Pediatric Allergic Rhinitis Clinical Presentation

The history of the patient with allergic rhinitis (AR) may be straightforward or may include a complex set of symptoms. The diagnosis is easy to make in a patient with a new pet or with symptoms that have distinct seasonal variation. Alternatively, younger patients may present with varying signs or symptoms, the family may not appreciate the nasal stuffiness but may note the chronic nasal congestion. In older children, symptoms may have been present for years and, therefore, appear to be less severe because the child has accommodated them.

Physicians should try to identify seasonal variations, provocative elements in the environment, and the timing of events that lead to symptoms. For example, if the patient only has issues during the week, this may lead to investigating the environment of the child's classroom or daycare for allergens like pets or molds. Few patients present soon after the onset of AR symptoms. Usually, AR symptoms have been present for years and have been slowly worsening during each allergy season.

This is especially true for patients with pet allergies. The symptoms appear slowly, over years. They can worsen in the spring and fall and be confused with pollen allergy. This occurs for pets usually shed more in the warmer weather and then in the fall when more time is spent indoors with worsening symptoms. Also, many families believe that the fact that the pet was present before the onset of the child's symptoms exclude the possibility of allergy to the family pet, but this is not true. The family often believe that the family pet is hypoallergenic. No cats or dogs are truly hypoallergenic. Some pets trigger less allergic symptoms in some individuals. In addition, dander exposure is crucial in triggering symptoms. Therefore, a large home without carpeting and a small pet will probably trigger less severe symptoms than a large pet in a small house. An interesting phenomenon is what is referred to as the "Thanksgiving effect," which is when a child goes off to college and returns home for Thanksgiving to discover that their family pet, which  did not previously trigger allergy symptoms, now does in fact trigger them. This is because the individual's mast cells have had a chance to no longer be saturated with pet dander and can now degranulate. This situation may also occur when a child is away from a pet for a shorter period of time (several days).

Unless a new exposure to large amounts of allergens is reported (eg, pet, feather pillow), a patient who describes a sudden onset of nasal allergy symptoms is probably not experiencing allergic symptoms. Sudden onset of nasal symptoms is often associated with either an upper respiratory tract infection or acute sinusitis or acute bacterial sinusitis superimposed on chronic sinusitis. In children younger than 5 years, differentiating allergy symptoms from recurrent upper respiratory viral infection is even more difficult, especially in those who attend daycare and experience frequent rhinitis symptoms.

Nature of symptoms

Symptoms of rhinitis consist of rhinorrhea, nasal congestion, postnasal drainage, repetitive sneezing, and itching of the palate, ears, nose, or eyes. Snoring, frequent sore throats, constant clearing of the throat, cough, itchy eyes, and headaches are symptoms often associated with rhinitis.

When obtaining the history, ascertain the following:

• Determine which symptoms are reported by the patient or parent

• Ask if symptoms occur in different locations

• Determine whether the patient has rhinorrhea, sniffling, nasal itching, sneezing, cough, congestion, or nasal discharge. Determine the color of the nasal discharge

• Determine whether any associated ocular or respiratory symptoms are present

• Ask about snoring, which may worsen in pollen season or be related to adenoidal hypertrophe

Timing of symptoms

Identify whether symptoms are present or worsen during certain seasons, such as the spring or fall. In addition, try to identify whether symptoms are worse in specific places, such as home, work, school, or on vacation or when the patient is around animals.

Determine when symptoms occur and whether they occur primarily at night, in school, outdoors, or at a relative's or friend's home.

Determine whether symptoms occur only at a certain time of the year or throughout the year. Remember that symptoms in the fall and spring may still indicate a pet allergy.

Determine whether symptoms ever improve and, if so, what actions help alleviate symptoms. Most patients have tried over-the-counter antihistamine medication. If these medications help, AR should be suspected; however, a negative response does not eliminate the possibility of AR. Ask if the patient's symptoms improve when they are away from certain locations. For example, a child who has less symptoms at college or camp may have an allergy to the family pet, feather pillows, or dust mites in their bedding.

Determine whether symptoms improve when the patient is taking antibiotics. Most patients receive antibiotics for various reasons unrelated to nasal symptoms. If symptoms respond to antibiotic therapy, the clinical diagnosis may be sinusitis, which may have been either primary sinusitis or secondary sinusitis caused by allergic rhinitis.

Duration of symptoms

Determine whether symptoms last for weeks, months, or hours.

Most pollen seasons are at least 6 weeks long in more moderate climates. In the south and far north, the season can be longer or shorter, respectively. Symptoms that last less than 2 weeks rarely indicate AR, unless concomitant exposure occurs. For example, a child only allergic to one type of tree could have 2 weeks of exposure, but this is less common.

In winter in the northern regions, virtually all outdoor pollens are absent; therefore, any AR–like symptoms are the result of indoor allergen exposure or are associated with nonallergic causes. Although patients are usually exposed to the same allergens throughout the year, AR symptoms triggered by indoor allergens can worsen in winter secondary to longer hours spent indoors during the cold months. This may also be associated with closed windows and doors in winter, resulting in increased recirculation of indoor allergens. An example of winter-only exposure is a person who is allergic to dust mites who uses a down comforter only during the winter (dust mites are highly infested in a down comforter.), also a patient with adenoidal hypertrophy may be worse in the winter due to lower ambient humidity leading to more nasal irritation. Nasal symptoms can also be worse in the winter due the dryness of the air that is found in forced air heat. Now, with most homes being more tightly sealed and kept at warmer temperatures, the use of a fan in the winter is more common. The use of a fan increases overall dryness for it blows warm, dry air.

