It’s just a bit of sneezing and eye-rubbing isn’t it?

Dr Omer Berk, Dr Liz Powell, Dr Zaraquiza Zolkipli     

Allergic rhinitis – like other allergic diseases – is becoming more common, affecting up to 20% of children in the UK. It happens due to IgE mediated inflammation of the nasopharynx in response to common environmental proteins like pollens and house dust mites.

The symptoms of itchy eyes, sneezing and a runny nose are sometimes not taken particularly seriously – but for some young people these are bad enough to affect their sleep, education and quality of life as a whole.

In this piece, we will help you understand this condition and give you some strategies to help you manage it effectively in clinic. Your sneezy, snuffly patients will thank you!     

THE CASE

Ben is a 13 year old patient whom you see in the paediatric clinic complaining of hayfever symptoms during the summer.  He had his end of year exams in June and his parents and teachers were surprised by unexpectedly poor results. He is completely well now (October). Ben says he took a nasal steroid spray for 10 days without any change in symptoms and that it tasted disgusting, and otherwise has taken oral antihistamines throughout the summer. You wonder about his treatment options, you’ve heard of immunotherapy but is this relevant here?

To answer that question we need to find out a bit more to confirm the diagnosis and evaluate our treatment options:

Establishing the diagnosis

We need a bit more information about Ben’s symptoms

You ask Ben about risk factors for allergic rhinitis and discover that he had eczema as a child and that one of his parents is asthmatic.  There are no pets at home. Ben has typical symptoms of sneezing, nasal itching and nasal obstruction. Ben’s symptoms last for most of June and July (seasonal, and likely related to grass pollen allergy given the months he’s affected) and are present every day during the season.

Establishing the impact

We want to know how severe his disease is so we know where to start in a stepwise approach to treatment.  Has he got mild disease? or moderate/severe classified as an impairment of school/work performance, sleep disturbance or impairment of daily activities? Allergic rhinitis can have a huge impact on quality of life – even affecting their school

performance and the GCSE grades which the young person achieves.  School (and exam) performance is often a worry that families will bring up in allergy clinic, particularly as the GCSE exams are mostly held in the summer months, just when allergic rhinitis symptoms are at their worst.       

We already know Ben has had unexpectedly poor exam results. He reports his symptoms were stopping him sleeping and concentrating on his exams.  We would place him in the moderate/severe category.

What has he tried so far and has he done this in the right way?

So far, we know Ben has had a brief trial of nasal steroid spray and regular cetirizine.  We want to know more about his nasal steroid spray technique – has he sprayed this straight up his nose? (the wrong way) or away from the septum using the opposite hand for each nostril (the right way).  There is heaps of information leaflets and videos for nasal spray technique online – allergy UK and BSACI have great resources.  Also, nasal steroid sprays need to be given for at least 2 weeks to work.

Ben confirms that when he took the nasal spray he sprayed straight backwards and sniffed immediately afterwards. You discover he’s a West Ham football supporter, and he appreciates the reminder of the crossed hammers on the emblem for using the opposite hand for spraying each nostril.

Are we missing anything?

You examine Ben for signs of allergic rhinitis. There may be obvious clinical signs observed when you are talking to these patients such as persistent mouth breathing, frequent rubbing of the nose which can result in an obvious transverse crease, repetitive sniffing and ‘allergic shiners’ (dark circles under the eye).  Examine the nose with an otoscope with a clear explanation of what you are about to do!  You are often met with a quizzical look at this point. 

Clear nasal secretions with oedematous pale mucous membranes are in keeping with allergic rhinitis, whereas coloured secretions suggest infection. BEWARE the nasal polyp in a child between the age of 2 and 10 years – they are rare in this age group and if found cystic fibrosis should be excluded.

Ben’s examination is entirely normal – as is common in seeing these patients out of their season of symptoms.

Do we need to do any investigations?

If the history and suspected allergen is clear – then no.  Blood tests or skin prick tests can be useful to identify an allergen for the patient to avoid or if considering immunotherapy. Skin prick tests are great as they can be carried out at the same appointment and you can chat through the results in a one-stop-shop style.

Ben has a clear story of symptoms in June and July and you suspect grass pollen allergy. You decide to treat on the basis of this and optimise his treatment.

Optimising treatment

Treatment of allergic rhinitis is based on avoidance, medication and immunotherapy.

Avoidance of the allergen depends on the aeroallergen in question, a useful source of patient information is the Allergy UK website.  For grass allergy, simple advice of avoiding walking in open fields particularly where the grass has just been mown and keeping windows shut in the season can help. Having a shower when coming in from outside can also help.

In mild symptoms simple treatment with nasal saline irrigation can be effective and particularly popular with families wanting to avoid medication.  Or it can be used as an add on to other therapy in moderate/severe symptoms. 

A combination of oral antihistamines (avoiding first generation antihistamines as they can affect sleep quality and learning) and intra-nasal corticosteroids is the mainstay of medical therapy for moderate/severe allergic rhinitis.  Intranasal steroids have the most effect and for children we choose the preparations with minimal systemic absorption such as fluticasone and mometasone.

You check Ben’s nasal steroid spray – he has been given fluticasone in the past, so you recommend he tries this again with the right technique you have now taught him.  You tell him he can take his cetirizine alongside this.  You also advise him that he should start his treatment in the middle of May 2 weeks before his symptoms usually start to give the medication enough time to achieve the best effect.

So all sorted.  Or not – his mother asks as they are about to head out the door…. Why can’t he just have the immunotherapy treatment she read about via google rather than all these drugs?

Immunotherapy has its place in patients who have poor symptom control on maximum therapy.  Ben has not been taking his medication appropriately and this is a common reason for treatment failure.  There is also another step he can try if there is no symptom control-  adding an intranasal antihistamine, this is licensed for over 12 years of age in a combined intranasal steroid and antihistamine spray which may improve compliance rather than using two separate nasal sprays.

Despite using all the medication appropriately, some patients do need to be considered for immunotherapy.  The aim of allergen immunotherapy is to give increasing amounts of the allergen in order to induce tolerance and has been shown to decrease symptoms, reduce medication use and improve quality of life.  This is given as either sub-

lingual immunotherapy (SLIT) or subcutaneous immunotherapy (SCIT).  This is a big commitment – it needs to be given for a minimum of three years and patients need to be aware they will still have to take their medication alongside this (at least initially).

You explain this to Ben and his mother and they agree to your plan, arranging to see him at the beginning of July next year during his usual season so you can see the difference you have made!

Authors: Dr Omer Berk, Dr Liz Powell, paediatric trainee doctors. Consultant review: Dr Zaraquiza Zolkipli, Paediatric Allergy Consultant, Addenbrooke’s Hospital, Cambridge