Allergic rhinitis affects the duration of rapid eye movement sleep in children with sleep-disordered breathing without sleep apnea

Allergic Rhinitis and Its Effect on Sleep

Allergic rhinitis (AR) is associated with increased sleep disturbances in adults and children. Pathogenesis is multifactorial, with nasal obstruction playing a large role. Intranasal corticosteroids, antihistamines, leukotriene inhibitors, and allergen immunotherapy have been demonstrated to relieve self-reported symptoms of sleep impairment. Given the high prevalence of sleep impairment in AR, providers should consider evaluating any patient with AR for sleep disturbances and sleep-disordered breathing.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Allergic rhinitis and sleep disorders in children - coexistence and reciprocal interactions

OBJECTIVE

To review, critically analyze and synthesize knowledge from the international literature regarding the association between allergic rhinitis (AR) and sleep disorders, the impact of AR treatment on children's sleep, and lay the foundation for future research on this topic.

SOURCE OF DATA

A literature search using PubMed database including original and review articles, systematic reviews and meta-analyses using keywords related to AR, sleep disorders and sleep-disordered breathing.

SYNTHESIS OF DATA

Sleep is fundamental to health, and its assessment and control of conditions that trigger or aggravate disturbances are of the uttermost importance. Allergic rhinitis (AR) is common in children and may interfere with both their quality of life and quality of sleep. It has emerged as one of the most important risk factors for habitual snoring in children and appeared to increase the risk of Obstructive Sleep Apnea (OSA), with AR severity exhibiting a significant and independent association with pediatric OSA severity. However, in some studies, those associations between AR and OSA in children are not very consistent.

CONCLUSIONS

A substantial level of controversy exists regarding the interactions between AR and OSA in children. Notwithstanding, identifying and treating AR in clinical settings is probably an important step toward improving symptoms and preventing deterioration of sleep quality in children and may improve the severity of underlying OSA. Considering the high prevalence, morbidity, economic and social implications of both AR and sleep problems, it is crucial that healthcare providers improve their understanding of the relationships between those conditions among children.

Rhinologic disease and its impact on sleep: a systematic review

BACKGROUND

Rhinologic disease can be responsible for systemic symptoms affecting mood, cognition, and sleep. It is unclear whether sleep disturbance in specific rhinologic disorders (chronic rhinosinusitis [CRS], rhinitis, and nasal septal deviation [NSD]) is an obstructive phenomenon or due to other mechanisms. In this review we examine the impact of CRS, rhinitis, and NSD on objective and subjective sleep outcome metrics and draw comparisons to normal controls and patients with known obstructive sleep apnea (OSA).

METHODS

A systematic review of 4 databases (PubMed, Scopus, Cochrane Library, and Web of Science) was performed. Studies reporting on objective (apnea-hypopnea index [AHI], respiratory disturbance index [RDI], oxygen nadir) and subjective (Epworth Sleepiness Scale [EpSS], Pittsburgh Sleep Quality Index [PSQI], Fatigue Severity Scale [FSS]) sleep parameters and disease-specific patient-reported outcome measures (PROMs; 22-item Sino-Nasal Outcome Test [SNOT-22], Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ], Nasal Obstruction Symptom Evaluation [NOSE]) were included.

RESULTS

The database search yielded 1414 unique articles, of which 103 were included for analysis. Baseline PROMs were at the high end of normal to abnormal for all 3 conditions: EpSS: CRS (9.8 ± 4.0), rhinitis (9.7 ± 4.3), and NSD (8.9 ± 4.6); and PSQI: CRS (11.0 ± 4.5), rhinitis (6.1 ± 3.7), and NSD (8.6 ± 3.5). Objective measures demonstrated a mild to moderate OSA in the studied diseases: AHI: CRS (10.4 ± 11.5), rhinitis (8.6 ± 8.8), and NSD (13.0 ± 6.9). There were significant differences when compared with reported norms in all measured outcomes (p < 0.001).

CONCLUSION

Sleep quality is impacted by rhinologic (CRS, rhinitis, NSD) disease. There is likely a mild obstructive component contributing to poor sleep, but other contributing factors may be involved.

Analysis of the impact of allergic rhinitis on the children with sleep disordered breathing

OBJECTIVES

We assessed the influence of allergic rhinitis (AR) on sleep disordered breathing (SDB) in children with adenotonsillar hypertrophy (ATH), and compared sleep quality and polysomnographic data in habitually snoring children with or without AR.

