Rhinitis in Young Children Hugo Van Bever Singapore

Rhinitis in Young Children Hugo Van Bever Singapore Cambodia, February 20, 2010.

Cumulative prevalence of rhinitis in Singaporean children 1 - 2 yrs-old 2002 -2003 4 - 6 yrs-old 2000 6 – 7 yrs-old 2001 12 – 15 yr-old 2001

Chronic rhinitis in preschool children - NO DEFINITION (ARIA? ) : not for preschool children = > 1 - 2 months at least 1/2 hr per day (? ) - A SYNDROME a combination of - rhinitis - sinusitis – rhino-sinusitis - adenoidal hypertrophy - dysfunction of Eustachian tube

Chronic rhinitis in asthmatic children 1. INFANTS > 90 % 2. PRESCHOOL CHILDREN 70 % 3. SCHOOL CHILDREN 50 %

Symptoms - nasal congestion (blocked nose) - nasal discharge (runny nose) - sneezing - itch (‘ salut allergique ‘) conjunctivitis

Chronic rhinitis in preschool children ETIOLOGY 1. Hyperreactivity (intrinsic - postviral) (> 60 %) 2. Allergy ( 30 %) 3. Specific diseases (< 1 %) - CF - ciliar dyskinesia - immune deficiency

Allergy in childhood asthma-rhinitis

Allergens 1. House dust mites 2. Cockroaches 3. Pets (dog – cat) 4. Pollen 5. Moulds 6. Food

SPT in young children ( < 3 yrs old) suffering from rhinitis

Chronic rhinitis in preschool children Chronic rhinitis Adenoidal hypertrophia Otitis (acute - chronic) Sinusitis (acute - chronic) OSAS Bronchial hyperreactivity = ASTHMA

Acute sinusitis Chronic sinusitis

Psycho-social impact of allergic rhinitis in children. q sleep problems (OSAS) q learning problems q social problems

Treatment of chronic rhinitis in preschool children 1. Causal treatment (allergic rhinitis) - avoidance of allergens - immunotherapy (SLIT) 2. Symptomatic treatment - nasal washes (saline) - intranasal medication - antihistamines (1 st choice) 3. Chirurgical treatment

Chronic rhinitis in preschool children INTRANASAL MEDICATION 1. saline 2. decongestants 3. cromoglycate 4. levocabastine 5. corticosteroids 1. Limited data in young children (few studies) 2. Young children hate them !

Intranasal medication in young children … a daily fight !!! Low compliance

Treating chronic rhinitis in young children 1. a sweet syrup 2. once daily

The role of SUNC ? ? ?

Singaporean University of Nose Cleaning (SUNC)

Intranasal corticosteroids

Intranasal and intrabronchial corticosteroids in preschool children beclomethasone diprop. ASTHMA +++ budesonide +++ - + + fluticasone prop. RHINITIS +

Intranasal corticosteroids in preschool children INDICATIONS 1. Chronic rhinitis 2. Chronic sinusitis 3. Hypertrophia of adenoids 4. OSAS

Antihistamines = 1 st choice in preschoolers 1. easy to administer (better compliance) 2. effective (studies in preschool children) 3. good safety data ( ETAC, EPAAC)

The 3 generations of antihistamines - 1 st chlorpheniramine, clemastine, promethazine, hydroxyzine, oxatomide, azatadine, ketotifen, etc… - 2 nd terfenadine, cetirizine, loratidine, astemizole, etc… - 3 rd levocetirizine, fexofenadine, desloratidine

Antihistamines - indications level of evidence 1. Allergic rhinitis 2. Urticaria 3. Anaphylactic reactions 4. Eczema (? ) 5. Asthma (? )

Side effects of 2 nd generation antihistamines 1. Less central nervous system toxicity 2. Terfenadine and astemizole can cause cardiac toxicity in children. - Ventricular arrhythmias - torsades de pointes

3 rd generation antihistamines LEVOCETIRIZINE - FEXOFENADINE - DESLORATIDINE 1. Metabolites 2. 24 -hour effectiveness + fast onset 3. Non-sedating 4. No cardiac effects 5. No hepatic metabolism

Antihistamines in children < 3 years 1. Limited number of studies ! 2. No safety studies on 1 st generation antihistamines 3. Association with SIDS ? 4. Safety studies in young children cetirizine - levocetirizine > ketotifen > loratidine 5. Cetirizine has an extensive safety file (ETAC n = 399) (EPAAC n = 255)

Conclusion Management of allergic rhinitis in young children 1. Allergen avoidance impossible 2. Immunotherapy (SLIT) earlier in life (? ) 3. Medication antihistamines 4. Intranasal corticosteroids = daily fight !