Current and future directions in pediatric allergic rhinitis

Allergic Rhinitis

Allergic rhinitis (AR) affects more than 400 million people worldwide, making it 1 of the most prevalent chronic diseases. Childhood AR is increasing, and almost half of patients with AR develop symptoms before age 6 years. Although a diagnosis of AR is associated with higher socioeconomic status, underserved and urban populations have more indoor aeroallergen sensitizations and are likely underdiagnosed with AR, further exacerbating health-care disparities. AR negatively impacts quality of life, school performance, and overall health outcomes. Untreated AR in children increases the risk for poor asthma control, increased asthma severity, and exacerbations. Many patients believe that they have seasonal allergies only but in reality have both perennial and seasonal AR, which may change the approach to allergen avoidance measures and treatment recommendations. Pharmacotherapy of AR has expanded, with many intranasal corticosteroids, intranasal antihistamines, and second-generation oral antihistamines approved for pediatric use. Allergen immunotherapy, including both subcutaneous and sublingual forms, are approved for children and are disease modifying, potentially reducing further allergen sensitization and progression to asthma. Many of the currently available biological therapies indicated for pediatric asthma and/or atopic diseases reduce AR symptoms as well. Children with moderate to severe or refractory AR or those with comorbidities should be referred to allergists for diagnostic testing and expanded management options, including immunotherapy and potential biological treatment.

Association Between Exposure to Outdoor Artificial Light at Night and Sleep Disorders Among Children in China

IMPORTANCE

Healthy sleep has an important role in the physical and mental health of children. However, few studies have investigated the association between outdoor artificial light at night (ALAN) and sleep disorders in children.

OBJECTIVE

To explore the associations between outdoor ALAN exposure and sleep disorders in children.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study, part of the National Chinese Children Health Study, was conducted from April 1, 2012, to June 30, 2013, in the first stage and from May 1, 2016, to May 31, 2018, in the second stage in 55 districts of 14 cities in China. This analysis included 201 994 children and adolescents aged 2 to 18 years. Data were analyzed from February 20 to March 21, 2022.

EXPOSURES

Outdoor ALAN exposure (in nanowatts per centimeters squared per steradian) within 500 m of each participant's residential address obtained from the satellite imagery data, with a resolution of approximately 500 m.

MAIN OUTCOMES AND MEASURES

Sleep disorders were measured by the Chinese version of the Sleep Disturbance Scale for Children. Generalized linear mixed models were used to estimate the associations of outdoor ALAN with sleep scores and sleep disorders.

RESULTS

The study included 201 994 children and adolescents (mean [SD] age, 11.3 [3.2] years; 106 378 boys [52.7%]), 7166 (3.5%) of whom had sleep disorder symptoms. Outdoor ALAN exposure of study participants ranged from 0.02 to 113.48 nW/cm2/sr. Compared with the lowest quintile (Q1) of outdoor ALAN exposure, higher quintiles of exposure (Q2-Q5) were associated with an increase in total sleep scores of 0.81 (95% CI, 0.66-0.96) in Q2, 0.83 (95% CI, 0.68-0.97) in Q3, 0.62 (95% CI, 0.46-0.77) in Q4, and 0.53 (95% CI, 0.36-0.70) in Q5. Higher quintiles of exposure were also associated with odds ratios for sleep disorder of 1.34 (95% CI, 1.23-1.45) in Q2, 1.43 (95% CI, 1.32-1.55) in Q3, 1.31 (95% CI, 1.21-1.43) in Q4, and 1.25 (95% CI, 1.14-1.38) in Q5. Similar associations were observed for sleep disorder subtypes. In addition, greater effect estimates were found among children younger than 12 years.

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that sleep disorders are more prevalent among children residing in areas with high levels of outdoor ALAN and the associations are generally stronger in children younger than 12 years. These findings further suggest that effective control of outdoor ALAN may be an important measure for improving the quality of children's sleep.

Allergic Rhinitis: A Clinical and Pathophysiological Overview

Allergic rhinitis (AR) represents a global health concern where it affects approximately 400 million people worldwide. The prevalence of AR has increased over the years along with increased urbanization and environmental pollutants thought to be some of the leading causes of the disease. Understanding the pathophysiology of AR is crucial in the development of novel therapies to treat this incurable disease that often comorbids with other airway diseases. Hence in this mini review, we summarize the well-established yet vital aspects of AR. These include the epidemiology, clinical and laboratory diagnostic criteria, AR in pediatrics, pathophysiology of AR, Th2 responses in the disease, as well as pharmacological and immunomodulating therapies for AR patients.

