What are the causes and treatments of allergic rhinitis in children?

From the Guidelines

Laaerigc rhinitis in children is best managed with a combination of allergen avoidance, medication, and in some cases, immunotherapy, with intranasal corticosteroids being the most effective medication for moderate to severe symptoms. The management of rhinitis should be individualized, considering factors such as the patient's age, symptoms, and comorbidities 1.

Key Considerations

• Identifying and minimizing exposure to triggers such as pollen, dust mites, pet dander, or mold is crucial in managing laaerigc rhinitis in children.
• Medication options include non-sedating antihistamines like cetirizine, loratadine, or fexofenadine, and intranasal corticosteroids like fluticasone propionate, mometasone furoate, or budesonide 1.
• Intranasal corticosteroids are the most effective medication for moderate to severe symptoms, and should be used at the lowest effective dose in children 1.
• Saline nasal irrigation can help clear mucus and allergens, and antihistamine eye drops like ketotifen can be added for eye symptoms.
• If symptoms persist despite these measures for 2-3 months, consider referral to an allergist for possible allergen immunotherapy 1.

Treatment Approach

• The treatment plan should be developed jointly with the patient and family, taking into account the patient's school or work schedule, medication preferences, and realistic goals for environmental modification 1.
• A step-up approach (when therapy is inadequate) or step-down approach (after symptoms relief is achieved or maximized) should be used to adjust the treatment plan as needed 1.
• The selection of pharmacologic agents should be individualized based on the patient's age, symptoms, tolerability of route of administration, overall clinical condition, comorbidities, and concomitant medication 1.
• Oral anti-LT agents, such as montelukast, may be considered as an alternative treatment for patients who are unresponsive to or not compliant with intranasal corticosteroids, or for whom intranasal corticosteroids are contraindicated 1.

From the FDA Drug Label

The efficacy of SINGULAIR for the treatment of seasonal allergic rhinitis in pediatric patients 2 to 14 years of age and for the treatment of perennial allergic rhinitis in pediatric patients 6 months to 14 years of age is supported by extrapolation from the demonstrated efficacy in patients 15 years of age and older with allergic rhinitis as well as the assumption that the disease course, pathophysiology and the drug’s effect are substantially similar among these populations.

The FDA drug label supports the use of montelukast for the treatment of allergic rhinitis in children, including seasonal allergic rhinitis and perennial allergic rhinitis, in patients 2 to 14 years of age and 6 months to 14 years of age, respectively 2.

• Key points:
  • The efficacy of montelukast in pediatric patients is supported by extrapolation from adult data.
  • The safety and effectiveness of montelukast in pediatric patients below the age of 12 months with asthma and 6 months with perennial allergic rhinitis have not been established.
  • Montelukast is available in various formulations, including 4-mg oral granules, 4-mg and 5-mg chewable tablets, and 10-mg film-coated tablets, with different age indications for each formulation 2.

From the Research

Allergic Rhinitis in Children

• Allergic rhinitis (AR) affects a large percentage of pediatric patients, with symptoms including nasal congestion, rhinorrhea, sneezing, and itching of the eyes, nose, and throat 3, 4.
• The treatment of AR in children includes second-generation antihistamines, such as cetirizine, levocetirizine, loratadine, desloratadine, and fexofenadine, which have been found to be relatively safe and effective in reducing symptoms associated with AR in children 3.
• Alternative dosage forms, such as liquids or oral disintegrating tablets, are available for most agents, allowing ease of administration to young children and infants 3.
• Montelukast, a leukotriene receptor antagonist, is also used to treat AR in children, and has been found to be well tolerated with minimal cardiotoxicities 3.

Treatment Options

• Second-generation antihistamines, such as cetirizine, fexofenadine, desloratadine, and loratadine, are commonly used to treat mild intermittent or mild persistent AR in children 4.
• Intranasal corticosteroids, such as fluticasone, triamcinolone, budesonide, and mometasone, are recommended as first-line treatment for moderate to severe AR in children 4, 5.
• Combination therapy of intranasal corticosteroids and oral antihistamines may also be effective in treating AR in children 5.

Safety and Efficacy

• Second-generation antihistamines have been found to be relatively safe and effective in reducing symptoms associated with AR in children, with minimal adverse effects 3, 6.
• However, there are still concerns about the safety profile of antihistamines in children, especially in the first years of life, and many antihistamines are prescribed off-label in this age group 6.
• The safety and efficacy of antihistamines in children should be carefully considered, and treatment should be individualized based on the type, duration, and severity of symptoms, comorbidities, prior treatment, and patient preference 5, 6.