METHODS

Children with snoring resulting from adenoid/tonsils hypertrophy were recruited between Jan 1st, 2018 and Jun 30th, 2018. The exclusion criteria were congenital disorders, metabolic disorders, neurological disorders and pulmonary diseases, such as, asthma etc. Overnight polysomnography (PSG) and Sleep Questionnaire (SQ) were assessed on each participant to identify children with obstructive sleep apnea (OSA). Cross-sectional study design was used to examine PSG and SQ data. The diagnosis of AR was based upon history of allergies and positive clinical examinations, then confirmed by allergen test. Participants were categorized into four groups (AR and Non-OSA group; AR and OSA group; Non-AR and Non-OSA group; Non-AR and OSA group). Non-parametric rank sum test was used for statistical analysis.

RESULTS

Six hundred and sixty children (age between 3yrs and 14yrs) with SDB were enrolled in the study (mean age 6.7 ± 2.1yrs, 67.4% male). The number of children diagnosed with OSA was 495 (74.3%). The prevalence of AR among all participating SDB children was 25.8%, and AR with OSA was19.4%. The behavioral problems scores in SQ showed significant difference among SDB children with AR (P<.0001). No difference was observed in the OAHI (obstructive apnea-hypopnea index) and AHI (apnea-hypopnea index) between the groups of children with and without AR regardless whether OSA was coexisting. The percentage of time spent in the rapid eye movement (REM) sleep stage was shortened among children with AR without OSA (P = 0.031), however, the percentage of time spent in the REM sleep stage was not different among children with OSA (P = 0.98). The total sleep time was shorter among children with AR (OSA P = 0.02; without OSA P = 0.03).

CONCLUSIONS

Despite the high prevalence of AR in patients with SDB, AR is not an aggravating factor for the severity of AHI. High risk behavioral problems link to SDB with AR. AR is associated with shortened REM sleep stage in children with SDB without sleep apnea, and shortened total sleep time in children with SDB.

House Dust Mite Related Allergic Rhinitis and REM Sleep Disturbances

PURPOSE

Sleep disturbances are common in patients with allergic rhinitis (AR). Perennial allergens like house dust mites (HDM) are difficult to avoid and have nocturnal impacts on the respiratory system and Quality of Life (QOL). The Rapid Eye Movement (REM) sleep stage is associated with memory, cognition, dreams, and overall restfulness, which can be impaired in AR patients with Sleep Disordered Breathing (SDB) even when normal all-night apnea-hypopnea (AHI) or respiratory disturbance (RDI) indices are noted on polysomnography (PSG). We hypothesized that AR HDM allergen positive patients would show REM-specific SDB reflected in their objectively elevated REM-RDI values.

MATERIALS AND METHODS

This retrospective analysis of 100 patients included 47 with HDM positive allergy testing. All patients underwent PSG testing calculating the RDI during REM. Multivariate logistic regression models evaluated relationships between allergic statuses and sleep parameters while controlling for potential confounders.

RESULTS

Compared with allergy negative patients, HDM allergen positive patients were significantly more likely (OR 4.29, 95%CI 1.26-14.62) to have a REM-RDI in the moderate/severe range (≥15 events/h).

CONCLUSIONS

Our study highlighted the significance of respiratory allergies to HDM in patients with SDB. We revealed a significant relationship between HDM allergen positivity and SDB characterized by elevated REM-RDI regardless of all-night AHI, RDI, or REM-AHI values. Clinical implications of knowing about disturbed REM and/or HDM allergenicity include better preparation, treatment, outcomes, and QOL for allergic, SDB, and upper airway surgery patients.

Clinical symptoms and biomarkers of Bermuda grass-induced allergic rhinitis using the nasal allergen challenge model

BACKGROUND

Bermuda grass is a prevalent allergen that flourishes in tropical climates. Its exposure is traditionally believed to be low in Ontario due to the colder environment. However, high sensitization rates have been observed in Kingston, Ontario.

OBJECTIVE

We sought to investigate whether its allergens can provoke allergic rhinitis (AR) symptoms in sensitized participants from south-eastern Ontario and determine if nasal allergen challenge (NAC) model is appropriate to study Bermuda grass-induced AR.

