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Allergic rhinitis (Hay fever)

The following pre-referral guideline covers allergic rhinitis (hay fever) for children of all ages.

Initial work-up

Symptoms

Similar to those of common URTIs. Think allergic rhinitis if:

• Continuous/recurrent URTIs.
• Frequent sore throats.
• Hoarse voice.
• Persistent mouth breathing.
• Persistent throat clearing.
• Snoring.
• Feeling pressure over sinuses.
• Recurrent headaches.
• Recurrent middle ear infections.
• Coughing (especially those who habitually cough soon after lying down at night).
• Halitosis.
• Poor sleep and daytime fatigue or poor concentration.
• Loss of sense of smell.
• Persistent respiratory symptoms despite stable, well controlled asthma, appropriate treatment and good lung function.

Rule out -

• Non allergic causes of rhinitis (e.g. vasomotor rhinitis, bacterial and viral infections, sinusitis).
• Overuse of decongestant sprays (less common).
• Tumours or vocal chord dysfunction (rare).

History

• History of other allergic disease (e.g. atopic eczema/asthma).
• Family history of allergic disease.
• History of symptoms - onset, duration and pattern of symptoms.
• Systemic symptoms (e.g. daytime fatigue).
• Triggering and relieving factors.
• Use of medication, adherence and response.
• Physical examination (nose, throat, eyes and ears. Look for nasal polyps - presents with congestion and loss of sense of smell).

Diagnostics

• RAST test to assess for specific allergy if history indicates (e.g. cat, dust mite, grass pollen).

Notes

Seasonal allergic rhinitis

• Seasonal allergic rhinitis or hay fever is due to pollen allergy.
• Australia - grass pollens most common.
• Tree and weed pollens also.
• Symptoms start abruptly in spring and continue for a variable time, depending on the geographical area.
• Syptoms are worse out doors.

Perennial allergic rhinitis

• Perennial allergic rhinitis is usually due to house dust mite allergy.
• Symptoms are often worse at night or early in the morning.
• Also cat and other animal danders.
• Mould and cockroaches (although less common in Australia).

Pre-referral assessment/treatment

Topical corticosteroid nasal spray (ICNS)

• First line treatment for perennial and seasonal allergic rhinitis.
• Take for 2 weeks before maximum benefit is achieved.
• Continue for a minimum 3-6 months. This should be continuous treatment.
• Treatments:
  • Nasonex - children over 3 years (mometasone furorate, on prescription).
  • Rhinocort - children over 6 years (budesonide, 32mcq over the counter or 64mcq on prescription).
  • Beconase Allergy and Hay fever 24 hours - children over 12 years (fluticasone propionate, on prescription).
• These newer topical corticosteroids have low systemic bioavailability and are generally not associated with systemic effects on the adrenal axis.
• Emphasize correct spray technique (away from septum).
• In seasonal rhinitis, commence spray one month prior to relevant pollen season and continue over the syptomatic period.
• Contraindications for INCS  include severe nasal infections, haemorrhagic diatheses or a history of recurrent nasal bleeding.

Antihistamines

• Less sedating oral antihistamines can be used to manage itching and sneezing or associated eye symptoms. Loratidine (Claratyne) and certirizine (Zyrtec) are suitable for children over one year old, and available as syrup.

Decongestants

• Intranasal and oral decongestants are not recommended and can only be used for short courses.

Nasal irrigation

• Consider nasal irrigation with saline spray.
• 4.5 common salt added to 50ml of boiled water, approximately 1 teaspoon per 600 ml.
• Can be effective in children with allergic rhinitis, possibly due to enhanced cillary function or removal of inflammatory cytokines via mucus clearance.

Allergen avoidance

• Where history and RAST test positive for pet or dust mite, consider allergen avoidance.
• Detailed information on allergen avoidance is available at www.allergy.org.au
• Some avoidance measures are costly (e.g. house dust mite). Confirm diagnosis and causative allergen before recommending expensive/inconvenient avoidance strategies.
• Reassure patients that food allergies do not cause allergic rhinitis. Nasal symptoms in reaction to food (e.g. spicy food, wine) are almost never due to allergy but may indicate irritation or chemical intolerance.
• Rhinitis in response to fumes (e.g. fragrances and paints) is not an allergic reaction.

Think about asthma

• Allergic rhinitis and asthma frequently co-exist and effective treatment of rhinitis can improve asthma symptoms. 

When to refer

RCH Department of Allergy and Immunology

Refer when:

• Medication is ineffective despite 3-6 month trial or causes adverse reaction.
• Allergic rhinitis is complicated by a polyp.
• Allergen desensitization is required.
• Ongoing symptoms despite optimal topical nasal corticosteroid therapy and allergen avoidance.
• Other severe allergic disease also presents (e.g. eczema, food allergy, asthma).
• Refer all children under 3 years old.

Information needed for referral:

• Symptoms (including onset, duration and pattern).
• Treatment given and patient response.
• RAST test result, if performed.
• Details of other allergic disease.
• Presence of asthma yes/no.

Contact information

Resources

• Clinical practice guidelines
• Information booklet
• Parent information website Kids Health Info
• Kids Connect (RCH Primary Care Liaison) www.rch.org.au/kidsconnect
  Contains all referral forms, clinic information, other pre-referral guidelines and parent information.
• Feedback
  We welcome your feedback on this guideline: kids.connect@rch.org.au / tel (03) 9345 4645 / fax (03) 9345 4650.

References

Paediatric Handbook (2003).  Seventh Edition, Blackwell Publishing. By the staff of the Royal Children's Hospital, Melbourne, Australia.

These guidelines were developed by specialists at the Royal Children's Hospital and reviewed by a working group of metropolitan and rural general practitioners in Victoria. Last reviewed in December 2008.

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