Sublingual immunotherapy increases Treg/Th17 ratio in allergic rhinitis

Background

Few studies investigated the effects of sublingual immunotherapy (SLIT) on the peripheral regulatory T cells (Tregs)/Th17 ratio.

Objective

To investigate the effectiveness of SLIT in children with allergic rhinitis (AR) and the effects on the Tregs/Th17 ratio.

Methods

This was a retrospective study of children who were treated for AR between April 2017 and March 2018 at one hospital. The patients were grouped according to the treatments they received: SLIT + pharmacotherapy vs pharmacotherapy alone.

Results

Eighty children (51 boys and 29 girls; 40/group) were included. The visual analog scale (VAS) and medication scores at 1 year in the SLIT + pharmacotherapy group were 2.70 ± 1.08 and 1.1 ± 0.8, respectively, which were lower than at baseline (7.7 ± 1.2 and 3.6 ± 1.0, respectively) (both Ps < 0.05). For the pharmacotherapy group, the VAS score was decreased at 1 year vs baseline (3.3 ± 1.2 vs 7.4 ± 1.0; P < 0.05), but the medication score did not change (P > 0.05). In the SLIT + pharmacotherapy group, the Treg percentage increased, while the Th17 percentage decreased at 1 year (both Ps < 0.01). The percentages of Tregs and Th17s did not change in the pharmacotherapy group (both Ps > 0.05).

Conclusions

SLIT + pharmacotherapy can increase the Treg percentage and decrease the Th17 percentage in the peripheral blood of children with AR.

Real-life safety of 5-grass pollen tablet in 5-to-9-year-old children with allergic rhinoconjunctivitis

BACKGROUND

Although 5-grass pollen sublingual immunotherapy has a good safety profile in controlled clinical trials, additional safety information among pediatric patients in a real-world setting would be useful.

OBJECTIVE

To further document the safety of 5-grass tablet among children aged 5 to 9 years with allergic rhinoconjunctivitis (ARC).

METHODS

This multicenter, observational study included allergy immunotherapy-naïve 5- to 9-year-old children with grass pollen-induced ARC prescribed with 5-grass tablet daily (3-day dose escalation to 300 index of reactivity [IR]). Patients were followed up daily for safety and tolerability over the first 30 treatment days. Adverse events (AEs) and adverse drug reactions (ADRs) were analyzed descriptively.

RESULTS

Three hundred seven children (mean age, 7.1 years) were enrolled. Fifty-eight percent were confirmed as polysensitized, and 36% had mild-to-moderate asthma. Of 307 patients, 233 (76%) reported AEs, and 173/307 (56%) reported ADRs, most frequently mild application-site reactions (throat irritation, oral pruritus, oral paresthesia). Sixteen of 307 (5.2%) patients withdrew because of ADRs. In 143 of 173 (83%) patients, ADRs first occurred within 1 week of starting treatment. More than half of the ADRs lasted less than 2 days, and ADRs resolved spontaneously in 161 of 173 (93%) patients. Recurrences of ADRs were reported in 45 of 173 (26%) patients and were also mainly application-site reactions. No notable differences were found in ADRs related to whether patients had asthma at inclusion. Neither epinephrine use nor admission to intensive care unit was reported.

CONCLUSION

The safety profile of 5-grass tablet in pediatric ARC patients aged 5 to 9 years was consistent with safety findings in older patients, most ADRs being at the application site and mild to moderate. ClinicalTrials.gov identifier: NCT02295969; EUPAS registration number: 8104.

Will every child have allergic rhinitis soon?

OBJECTIVES

Given the increasing prevalence of AR amongst children, we aimed to review the literature regarding the future of AR in this population.

METHODS

We searched the PubMed, Google and Proquest Central databases at Kırıkkale University Library. Search terms used were: "allergic rhinitis", "children", "paediatric", "allergy", "future", "risk factors", "treatment", "pharmacotherapy" and/or "allergen - specific immunotherapy". With regard to risk factors for allergic rhinitis, the terms "Environmental factors", "Improved hygiene", "Increased indoor allergen exposure", "Farms, villages, worms, and other parasites", "Environmental toxicants", "Diet", "Lifestyle changes", "Air pollution" and "Climate factors" were searched for. "Prevention of allergic diseases" and "Allergen-specific immunotherapy in the future" were also included in the search.