Family history

Children with parents who have allergies or asthma are more likely to be affected.

If a child has one parent with allergies, chances are 30% that a child will have AR. This increases to 50–70% if both parents have allergies or atopic asthma.

Related medical history

Patients with a history of infantile eczema (atopic dermatitis) have a 70% chance of having AR, asthma, or both. Patients with a history of asthma also have higher incidence of AR.

Social and environmental history

The patient's environment is very important. Ask about the presence of a pet or beddings (eg, pillow, bedspread, comforter [especially containing feathers]) and other home items likely infested by dust mites (eg, carpeted floor, stuffed animals, dusty closet, nonleather furniture) as well as the timing of initial exposure. Many times, exposure to dust, feathers, or pets coincides with the onset of symptoms, making diagnosis and treatment easier. However, patients could become sensitized to indoor allergens by exposure in places other than the home where they spend a fair numbers of hours (eg, schools, daycare center, baby sitters' and relatives' homes). Cigarette smoke can also be an irritant and trigger symptoms, so the presence of a smoker in the home can also play a part in the child's symptoms.

Questions must be raised regarding any environment in which the patient spends more than a few hours per week. This includes baby-sitters' and relatives' homes, daycare facilities, and schools (classroom pets).

For children younger than 3 years, ask about the child's bed. Cribs or toddler beds that use crib mattresses do not have dust mites because these mattresses rountinely have plastic covers, but standard bedding (bed mattress) can harbor dust mites.

A full examination should always be performed to detect other diseases, such as asthma, eczema, adenoidal hypertrophy, and cystic fibrosis, which occur in connection with allergic rhinitis (AR). Evaluation involves the head, eyes, ears, nose, and throat. Upon inspection, signs described below can be noted.

Head

Allergic shiners (dark, puffy, lower eyelids) may be present (see image below).

Morgan-Dennie lines (lines under the lower eyelid) may be observed.

Transverse crease at the lower third of the nose secondary to the allergic salute (shown below), which is the upward rubbing of the nose, is commonly seen in parents as well.

Eyes

Marked erythema of palpebral conjunctivae and papillary hypertrophy of tarsal conjunctivae are observed. Chemosis of the conjunctivae may be present. Patients usually have a watery discharge.

Cataracts have occurred from severe rubbing secondary to itching.

Ears

Tympanic membranes should be examined for the presence of chronic infection or middle ear effusion.

The role of AR in chronic otitis media is not clear, but decreased numbers of infections have been noted in AR children once therapy was instituted.

Nose

Nasal examination is often helpful in the diagnosis.

Turbinates are enlarged and have a pale-bluish mucosa due to edema.

Discharge is usually clear but can be white. The discharge is rarely yellow or green. If colored discharge is observed, a diagnosis of viral infection or sinusitis should be considered.

Dried blood is commonly observed secondary to trauma from rubbing the nose.

Polyps are rarely observed in children. If polyps are noted or suspected, perform rhinoscopy. If polyps are detected, a workup for cystic fibrosis is mandatory in children. Also consider the diagnosis of aspirin sensitivity in adults.

Throat

Inspection of the dentition can be informative. Discoloration of frontal incisors and a high arched palate are associated with chronic mouth breathing. Malocclusion is commonly associated with chronic mouth breathing.

Cobblestoning in the posterior pharynx is also a sign of follicular hypertrophy of mucosal lymphoid tissue secondary to chronic nasal congestion and postnasal drainage.

Note the size of tonsillar tissue, which may provide a clue to the size of the adenoids; large adenoids (adenoidal hypertrophy) can mimic the signs and symptoms of AR. Chronic nasal congestion due to adenoid hypertrophy is frequently seen in young children with recurrent otitis media and sinusitis.

Perennial symptoms are usually caused by indoor allergens, including the following:

• Dust mites

• Cat dander

• Dog dander

• Indoor molds

• Cockroaches

• Feathers: In most occasions, feather pillows and comforters are highly allergenic, secondary to dust mite infestation. Nonfeathered bedding usually has less dust mite infestation but does have progressively more dust mites over time; dust mites lay eggs every 3 weeks and accumulate where human dander accumulates. Thus nonwashable beddings (eg, pillows, bed mattress) should be encased by dust mite–proof encasings.

• Other furry animals

Seasonal symptoms are usually caused by airborne pollen and outdoor molds, which are usually highest in late afternoon and early morning hours. These allergens include the following:

• Tree pollen

• Grass pollen

• Outdoor mold spores

• Weed pollen: Flowers do not cause allergic rhinitis because they do not use wind-borne pollination.

See the list below:

• Primary complications of allergic rhinitis (AR) are associated diseases.

• Sinusitis is a common complication occurring secondary to the inflamed nasal turbinates that block the ostiomeatal complex of the sinuses and other sinus passages.

• Recurrent or chronic otitis media can also be a secondary complication. It is thought to occur as a result of an inflamed nasal passages that adversely affect the drainage of the auditory tube.

• AR can lead to rhinitis medicamentosa when topical nasal decongestants are used in excess.

• AR can cause other conditions, such as insomnia, irritability, headache, chronic fatigue, and pharyngitis. These occur secondary to chronic nasal congestion and discharge, mouth breathing, and sleep disturbance.  It was reported that uncontrolled allergic rhinitis can exacerbate symptoms of ADHD, tic disorder, anxiety and OCD.