METHODS

Twenty-one participants sensitized to Bermuda grass and 12 nonallergic participants completed a titrated NAC with increasing allergen concentrations at a screening visit. Total nasal symptom score (TNSS) and peak nasal inspiratory flow were collected before allergen exposure and 10 minutes after delivery of each concentration. Twelve participants with a Bermuda grass allergy who met the qualifying criteria (TNSS ≥ 8 and peak nasal inspiratory flow fall ≥ 50%) and 11 nonallergic controls returned for single-dose NAC visit.

RESULTS

At titrated NAC, 19 of 21 sensitized participants met the criteria of positive allergic response when challenged. During single-dose NAC, participants with allergy had significantly greater TNSS between 15 minutes and 3 hours after NAC than controls. Likewise, allergic participants had a significantly increased number of nasal lavage eosinophils at both 1 and 6 hours after NAC. Bermuda grass-specific immunoglobulin E was significantly increased in Bermuda grass allergic participants at NAC than screening visit.

CONCLUSION

Although Bermuda grass is a non-native allergen in Ontario, it can induce AR symptoms in sensitized participants, and the NAC model is appropriate to study Bermuda grass-induced AR.

Cognitive and Quality of Life-Related Burdens of Illness in Pediatric Allergic Airway Disease

OBJECTIVE

To analyze the prevalence of pediatric allergic airway disease (PAA) and recognize its impact on cognitive function, childhood activities, use of early intervention, and missed school days.

STUDY DESIGN

Cross-sectional analysis of National Health Interview Survey (NHIS), 2014 to 2017.

SETTING

US households.

SUBJECTS AND METHODS

An NHIS survey of US children and responding caregivers was analyzed to determine the prevalence of PAA, including allergic rhinitis and allergic asthma. Associations were determined between the presence of PAA and activities limited by difficulty remembering, limitation in the amount of childhood play, use of special education/early intervention, and number of missed school days in the past 12 months. Multivariate analysis was used to adjust for age, sex, race, ethnicity, and income level.

RESULTS

An estimated 11.1 million (10.6-11.6 million, 95% confidence interval) children (mean age, 9.9 years; 56.9% male) reported a diagnosis of PAA (15.1% [14.6-15.6%]). Children with PAA missed 4.0 (3.7-4.4) school days per year vs 2.2 (2.1-2.4) days for those without PAA (P < .001, adjusted). PAA was associated with limited daily activities due to difficulty with memory (odds ratio, 1.8 [1.2-2.9]), limitations in childhood play (3.2 [2.2-4.7]), and need for special education/early intervention services (1.6 [1.4-1.8]) after adjusting for age, sex, race, ethnicity, and income level.

CONCLUSION

PAA is a common condition and is associated with declines in cognitive function and school attendance as well as increased use of special education/early intervention. Given the significant prevalence and burden of illness of PAA, further attention is needed to ensure timely diagnosis and treatment.

Risk Factors for Obstructive Sleep Apnea Syndrome in Children: State of the Art

The obstructive sleep apnea syndrome (OSAS) represents only part of a large group of pathologies of variable entity called respiratory sleep disorders (RSD) which include simple snoring and increased upper airway resistance syndrome (UARS). Although the etiopathogenesis of adult OSAS is well known, many aspects of this syndrome in children are still debated. Its prevalence is about 2% in children from 2 to 8 years of age, mostly related to the size of the upper airways adenoid tissue. Several risk factors linked to the development of OSAS are typical of the pediatric age. The object of this paper is to analyze the state of the art on this specific topic, discussing its implications in terms of diagnosis and management.

Association of allergic rhinitis with obstructive sleep apnea: A meta-analysis

BACKGROUND

The co-existence of allergic rhinitis (AR) and obstructive sleep apnea (OSA) is a common phenomenon in clinical practice. AR has long been considered a risk factor for OSA. However, the relationship is not completely clear. Therefore, we conducted a meta-analysis to evaluate the prevalence of AR in sleep-disordered breathing (SDB) /OSA and their relationship.

METHODS

A comprehensive literature search was performed in PubMed/Medline, Google Scholar, Wiley Online Library, EMBASE, and Web of Science. Data were analyzed and pooled to estimate effect size (ES) /odds ratio (OR) with 95% confidence intervals (95%CI). Heterogeneity was quantified and evaluated by chi-squared-based Q-test and I2 test, with P < .05 and I > 50% indicating evidence of heterogeneity.