RESULTS

AR has a high prevalence and causes considerable morbidity, has associated comorbidity and features specific complications. The principal treatments rely on avoiding the allergens responsible, and administering drug treatment or immunotherapy, which targets specific antigens. Genetic drift does not explain the rising prevalence of allergic disorders, but multifactorial environmental factors are likely culprits. Amongst such environmental factors to consider are the rise in caesarean births, decreases in breast feeding, dietary changes resulting in less fresh produce being consumed, the eradication of intestinal worm infestations, alterations in the way homes are aired and heated, children taking less exercise and being outdoors for shorter periods, whilst also having more contact with pollution.

CONCLUSION

Barring substantial lifestyle alterations, more and more children are likely to develop AR. It may prove feasible to stop allergy developing in the first place through manipulation of the microbiome, but the exact format such a modification should involve remains to be discovered. Molecular allergological techniques do offer the prospect of more precisely targeted immunotherapy, the sole disease modifier at present. However, at present the complexity and cost of such interventions prevents their widespread use and research in this area is still needed. The majority of children with AR are going to be managed using nasal saline sprays, since they are the most straightforward and least risky alternative for first line treatment.

Safety of a novel intranasal formulation of azelastine hydrochloride and fluticasone propionate in children: A randomized clinical trial

BACKGROUND

The safety of a novel intranasal formulation of azelastine hydrochloride (AZE) and fluticasone propionate (FP) has been established in adults and adolescents with allergic rhinitis but not in children <12 years old.

OBJECTIVE

To evaluate the safety and tolerability of an intranasal formulation of AZE and FP in children ages 4-11 years with allergic rhinitis.

METHODS

The study was a randomized, 3-month, parallel-group, open-label design. Qualified patients were randomized in a 3:1 ratio to AZE/FP (n = 304) or fluticasone propionate (FP) (n = 101), one spray per nostril twice daily, and to one of three age groups: ≥4 to <6 years, ≥6 to <9 years, and ≥9 to <12 years. Safety was assessed by child- or caregiver-reported adverse events, nasal examinations, vital signs, and laboratory assessments.

RESULTS

The incidence of treatment-related adverse events (TRAEs) was low in both the AZE/FP (16%) and FP-only (12%) groups after 90 days' continuous use. Epistaxis was the most frequently reported TRAE in both groups (AZE/FP, 9%; FP, 9%), followed by headache (AZE/FP, 3%; FP, 1%). All other TRAEs in the AZE/FP group were reported by ≤1% of the children. The majority of TRAEs were of mild intensity and resolved spontaneously. Results of nasal examinations showed an improvement over time in both groups, with no cases of mucosal ulceration or nasal septal perforation. There were no unusual or unexpected changes in laboratory parameters or vital signs.

CONCLUSION

The intranasal formulation of AZE and FP was safe and well tolerated after 3 months' continuous use in children with allergic rhinitis.The study was registered on <ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="http://ClinicalTrials.gov">ClinicalTrials.gov</ext-link> (NCT01794741).

Knowledge, perspectives and attitudes about allergen-specific immunotherapy for respiratory allergic disease among paediatricians in Turkey

BACKGROUND

Allergen-specific immunotherapy (ASI) is the only effective treatment for allergic respiratory diseases which has the potential to change the natural course of the disease. In this present study we aimed to evaluate the paediatricians' knowledge, perspectives and attitudes about ASI for allergic respiratory diseases.

MATERIALS AND METHODS

The study was conducted between September 2014 - January 2015. A survey of 25 questions assessing paediatricians' knowledge, perceptions and attitudes about ASI was developed by an expert panel and applied by physicians in hospitals in Izmir, Turkey, where the paediatricians work. Data were recorded in SPSS for Windows v.16. Descriptive statistics, chi square analysis was used. P<0.05 was considered as significant.

RESULTS

Fully completed surveys from 180 paediatricians were analysed. The respondent paediatricians had an age of 37±8.2 years, and 56 of them were male. The majority of the respondents (n: 146) were working fewer than five years as a paediatric specialist. 93.9% of the paediatricians believed that ASI was effective for the treatment of allergic respiratory diseases. There was satisfactory knowledge of the characteristics, aims, effects and limits of ASI.

