Allergic rhinitis is a common condition that affects everyone differently. It can be a perennial (year-round) or seasonal condition and many children and young people are affected by both forms. Perennial allergic rhinitis is triggered by indoor allergens and although symptoms can be persistent throughout the year, they are often worse in winter when we spend more time indoors and exposure to indoor allergens is greater. Seasonal allergic rhinitis occurs at various points of the year depending on what the individual is allergic to. As we enter spring and summer, we all look forward to warmer weather, longer days and spending more time outdoors. But for children and young people with seasonal allergic rhinitis, these months can be truly miserable and come just at the time when they should be getting fresh air, exercise and having fun with friends and family.
This article will evaluate the impact of allergic rhinitis on children and young people, and consider how practice nurses and other primary healthcare professionals can make use of practice routines to improve health and wider outcomes for children and young people.
Overview of allergic rhinitis in children and young people
Allergic rhinitis affects many children and young people in the UK causing significant symptoms and a reduction in quality of life. It can be poorly perceived by children, their families and health professionals and is a condition that tends to be trivialised. This may be because it is so common, or because it is a condition that tends to be self-managed with home or over-the-counter remedies. However, management is not straightforward and guidance from knowledgeable and experienced health professionals can lead to improved outcomes. Perennial allergic rhinitis is triggered by indoor allergens such as house dust mite (HDM), pets and mould spores. It can be further aggravated by poor indoor air quality caused by smoke, cooking fumes and chemicals from cleaning products or air fresheners (Royal College of Paediatrics and Child Health (RCPCH)/Royal College of Physicians (RCP), 2020). Seasonal allergic rhinitis, or hayfever, is triggered by tree, grass and weed pollens and is further aggravated by poor outdoor air quality caused by pollution. For children with both seasonal and perennial allergic rhinitis, symptoms occur all year, with periods of worsening during their allergy season.
Understanding allergic rhinitis
Allergic rhinitis is a condition where inflammation of the nasal mucosa leads to a set of characteristic symptoms such as:
- Itchy nose
- Sneezing
- Runny nose (rhinorrhoea)
- Blocked nose.
Rhino-conjunctivitis is diagnosed in people who have ocular symptoms such a watery, itchy eyes or swollen conjunctiva in addition to nasal symptoms (Bartle et al, 2017). Around 10–15% children in the UK experience allergic rhinitis and it is strongly associated with asthma (Scadding et al, 2017) and frequently impacts asthma control. Although rhinitis can be allergic or non-allergic, the allergic form is more common, particularly in children and young people (Scadding et al, 2017).
Impact of allergic rhinitis
Uncontrolled allergic rhinitis leads to adverse effects and impacts quality of life: these effects include headache, sore throat, hearing problems, sleep disturbance, poor concentration and behaviour changes (Scadding et al, 2017). Furthermore, a detrimental impact on school attendance, productivity and performance in adolescents is well reported (Blaiss et al, 2018), with a negative impact on school examinations that can adversely affect career options and life chances (Lepkowska, 2014). The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines developed the now widely used framework for classifying allergic rhinitis (Figure 1); it is this framework that enables health professionals to assess patients and guide management decisions.
Allergic rhinitis and asthma
Allergic rhinitis is a risk factor for the development of asthma, and it also adversely affects asthma control (Scadding et al, 2017). Asthma is the most common medical condition in children and allergic rhinitis is a common asthma comorbidity in this age group (Kaplan et al, 2020). Allergic asthma is the predominant asthma phenotype in children and young people; therefore, allergy management is a vital element of essential asthma care in this age group. The National Review of Asthma Deaths (NRAD) found that there were allergic links to child asthma deaths and that most children in the audit period died during the summer months (RCP, 2014). Inclusion of allergy assessment and management in routine asthma care with consideration of the principles of ‘one airway, one disease’ leads to better overall disease control (Giavina-Bianchi et al, 2016).
The pollen season
Seasonal allergic rhinitis occurs when plant pollens are dispersed during the plant's growing season; allergic reactions to specific pollens occur only when dispersal is taking place. Pollen dispersal occurs during dry weather and even when air pollen levels are low, people who are highly sensitive can still be affected (Bartle et al, 2017). The growing season for plants occurs at approximately the same time every year and knowledge of this helps with planning and implementing management strategies (Figure 2).
Managing allergic rhinitis
Effective symptom control of allergic rhinitis usually requires a multi-factorial approach. Poor perception of the condition can result in delays seeking medical advice (Demoly et al, 2020), but routine asthma reviews offer a valuable window of opportunity for practice nurses to assess and manage this common asthma co-morbidity.
Combining non-pharmacological and pharmacological strategies will be needed to achieve effective disease control for most children and young people, and it is important to remember that one size does not fit all.
Individual assessment, management, advice and education is as important with allergic rhinitis as it is for any other long-term medical condition.
Non-pharmacological management
Allergen avoidance can be effective depending on the allergen; however, many allergens are difficult to avoid. For example, it is known that hayfever occurs when pollen is being dispersed; unfortunately, complete avoidance of pollen during this time is virtually impossible. Reduction strategies such as staying indoors and keeping windows shut when pollen counts are high are helpful for some, but for many these avoidance tactics are impractical and unrealistic. Other strategies such as wearing sunglasses and applying ointment to the nose when outdoors may be helpful (Scadding et al, 2017).