RESULTS

44 studies contained 6086 participants were included in this meta-analysis. For adults, the prevalence of AR was 22.8 (95% CI, 15.0-30.6) % in SDB and 35.2 (95% CI, 25.6-44.7) % in OSA. In children with SDB and OSA, the prevalence of AR was 40.8 (95% CI, 24.3-57.2) %, and 45.2 (95% CI, 25.4-65.0) % respectively. The odds ratios of prevalence of the SDB pediatric patients with AR was 2.12 (95%CI, 1.75, 2.57; P < .0001) times higher than that of non-SDB pediatric patients. There were no significant differences between OSA adults with or without AR in BMI (Body Mass Index), neck circumference, apnea hypopnea index (AHI) and epworth sleep scale score (ESS).

CONCLUSION

The prevalence of AR in OSA/SDB is considerably high and children with SDB suffering from a higher incidence of AR than non-SDB. OSA adults accompanied with AR do not have any influences on sleep parameters.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Association of Asthma and Allergic Rhinitis With Sleep-Disordered Breathing in Childhood

Objective: Asthma and allergic rhinitis (AR) are the most common chronic conditions in childhood and have previously been linked to sleep-related breathing disorder (SRBD). Aim of the study was to examine the association between SRBD risk and asthma control in children with asthma and with or without AR. Methods: The assessment of FeNO and pulmonary function tests were performed in 140 children (65 with asthma, 57 with both asthma, and AR, 18 with only AR). Children with asthma completed the childhood Asthma Control Test (c-ACT), and the Sleep-Related Breathing Disorder scale, extracted from the Pediatric Sleep Questionnaire (PSQ). C-ACT scores ≤ 19 are indicative of poor asthma control whereas SRBD from PSQ scores ≥ 0.33 are suggestive of high risk for SRBD. Results: Mean age ± SD was 7.8 ± 3.1 years. Mean PSQ ± SD and c-ACT ± SD scores were 0.17 ± 0.14 and 24.9 ± 3.2, respectively. High risk for SRBD was identified in 26 children. Children at high risk for SRBD had significantly decreased c-ACT score (P = 0.048), verified by a negative association between c-ACT and PSQ-SRBD scores (r = -0.356, P < 0.001). Additionally a difference in diagnosis distribution between children at high or low risk for SRBD was observed. More specifically, among children at high risk, 88.5% were diagnosed with both atopic conditions, while this percentage among children at low risk was 29.8%. Asthma was mainly diagnosed in the latter group (P < 0.001). Conclusions: Poor asthma control is associated with SRBD. The presence of AR in children with asthma seems to increase the prevalence of SRBD in that particular population, requiring further investigation toward this direction.

Sleep disorders in children with moderate to severe persistent allergic rhinitis

Introduction

Allergic rhinitis is associated with several complications, including sleep disorders. The Children's Sleep Habits Questionnaire has been recently translated and validated in Portuguese for the evaluation of sleep disorders in children.

Objective

To assess sleep disorders in children with moderate to severe persistent allergic rhinitis and to correlate the findings with disease severity markers.

Methods

We evaluated 167 children (4–10 years), 112 with allergic rhinitis and 55 controls. Parents/guardians of the children answered the Children's Sleep Habits Questionnaire, consisting of 33 questions divided into eight subscales, which refers to the previous week. Patients with rhinitis were also evaluated regarding the score of nasal and extra-nasal symptoms related to the previous week and the peak nasal inspiratory flow.

Results

There were no significant differences between groups of different age. All patients with rhinitis were being treated with nasal topical corticosteroids. The total Children's Sleep Habits Questionnaire score was significantly higher among children with rhinitis than in controls (median 48 vs. 43, p < 0.001). Significantly higher values were also observed for the parasomnia (9 vs. 8), respiratory disorders (4 vs. 3) and daytime sleepiness (14 vs. 12) subscales. Among the patients with rhinitis, no significant correlation was observed between the total Children's Sleep Habits Questionnaire score and disease activity variables, but moderate correlations were observed for the respiratory distress subscale vs. nasal symptom score (r = 0.32) and vs. extra-nasal symptom score (r = 0.32).

Conclusion

Children with moderate to severe persistent allergic rhinitis, even when submitted to regular treatment, have a higher frequency of sleep disorders than controls, particularly concerning nocturnal breathing disorders, daytime sleepiness, and parasomnias. The intensity of sleep disorders found in some subscales was correlated with objective markers of allergic rhinitis severity.