Allergic Rhinitis in Childhood and the New EUFOREA Algorithm

Abstract

Allergic rhinitis in childhood has been often missed, mistreated and misunderstood. It has significant comorbidities, adverse effects upon quality of life and educational performance and can progress to asthma or worsen control of existing asthma. Accurate diagnosis and effective treatment are important. The new EUFOREA algorithm provides a succinct but wide- ranging guide to management at all levels, based on previous guidelines with updated evidence and has been adjusted and approved by experts worldwide.

Keywords: allergen specific immunotherapy; antihistamines; asthma; fixed dose combinations; intranasal corticosteroids; pediatric allergic rhinitis; sleep.

Figure 1

The burden of allergic rhinitis in children aged 6–15 years. Moderate to severe rhinitis and poor symptom control cause over 6 unhealthy days per month. Reproduced from Bosnic-Anticevich S et al. Impact of allergic rhinitis on the day-to-day lives of children: insights from an Australian cross-sectional study. BMJ Open. (2020) 10:e038870. doi: 10.1136/bmjopen-2020-038870, with permission. *Unhealthy days = number of days of poor emotional health and number of days of poor physical health combined. ^† Statistically significant difference between groups for each metric (healthy days and unhealthy days).

Figure 2

The gradual increase in the incidence of rhinitis symptoms and co- morbidities in the the German Multicentre Allergy Study (MAS), which began in 1990 in five German cities and included 1,314 newborns for the study of the natural course of atopic diseases (26, 27).

Figure 3

Development of molecular IgE responses of children who developed grass pollen allergy in the first decade of life. Sequential blood samples were obtained in the preclinical phase as well as during the first 5 years with seasonal symptoms. Children were part of the prospective birth cohort study MAS (29).

Figure 4

This child shows typical facial changes associated with allergy: he is pale, mouth breathing, with dark circles beneath eyes, a transverse nasal crease, double eye creases and loss of the lateral eyebrow. He is seen giving an allergic salute in the right-hand photo.

Figure 5

The EUFOREA management algorithm for pediatric allergic rhinitis. This includes measures common to all sufferers and provides a graduated guide to therapy based upon symptoms and their response to therapy. A pictorial visual analog scale is suggested, with poor control being indicated by the two sad faces shown. This requires verification.

Figure 6

How to use a nasal spray. It is necessary to put the spray onto the lateral walls of the nose, not the septum. It should not be sniffed back hard into the nose but should be moved slowly by mucociliary clearance over the nasal mucosa where the corticosteroid can enter epithelial cells to exert its effects. From Scadding et al. (12), with permission.

Figure 7

A suggested visual analog scale, using emojis, for younger children to express their feelings about their symptoms.

Figure 8

Outcome measures in the GAP study (65) show a reduction in asthma symptoms, medication use and FEV1 reversibility in children with grass pollen allergy who were treated by sublingual immunotherapy (SLIT) to grass pollen, compared to those who received placebo.