Complete HDM avoidance is impossible but families may want to try reduction strategies; there is some limited evidence to suggest effectiveness in improving control of both asthma and allergic rhinitis (Scadding et al, 2017; British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN), 2019); however, reduction measures are not routinely recommended. While the British guideline for the management of asthma does not recommend HDM reduction strategies, they do advise that families who want to take this approach should be informed that multiple strategies are likely to be most effective (BTS/SIGN, 2019). Combining good ventilation/humidity reduction, encasing mattresses and pillows, avoiding clutter and soft toys in the bedroom, damp dusting, hard flooring, soft furnishing elimination and filtered vacuum cleaning will derive more benefit than a single measure.
In cases of animal dander allergy where exposure leads to an immediate allergic response, complete avoidance is advised, and in cases where an individual is sensitised to their pet there is no firm evidence that reduction strategies such as washing the pet are effective (Scadding et al, 2017). Animal allergen is potent and can be carried on clothing, and even when removed from a home, animal allergen levels can take up to 6 months to subside (Cipriani et al, 2017).
Children living in poverty and deprivation have poor health outcomes (RCPCH, 2020). Damp housing, predominantly associated with poverty and deprivation, adversely affects all children's health. Mould is a common aeroallergen that thrives in warm, dark and humid conditions – caused by things such as condensation on windows and poorly maintained buildings – and can lead to allergy and asthma symptoms.
Rinsing of the nasal passages with saline solution reduces symptoms and may reduce the level of pharmacological treatment required; a Cochrane review found the method is easy to use, inexpensive and well tolerated by adults and children (Head et al, 2018). This non-pharmacological management strategy is widely used across Europe and becoming increasingly used in the UK.
Pharmacological management
Current guidelines recommend a stepwise approach to pharmacological management (Figure 3) based on the classification of disease severity set out in Figure 1 (Scadding et al, 2017).
Antihistamines are recommended as first-line therapy for mild-moderate intermittent allergic rhinitis and for mild persistent allergic rhinitis (Scadding et al, 2017). Oral, intranasal and ocular formulations are available and are most helpful for sneezing, runny nose and itching; they are less effective for nasal obstruction. Non-sedating antihistamines are preferred to avoid adverse effects of somnolence (Bartle et al, 2017) and these are widely available over-the-counter in shops, supermarkets and community pharmacies. Cetirizine and loratadine are the first-line treatment options for children and chlorpheniramine (Piriton) must be avoided. Regular treatment (usually daily) is required to achieve effective symptom control and it is best to begin treatment a week or so in advance of the anticipated commencement of symptoms.
Intranasal steroids are the most effective and appropriate treatment for persistent nasal allergy symptoms, particularly nasal obstruction (Scadding et al, 2017). They reduce nasal inflammation and hypersensitivity. However, treatment failure is common, usually due to poor concordance and poor technique (see Box 1 for tips when teaching children to use intranasal steroids). All intranasal steroids are effective but drug bioavailability varies; systemic bioavailability is lowest with mometasone and fluticasone (Scadding et al, 2017) – an important consideration for children taking other steroids, eg for asthma and/or eczema.
Box 1.Simple intranasal spray technique
- Blow nose, shake the bottle and remove the cap
- Look towards the floor
- Using the right hand insert the nasal spray just inside the left nostril and spray once – breathe in or sniff very gently (baby bunny rabbit sniff)
- Repeat using the left hand to insert the spray in the right nostril
- Dab any drips away – do not blow nose
Remember the purpose of treatment is to wet the lining of the nose with the nasal sprayAdverse effects such as unpleasant sensation at the bridge of the nose or a nasty taste in the mouth indicate poor techniqueIntranasal steroids need to be taken daily and may take up to 2 weeks to be fully effective
Sodium cromoglicate eye drops are helpful for children who continue to experience ocular symptoms despite regular antihistamine with or without intranasal steroid.
A combination of antihistamine and intranasal steroids may be needed to achieve symptom control. Additional options if control is difficult to achieve include:
- Ipratropium nasal spray
- Antileukotrienes
- Oral steroids.
Conclusion
Allergic rhinitis affects the health, wellbeing and quality of life in children and young people, and practice nurses are ideally placed to reduce their symptom burden. Opportunities such as asthma reviews enable practice nurses to assess allergy symptoms and support management with appropriate treatment plans, education and advice. Non-pharmacological and pharmacological strategies combine to form the overall approach to managing allergic rhinitis and improving outcomes for children and young people.
RESOURCES
Useful web resources
- National Paediatric Respiratory and Allergy Nurses Group (NPRANG): www.nprang.co.uk
- Allergy UK: https://www.allergyuk.org/
- British Society of Allergy and Clinical Immunology: https://www.bsaci.org/
- Asthma UK: https://www.asthma.org.uk/
- Asthma UK – how to use a nasal spray video: https://www.asthma.org.uk/advice/inhaler-videos/nasal-spray/
- Primary Care Respiratory Society: www.pcrs-uk.org
Courses:
- Paediatric Asthma Advancing Care: https://rotherhamrespiratory.com/
- Allergy Academy: http://www.allergyacademy.org/home
KEY POINTS:
- Allergic rhinitis is a common disease in children and young people
- It places considerable burden on the lives of children and their families
- Allergic rhinitis is strongly linked with asthma in children and young people
- Practice nurses are ideally placed to help children to gain control of and manage their symptoms
- Effective management combines both pharmacological and non-pharmacological approaches
CPD reflective practice:
- How can allergic rhinitis impact on the lives of children and young people?
- What non-pharmacological management methods could you recommend to your patients in combination with pharmacological measures?
- Do you adequately teach intranasal spray technique to your patients? Where could you find resources to help with this?
- How will this article impact on your future practice?