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

When to refer to RCH Department of Allergy and Immunology

• Ongoing symptoms despite optimal topical nasal corticosteroid therapy (see below) and allergen avoidance. (after 3-6 months)
•  Allergen desensitization is required.

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

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

Notes

Seasonal allergic rhinitis

• Seasonal allergic rhinitis or hay fever is due to pollen allergy.
• Australia - grass pollens most common.
• 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.

Pre-referral assessment/treatment

Topical corticosteroid nasal spray (ICNS)

• First line treatment for perennial and seasonal allergic rhinitis.
• Take for 2-4  weeks before maximum benefit is achieved.
• Continue for a minimum 3-6 months. This should be continuous treatment.
• Preparations (in no particular order):
  • Mometasone furorate - children over 3 years (eg. Nasonex, on private prescription).
  • Budesonide - children over 6 years (eg. Budamax, Rhinocort, 32mcq over the counter or 64mcq on PBS  prescription).
  • Fluticasone fluroate -children over 12 years (eg: Avamys - on private prescription).
  • Beclomethasone dipropionate-children over 6 years (eg: QVar, on PBS script)
  • Triamcinolone acetonide-children over 12 years (eg: Telnase- over the coucnter)
• 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). - video of how to use a nasal spray  - written information on nasal spray technique
• 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.
• 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 blood IgE 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. 

Contact information

Resources

• Asthma clinical practice guidelines
• Parent information Hay fever
• Feedback We welcome your feedback on this guideline: kids.connect@rch.org.au / tel (03) 9345 4645 / fax (03) 9345 4650.

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 August 2014.

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