CONCLUSION

ASI is generally well-known and accepted among paediatricians. A better synergy between paediatricians and paediatric allergy specialists can provide more use of this treatment method for allergic respiratory diseases in childhood.

HMGB1 in the Pathogenesis of Nasal Inflammatory Diseases and its Inhibition as New Therapeutic Approach: A Review from the Literature

Introduction  This study is a systematic review on recent developments about the importance of HMGB1 protein in the pathogenesis of rhino-sinusal inflammatory diseases. We also report data on the use of 18-β-glycyrrhetic acid (GA), which has been shown able to inhibit the pro-inflammatory activities of HMGB1, in young patients affected by allergic rhinitis and complaining of nasal obstruction as main symptom.

Objectives  The objective of this study was to review the literature to demonstrate the importance of HMGB1 in the pathogenesis of nasal inflammatory disorders and understand whether the inhibition of this protein may be an efficacious and innovative therapeutic strategy for patients with rhino-sinusal inflammation.

Data Synthesis  Authors searched for pertinent articles indexed in PubMed, Scopus, and other health journals between 2004 and 2015.

In total, the authors gathered 258 articles: 219 articles through Pubmed and 39 articles from other search engines. The search terms used were as follows: HMGB1 AND “respiratory epithelium,” “airway inflammation,” “rhinitis,” “allergic rhinitis,” “rhinosinusitis,” “nasal polyposis,” “glycyrrhetic acid,” “children.”

Conclusions  Patients with severe symptoms have the highest serum levels and the highest extracellular expression of HMGB1. GA inhibits HMGB1 chemotactic and mitogenic function by a scavenger mechanism on extracellular HMGB1 accumulation stimulated by lipopolysaccharides in vitro. Treatment of allergic rhinitis with GA is not associated with local or systemic side effects in children and adults.

Impact of rhinitis on lung function in children and adolescents without asthma

BACKGROUND

Subclinical spirometric abnormalities may be detected in patients with rhinitis without asthma, proportional to the severity established by ARIA (Allergic Rhinitis and Its Impact on Asthma) guidelines. New criteria of rhinitis classification were recently validated according to the ARIA modified (m-ARIA), which allow the discrimination between moderate to severe grades. The impact of rhinitis on lung function according to frequency and severity is unknown.

OBJECTIVES

To investigate subclinical spirometric impairment in children and adolescents with allergic and non-allergic rhinitis without overt symptoms of asthma, according to the frequency and severity criteria of rhinitis classified by m-ARIA.

METHODS

An observational cross-sectional study, including children and adolescents aged 5-18 years with allergic and non-allergic rhinitis without asthma. We analysed the functional abnormalities and bronchodilator response with spirometry in relation to the grade of rhinitis established by m-ARIA using an adjusted logistic model. A value of p<0.05 was considered statistically significant.

RESULTS

We studied 189 patients; 22.2% showed spirometric abnormalities. Patients with persistent rhinitis had greater impairment of lung function compared to intermittent grade (p=0.026). Lung functional impairment was more frequent in severe and moderate rhinitis than mild grade (p=0.005) and was independent of the atopic status to both frequency (p=0.157) and severity (p=0.538). There was no difference in bronchodilator reversibility between groups (p>0.05).

CONCLUSIONS

Impaired lung function was associated with persistence and severity of rhinitis and there was no significant difference between patients with moderate and severe rhinitis. The spirometric abnormality was demonstrated in patients with allergic and non-allergic rhinitis.

Early-life antibiotic use and subsequent diagnosis of food allergy and allergic diseases

BACKGROUND

Antibiotic use in early life has been linked to disruptions in the microbiome. Such changes can disturb immune system development. Differences have been observed in the microbiota of children with and without allergies, but there have been few studies on antibiotic use and allergic disease.

OBJECTIVE

We evaluated associations of early-life antibiotic use with subsequent occurrence of food allergy and other allergies in childhood using electronic health record data.

METHODS

We used longitudinal data on 30 060 children up to age 7 years from Geisinger Clinic's electronic health record to conduct a sex- and age-matched case-control study to evaluate the association between antibiotic use and milk allergy, non-milk food allergies, and other allergies. For each outcome, we estimated conditional logistic regression models adjusting for race/ethnicity, history of Medical Assistance, and mode of birth delivery. Models were repeated separately for penicillins, cephalosporins and macrolides.

