Children And Allergic Rhinitis: Quality Of Life Issues

Children And Allergic Rhinitis: Quality Of Life Issues
Allergic rhinitis is a major chronic respiratory disease which impacts on quality of life and work/school
performance, leading to a significant economic burden1. Allergic rhinitis, often known as hay fever, is a
condition, which can seriously impair quality of life for all who suffer from it, as well as close family who
have to care for them. In children particularly, the condition can be damaging, not only to a child’s
health, but also to their social development.
This condition is characterised by numerous symptoms, which include: headaches, throat and nasal
itching, persistent runny nose, post-nasal drip and, in most cases, by nasal congestion. Nasal
congestion profoundly affects quality of life, largely by undermining the restorative power of sleep.
Poor-quality sleep leads to daytime drowsiness, fatigue, indecision and significant impairment in
learning and cognition2. This can lead children to be shy, anxious, fearful or even depressed. Inevitably,
if left untreated, symptoms may also lead to absenteeism from school. For example, in the United
States alone, an estimated total of two million schooldays are lost annually3 owing to allergic rhinitis.
The bothersome qualities of allergic rhinitis symptoms and the potential disruption to the daily routine
for those affected are supported by a recently conducted landmark survey known as the Allergies in
Latin America (AILA) survey. The AILA survey is a comprehensive, first-of-its-kind survey carried out
across eight countries into the impact of allergic rhinitis amongst adults and children. It investigated the
range of symptoms associated with the condition, the needs patients believe are unmet by their current
medication and the overall effects on quality of life.
In many cases, parents will frequently self-adjust treatments for their children (both over-the-counter
and prescription medications) because of lack of efficacy, deterioration of efficacy, lack of 24-hour relief
and bothersome side-effects3. This is supported out by AILA survey, which stated that only 35% of
children thought their current medication actually provided 24-hour relief and over half (51%) stated that
their nasal allergy medication was not effective enough. As many as 68% of children were simply
dissatisfied with their current nasal allergy medication, demonstrating a major unmet need in Latin
American children.
Furthermore, according to AILA, more than half of Latin American children affected (53%) had to miss
school or had school interrupted owing to their symptoms 4. In addition to this, 33% reported significant
loss of productivity4, which translates into reduced academic performance.
Rhinitis is defined as inflammation of the nasal membranes 5. Allergic rhinitis involves inflammation of
the mucous membranes of the nose, eyes, eustachian tubes, middle ear, sinuses, and pharynx. The
nose invariably is involved and the other organs are affected in certain individuals. Inflammation of the
mucous membranes is characterized by a complex interaction of inflammatory mediators but ultimately
is triggered by an immunoglobulin E (IgE)–mediated response to an extrinsic protein6. The condition is
characterized by four major symptom types, namely: nasal itching, sneezing, rhinorrhoea (persistent
runny nose) and nasal obstruction7.
Approximately one-third of patients will present before six years of age8. Allergic rhinitis in itself is not a
life-threatening condition but it is concerning as it predisposes those affected to other co-morbidities,
such as conjunctivitis, sinusitis, otitis media, and, most notably, it is a strong independent risk factor in
the development of asthma9.
The prevalence of allergic rhinitis is showing an alarming rate of increase: a recent study in Italy
predicted that by that year 2020, as many as one out of two people up to 14 years of age may be
affected10. With this projected prevalence, allergic rhinitis is fast becoming the most common chronic
disease in the pediatric population11.
Categorization of allergic rhinitis
Allergic rhinitis is often divided into two sub-categories: seasonal and perennial rhinitis depending on
the occurrence of their symptoms throughout the year. Seasonal rhinitis tends to bring about symptoms
at specific given periods during the year, e.g. hay fever, which is rife during the pollen and fungal sporeproducing months. With perennial rhinitis, patients are fully symptomatic throughout the year. AILA
revealed that 62% of Latin American allergic rhinitis patients are seasonally affected, with the remaining
38% suffering year-long symptoms. Nasal congestion was reported as the most troublesome symptom,
affecting 54% of the respondents who were surveyed.
