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Rhinitis in Children

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					Rhinitis in Young Children


               Hugo Van Bever
                 Singapore




               Cambodia, February 20, 2010.
Cumulative prevalence of rhinitis in
      Singaporean children




   1 - 2 yrs-old   4 - 6 yrs-old   6 – 7 yrs-old   12 – 15 yr-old
   2002 -2003          2000            2001            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
              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

                            Adenoidal hypertrophia
Chronic rhinitis             Otitis (acute - chronic)
                            Sinusitis (acute - chronic)
                                       OSAS




Bronchial hyperreactivity = ASTHMA
Acute sinusitis
                  Chronic sinusitis
Psycho-social impact of allergic rhinitis in children.



             sleep problems (OSAS)

             learning problems

             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 (1st 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


                           ASTHMA      RHINITIS
beclomethasone diprop.      +++          +

budesonide                  +++           -

fluticasone prop.            +            +
Intranasal corticosteroids in preschool
                children


     INDICATIONS

      1. Chronic rhinitis
      2. Chronic sinusitis
      3. Hypertrophia of adenoids
      4. OSAS
Antihistamines = 1st 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


- 1st
chlorpheniramine, clemastine, promethazine,
  hydroxyzine, oxatomide, azatadine, ketotifen, etc…

- 2nd
terfenadine, cetirizine, loratidine, astemizole, etc…

- 3rd
levocetirizine, fexofenadine, desloratidine
Antihistamines - indications
                            level of evidence




1. Allergic rhinitis
2. Urticaria
3. Anaphylactic reactions
4. Eczema (?)
5. Asthma (?)
  Side effects of 2nd generation antihistamines


1. Less central nervous system toxicity

2. Terfenadine and astemizole can cause
 cardiac toxicity in children.
          - Ventricular arrhythmias
          - torsades de pointes
   3rd 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 1st 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 !

				
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