RESULTS

There were 484 milk allergy cases, 598 non-milk food allergy cases and 3652 other allergy cases. Children with three or more antibiotic orders had a greater odds of milk allergy (Odds Ratio; 95% Confidence interval) (1.78; 1.28-2.48), non-milk food allergy (1.65; 1.27-2.14), and other allergies (3.07; 2.72-3.46) compared with children with no antibiotic orders. Associations were strongest at younger ages and differed by antibiotic class.

CONCLUSIONS AND CLINICAL RELEVANCE

We observed associations between antibiotic orders and allergic diseases, providing evidence of a potentially modifiable clinical practice associated with paediatric allergic disease. Differences by antibiotic class should be further explored, as this knowledge could inform paediatric treatment decisions.

Administration and Burden of Subcutaneous Immunotherapy for Allergic Rhinitis in U.S. and Canadian Clinical Practice

BACKGROUND

Allergy immunotherapy (AIT) is the only available treatment that alters the natural course of allergies and has possible disease-modifying effects. AIT is administered primarily via subcutaneous injection delivered in a physician's office. Few studies have been conducted in the United States or Canada to evaluate the costs of subcutaneous immunotherapy (SCIT).

OBJECTIVES

To (a) describe SCIT administration processes, resources, and costs and (b) characterize the patient population receiving SCIT.

METHODS

A multisite, prospective, observational time and motion study was conducted. Injection and wait times were collected by a third-party observer on 1 visit for each patient. Extract preparation processes were also observed. Site staff reported on treatment protocols, administrative time, supplies, and patient medical history. Patients responded to questionnaires on demographics, reasons for treatment, medication use, productivity, and travel time. Costs were estimated by applying unit costs to the time observations and the patient- and staff-reported data.

RESULTS

A total of 670 SCIT patients were enrolled at 6 sites in the United States and 6 sites in Canada. Average age in the United States was 41 years (SD = 18) and 44 years (15) in Canada, with 10% of the patients aged ≥ 65 years. Annual incomes were over $100,000 for 40% of U.S. patients and 30% of Canadian patients. U.S. patients had over 4 times as many different allergens in their SCIT treatments as Canadian patients, with a mean of 18 versus 4. The most common reasons reported for starting SCIT was a "desire to cure allergies once and for all" (73%) and that "symptoms are not improved by allergy medications" (60%). Percentages of patients taking allergy medications in the 4 weeks prior to observation were 86% in the United States and 66% in Canada: antihistamines 75% United States, 54% Canada; inhaled corticosteroids 32% United States, 22% Canada. The predominant comorbidity was asthma, 43% United States, 24% Canada. Site protocols for build-up treatment phases were 1 to 2 injections per week for an average of 25 weeks (range 12-52). Maintenance phases were 1 injection every 3 to 4 weeks for an average of 4 years (range 2.5-5). Eight of the sites had total mean staff times per injection visit of 7 to 22 minutes; 1 site averaged fewer minutes, and 3 sites averaged more. Total direct medical costs were an average of $30 for Canadian patients per visit and $32 per visit for U.S. patients, half accounted for by the cost of the extract. Pre- and postinjection administrative tasks were the second largest driver of direct costs. Total injection visit-related time for patients, including round-trip travel time, averaged about 80 minutes per visit in the United States and in Canada.

CONCLUSIONS

Analyses revealed substantial variation in SCIT regimens among sites, but the sites had commonalities in the injection process components. SCIT requires patient commitment to a long-term treatment regimen involving numerous clinic visits and resources for administration.

Relevance of a 5-grass sublingual tablet for immunotherapy of patients with grass pollen allergy in North America

Grass pollen allergy is common and clinically consequential in North America. While it is frequently treated with subcutaneous or sublingual immunotherapy, debate remains regarding whether allergen immunotherapy is best carried out using a single representative or multiple cross-reactive allergen(s). Patients are commonly exposed to pollens from multiple allergenic grass species belonging to the Pooideæ subfamily. Beyond the known IgE cross-reactivity, considerable molecular heterogeneity exists with respect to allergen content among grass species, with further evidence that these molecular variants can be detected by the patients' immune system. These observations provide a compelling scientific rationale for the use of mixed pollen allergen extracts to broaden the allergen repertoire, with the aim of reorienting inappropriate immune responses in allergic patients.