However, the Allergic Rhinitis and its Impact on Asthma initiative12, in collaboration with the World
Health Organization, has also proposed the following two categories: intermittent (IAR) and persistent
(PER) in addition to ‘mild’ or ‘moderate/severe’ to classify severity of symptoms and quality of life
outcomes. Figure 1, below, illustrates the relationship between these categories 13.
Figure 1: Classify allergic rhinitis
Treatment goals for allergic rhinitis
The symptoms of allergic rhinitis are often intolerable without treatment. The AILA survey revealed that
over half (53%) of patients stated they could not cope without medication. According to the ARIA
guidelines, the goals for treatment of allergic rhinitis are both effective control of symptoms and
improvements in quality of life. The stated priorities within these goals include: unimpaired sleep; no
troublesome symptoms; no or minimal side-effects of rhinitis treatment and finally, the ability to
undertake normal daily activities, including work and school attendance, without limitation or impairment
and the ability to participate fully in sport and leisure activities1.
As mentioned previously, certain activities are impaired in those who responded to the AILA survey.
Over half of the children surveyed felt that their allergies lead to some or a lot of limitation in playing
sports and there was also a major decline in productivity at school. Almost a quarter of children also
suffered from disturbed sleep on account of the nasal symptoms of their allergic rhinitis.
Allergens and environmental triggers
Naturally, as allergic rhinitis is often exacerbated by physiological responses to an allergen, it is
important to consider the role that such mediators play in allergic response control. Of great benefit to
patients would be knowledge of exactly what environmental triggers tend to lead to allergic symptoms
and subsequent proliferation of symptoms. For example, food allergies can cause rhinitis symptoms in
70% of infants and young children8. A comprehensive list of all such triggers could be determined by
allergy skin prick or multi-allergen testing, which would give the patient a better idea of precisely what
factors to avoid. Also, other causes should also be considered, such as socioeconomic, environmental
and ethnic factors12, e.g. smoking parents of affected children.
Current management of symptoms
Once a child has been confirmed with allergic rhinitis, it is important that a treatment regimen is
immediately commenced. The first step for intermittent or mild persistent allergic rhinitis is usually a
course of antihistamines (such as cetirizine or loratadine) in combination with a decongestant (such as
pseudoephedrine). For more persistent symptoms, physicians may initiate a course of corticosteroid
nasal sprays such as budesonide, mometasone or beclometasone. The dilemma with prescribing
steroids, despite their potent and proven anti-inflammatory properties as the most effective
pharmacologic treatment of allergic rhinitis 14 is concern over side-effects that may be encountered.
These include: bone density loss, osteoporosis, growth retardation in children, adrenal suppression,
cataracts and glaucoma.
However, of the most recently developed steroid treatments for allergic rhinitis, ciclesonide has been
shown to have a particular mode of action with a lower tendency for systemic side effects. This is owing
to its properties as a steroidal pro-drug that is converted into an active metabolite by esterases in the
nasal mucosa. Therefore any pro-drug that is absorbed systemically does not induce side effects as it
can only become the active drug where the drug is required in a targeted fashion. Ciclesonide has also
shown similar efficacy to other INSs and is also effective over 24-hours 15. Additionally, ciclesonide
nasal spray is formulated in a hypotonic solution, which may speed absorption and improve patient
experience by eliminating “throat drip” and enhancing drug efficiency so less solution is wasted.
Allergen immunotherapy may also be a long-term multi-seasonal treatment for allergic rhinitis in more
severe patients. This involves gradual exposure to allergens by injection over a period of months and is
considered safe and effective8; however, sublingual therapy is the preferred therapy in young children16,
rather than injections, owing to their inability to communicate potential problems effectively.
The AILA survey results have shown that there is an unmet need in current allergic rhinitis
management for children and that their quality of life is significantly affected. The needs of treatment in
children are the same as those for adults with allergic rhinitis, i.e. the need for efficacious and well
tolerated medication that provides children with 24-hour relief from their debilitating symptoms.
However, safety is even more paramount in children and we have to look to the use of novel treatments
that have fewer systemic effects. It is vital that management of allergic rhinitis is improved, in order to
meet the needs of Latin American children, in line with the ARIA guidelines. The development of local
guidelines that consider the regional factors that can influence the behaviour of physicians and patients
is also vital in order to improve the lives of children with allergic rhinitis 17.
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