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Diagnosis and management of allergic rhinitis and conjunctivitis in children under 18.
Allergic rhinitis affects 30% of the world's population, and 20% of the UK population. Symptoms can adversely affect work, home, and social life .
In children poorly controlled symptoms can cause learning problems and sleep disturbance.
In UK teenagers it is linked to poor national exam performance.
Often co-exists with Asthma. Symptomatic rhinitis is a major risk factor for poor asthma control and exacerbation of symptoms.
Asthma is found in 15-38% of people with allergic rhinitis.
It is categorised as 'seasonal' or 'perennial', and recently as 'intermittent' or 'persistent'.
Allergic rhinitis is mainly seen in children over 2 years old caused by outdoor allergen sensitisation.
Children under 2 years old may have clinically significant sensitisation to indoor allergens e.g. house dust mites, moulds, pets, cockroaches or outdoor allergens if they have significant exposure.
The scope of this pathway does not extend to acute severe rhinosinusitis (common complication of rhinitis) and the management of this condition is not considered.
Two or more of the following for more than one hour per day on a recurrent or persistent basis:
Rhinitis may be accompanied by symptoms affecting eyes, ears, sinuses, throat and chest
Ask for triggers:
Unilateral symptoms, polyps, persistent purulent discharge or blood staining etc.
Secondary care referral for acute severe rhinosinusitis
Should be treated with oral non-sedating antihistamines at doses up to twice BNF maximum dose for effective treatment of rhinorrhoea
Note - may need doses twice BNF maximum. For optimal results should be given continuously or prophylactically (e.g. 2 weeks before the pollen season).
Add intranasal corticosteroids especially with nasal blockage (good safety data for long term use in children)
Systemic corticosteroids (in addition to intranasal corticosteroid) at doses of 15-20mg for maximum of 5 days. Can be used for severe symptoms uncontrolled on conventional therapy, or to control symptoms during important periods (e.g. exams or other major events).
Topical sodium cromoglicate eye drops are useful in allergic conjunctivitis. See section 11.4 Corticosteroids and other anti-inflammatory preparations
Consider a concomitant diagnosis of asthma and manage according to guidelines.
Treatment failure should prompt a review of the diagnosis and compliance with therapy (regular therapy is more effective than "as required" treatment).
For more information see:
Refer red flags to ENT – see red flag section.
There is no need to refer patients with rhinitis due to an obvious cause e.g. grass pollens, and who are responding to regular antihistamines.
Refer if persistent allergic rhinitis of uncertain cause, and those with troublesome symptoms not responding to optimal treatment
e-Referral Service Selection
This guideline has been signed off by South Devon and Torbay CCG
Publication date: August 2017