Longitudinal associations among asthma control, sleep problems, and health-related quality of life in children with asthma: a report from the PROMIS(®) Pediatric Asthma Study

OBJECTIVES

Few studies have investigated the complex relationship among asthma control, sleep problems, and health-related quality of life (HRQOL) among children with asthma. This study aimed to test the longitudinal effect of asthma control status on asthma-specific HRQOL through the mechanism of nighttime sleep quality and daytime sleepiness.

METHODS

The Patient-Reported Outcomes Measurement Information System (PROMIS(®)) Pediatric Asthma Study included 229 dyads of asthmatic children and their parents with two years of follow-up for assessing the change in asthma control, sleep problems, and asthma-specific HRQOL. The Asthma Control and Communication Instrument was used to measure asthma control status. Nighttime sleep quality assessment was based on difficulty falling asleep and getting up, and sleep disturbance. The Iowa Pediatric Daytime Sleeping Scale was used to assess daytime sleepiness. The PROMIS Asthma Impact Scale was used to measure asthma-specific HRQOL. Multilevel structural equation modeling was performed to quantify the direct and indirect effects of asthma control status on asthma-specific HRQOL through nighttime sleep quality and daytime sleepiness.

RESULTS

Poorer asthma control status was directly associated with lower asthma-specific HRQOL at within-subject and between-subject levels (p < 0.05); however, effects of asthma control on asthma-specific HRQOL were indirectly influenced through daytime sleepiness at the within-subject level (p < 0.05), and through nighttime sleep quality and daytime sleepiness at the between-subject level (p < 0.05).

CONCLUSIONS

Asthma control status is associated with asthma-specific HRQOL, and this association is mediated by nighttime sleep quality and daytime sleepiness. Clinicians should address sleep problems related to asthma control to improve HRQOL for asthmatic children.

The Future of Sublingual Immunotherapy in the United States

Sublingual immunotherapy (SLIT) is a safe and effective treatment for allergic rhinitis (AR) and allergic rhinoconjunctivitis (ARC). The Food and Drug Administration (FDA) in the USA has approved three SLIT tablets for the treatment of AR and ARC in relation to pollen. Specifically, Grastek® and Oralair® are two formulations approved to treat patients suffering with AR/ARC to grass pollen, and Ragwitek™ is a formulation approved to treat patients suffering with AR/ARC to ragweed pollen. Although these approvals provide support for physicians to prescribe SLIT, barriers to prescribing SLIT still remain such as FDA approval for additional formulations, a standard dose and dosing schedule, and cost/insurance coverage. In order to further support the use of SLIT, research is currently being conducted to expand the indication for SLIT to other common comorbidities to AR/ARC. For example, allergic asthma, food allergies, and atopic dermatitis are other diseases which are being explored. The future of SLIT in the USA is unknown; however, education will be necessary for both providers and patients.

The perception of allergen-specific immunotherapy among pediatricians in the primary care setting

BACKGROUND

Allergic respiratory diseases are constantly increasing in prevalence. Allergen Immunotherapy (AIT) represent a valuable therapeutic tool as symptomatic and preventative approach, expecially in children. In Italy, primary care pediatricians (PCP) represent the first-line contact and interface for prescription, use and management of AIT. We attempted to evaluate the perception of AIT practice among PCP.

METHODS

A questionnaire was built-up, based on literature, guidelines and with the contribution of pediatricians. The questionnaire, including 12 items, was e-mailed to 180 PCP, randomly chosen from mailing lists. The questionnaire explored the personal perception of AIT, the comparison between subcutaneous and sublingual AIT and the overall awareness about the treatment.

RESULTS

130 questionnaires were eligible for analysis. There was a satisfactory knowledge of the characteristics of AIT, its aims and limits, although the positioning of the treatment in guidelines was insufficiently known. Overall, the prescription of AIT made by other specialists was accepted and agreed (78 %). The majority of pediatricians felt that a more intense divulgation and information about AIT would be needed (90 %).

CONCLUSION

AIT is in general well known and accepted among PCP, although a more intense divulgation effort is required.

