. 2007 Oct;99(4):358-63.

  9. Hindmarch I. Comparing the safety consequences of newer antihistamines. Adv Stud Med 2004 Jul; 4(7A):S501-7.

  10. K Yanai, et al; Central Effects of Fexofenadine and Cetirizine: Measurement of Psychomotor Performance, Subjective Sleepiness, and Brain Histamine H1-Receptor Occupancy Using 11C-Doxepin Positron Emission Tomography. J Clin Pharmacol August 2004 vol. 44 no. 8 890-900.
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