A, Canales M, Morales S. RGE, Mardones P. P, Leiva G. MA. Trends and threshold exceedances analysis of airborne pollen concentrations in Metropolitan Santiago Chile

Pollen is one of the primary causes of allergic rhinoconjunctivitis in urban centers. In the present study, the concentrations of 39 different pollens in the Santiago de Chile metropolitan area over the period 2009–2013 are characterized. The pollen was monitored daily using Burkard volumetric equipment. The contribution of each type of pollen and the corresponding time trends are evaluated. The concentrations of the pollens are compared with the established threshold levels for the protection of human health. The results show that the total amount of pollen grains originating from trees, grasses, weeds and indeterminate sources throughout the period of the study was 258,496 grains m-3, with an annual average of 51,699 ± 3,906 grains m-3 year-1. The primary source of pollen is Platanus orientalis, which produces 61.8% of the analyzed pollen. Grass pollen is the third primary component of the analyzed pollen, with a contribution of 5.82%. Among the weeds, the presence of Urticacea (3.74%) is remarkable. The pollination pattern of the trees is monophasic, and the grasses have a biphasic pattern. The trends indicate that the total pollen and tree pollen do not present a time trend that is statistically significant throughout the period of the study, whereas the grass pollen and weed pollen concentrations in the environment present a statistically significant decreasing trend. The cause of this decrease is unclear. The pollen load has doubled over the past decade. When the observed concentrations of the pollens were compared with the corresponding threshold levels, the results indicated that over the period of the study, the pollen concentrations were at moderate, high and very high levels for an average of 293 days per year. Systematic counts of the pollen grains are an essential method for diagnosing and treating patients with pollinosis and for developing forestation and urban planning strategies.

Intranasal triamcinolone and growth velocity

BACKGROUND

Inadequate designs and conflicting results from previous studies prompted the US Food and Drug Administration to publish guidelines for the design of clinical trials evaluating the effects of orally inhaled and intranasal corticosteroids on the growth of children. This study conformed to these guidelines to evaluate the effect of triamcinolone acetonide aqueous nasal spray (TAA-AQ) on the growth of children with perennial allergic rhinitis (PAR).

METHODS

This randomized, double-blind, placebo-controlled, parallel-group, multicenter study evaluated the effect of once-daily TAA-AQ (110 μg) on the growth velocity (GV) of children aged 3-9 years with PAR by using stadiometry at baseline (4-6 months), during treatment (12 months), and at follow-up (2 months). Hypothalamus-pituitary-adrenal (HPA) axis function was assessed by measuring urinary cortisol levels. Details of adverse events were recorded.

RESULTS

Of 1078 subjects screened, 299 were randomized, and 216 completed the study (placebo, 107; TAA-AQ, 109). In the primary analysis (modified intent-to-treat: placebo, 133; TAA-AQ, 134), least-squares mean GV during treatment was lower in the TAA-AQ group (5.65 cm/year) versus placebo (6.09 cm/year). The difference (-0.45 cm/year; 95% confidence interval: -0.78 to -0.11; P = .01), although clinically nonsignificant, was evident within 2 months of treatment and stabilized thereafter. At follow-up, the GV approached baseline (6.70 cm/year) in the TAA-AQ group (6.59 cm/year) and decreased slightly in the placebo group (5.89 cm/year vs 6.06 cm/year at baseline). No HPA axis suppression was observed.

CONCLUSIONS

By using rigorous Food and Drug Administration-recommended design elements, this study detected a small, statistically significant effect of TAA-AQ on the GV of children with PAR.

Current recommendations and emerging options for the treatment of allergic rhinitis

Allergic rhinitis (AR) is one of the most common diseases and represents a global health problem, currently affecting up to 30% of the general population, with a continuously increasing prevalence and significant comorbidities and complications. The aim of this review is to provide an update on AR treatment, with a focus on current therapies defined by AR and its impact on asthma guidelines and with a particular emphasis on new and future therapeutic perspectives.

The Allergies, Immunotherapy, and RhinoconjunctivitiS (AIRS) survey: provider practices and beliefs about allergen immunotherapy

BACKGROUND

The practices and beliefs of the provider specialties that treat allergic rhinoconjunctivitis (ARC) with allergen immunotherapy (AIT) may vary.

METHODS

A telephone survey of 500 randomly selected health care practitioners in 7 specialties, conducted in 2012.

RESULTS

AIT was provided as a subcutaneous injection (SCIT) by 91% of allergist/immunologists, 54% of otolaryngologists, and 18% to 24% of other specialties. Otolaryngologists were the most frequent providers of sublingual drops of AIT (SLIT; 33%), compared to 2% to 10% of other specialties. AIT was recommended for adults with allergic rhinoconjunctivitis by 100% of allergist/immunologists vs 62% to 84% of the other specialties (p < 0.001). The primary reason for recommending AIT for adults (52%) or children (46%) was that other therapies did not work. Between 48% (nurse practitioners/physician assistants) and 93% (allergist/immunologists) of practitioners always or often decreased symptomatic medications over the course of AIT treatment. Most practitioners in all specialties (82-100%) thought that AIT was appropriate for patients with severe allergy symptoms. Significantly more allergist/immunologists and otolaryngologists than other specialists thought AIT was appropriate for mild allergy symptoms (p < 0.001 and p = 0.004, respectively, vs other specialties). Significantly more allergist/immunologists than other specialists thought that AIT was more effective than symptomatic medications (p < 0.001), could reduce the further development of allergies (p = 0.03), and could prevent the development of asthma.

CONCLUSION

SCIT was more frequently provided than SLIT by all the specialties. Otolaryngologists were the most likely to offer SLIT, while very few allergist/immunologists offered SLIT. Allergist/immunologists differed from other specialties in some beliefs about the effectiveness of AIT.

New developments in the treatment of pediatric allergic rhinitis and conjunctivitis

The primary care physician is the first line of treatment for allergic rhinitis, which affects approximately one-fourth of children in the United States. There is an increasing trend toward self-management by patients or parents due to high-deductible insurance plans and the over-the-counter availability of allergy medications. The primary care physician can offer guidance on appropriate selection of medications and potential adverse effects. Vitamin D deficiency has been proposed as a potential contributing factor in patients with allergic diseases, and studies are underway to determine whether supplementation with vitamin D is helpful for these conditions. Sublingual immunotherapy has recently received US Food and Drug Administration approval for grass and ragweed allergens; many children will be interested in this alternative to allergy shots. The relative advantages and disadvantages of sublingual vs subcutaneous immunotherapy are discussed.

Patient initiation and persistence with allergen immunotherapy

BACKGROUND

Allergen immunotherapy (AIT) is advised for patients with allergic rhinitis who remain symptomatic despite the use of pharmacotherapy and allergen avoidance. Several factors influence the decision to initiate and complete the AIT regimen.

OBJECTIVE

To evaluate patient initiation and persistence with subcutaneous and sublingual immunotherapies (SCIT and SLIT) according to physician recommendation.

METHODS

A retrospective review of electronic health records of patients with allergic rhinitis for whom AIT was recommended was conducted in a large private allergy practice in Pennsylvania.

RESULTS

Of 8,790 patients advised to consider AIT, 36.2% initiated AIT (57% adults, 43% children); 78% chose SCIT and 22% chose SLIT drops. Election of AIT was significantly associated with select comorbidities, specifically chronic sinusitis (8.1% for AIT vs 10% for no AIT), allergic conjunctivitis (12.5% for AIT vs 18.5% for no AIT), and asthma (33.8% for AIT vs 37.4% for no AIT; P < .05). Choice of SCIT vs SLIT drops was significantly associated with older age, female sex, select comorbidities, and more allergy medications at initiation (P < .05). Of adults, 30.2% completed at least 3 years of recommended treatment. Median time on treatment was longer for adults on SCIT vs SLIT drops (3 vs 1.6 years). Similarly, 35.4% of children completed treatment, with a longer median time on treatment for SCIT (4.7 years) vs SLIT drops (3.5 years).

CONCLUSION

A minority of patients initiated AIT according to allergist recommendation and a subset of these patients completed therapy. AIT might be an underused option that could benefit patients unable to manage allergic rhinitis symptoms by other means.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01549340.

Are you comfortable with over-the-counter intranasal steroids for children? A call to action

The early expression of allergic rhinitis in children is a potential red flag for lifelong problems and comorbid conditions. However, treating pediatric allergic rhinitis in the United States is trending toward a self-management or parental management model with little clinical supervision, which reflects changes in the delivery of health care. Of particular concern are the recent approval of an over-the-counter intranasal steroid to treat nasal allergy symptoms in adults and children as young as age 2 years and the push for a retail model of health care as exists in some other countries. For children with allergic rhinitis, treating nasal symptoms alone with over-the-counter products may further delay a diagnosis that is often already ignored due to its "annoyance factor" as opposed to being considered a serious health issue. How to ensure an appropriate diagnosis and management for these children remains a challenge, regardless of who is doing the treating. The call to action is for allergists and allergy medical organizations to drive the effort to ensure awareness of the why and how for appropriately diagnosing and treating allergic rhinitis in children. Starting points for the discussion are provided.