Clinical prescribing of allergic rhinitis medication in the preschool and young school-age child - What are the options?

Allergic rhinitis (AR) is the most common chronic condition in children and is estimated to affect up to 40% of all children. It is usually diagnosed by the age of 6 years. The major impact in children is due to co-morbidity of sinusitis, otitis media with effusion, and bronchial asthma. AR also has profound effects on school absenteeism, performance and quality of life. Pharmacotherapy for AR should be based on the severity and duration of sign s and symptoms. For mild, intermittent symptoms lasting a few hours to a fe w days, an oral second-generation antihistamine should be used on an as-nee ded basis. This is preferable to a less expensive first-generation antihist amine because of the effect of the latter on sedation and cognition. Four s econd-generation antihistamines are currently available for children under 12 years of age: cetirizine, loratadine, fexofenadine and azelastine nasal spray; each has been found to be well tolerated and effective. There are no clearcut advantages to distinguish these antihistamines, although for chil dren under 5 years of age, only cetirizine and loratadine are approved. Oth er agents include pseudoephedrine, an oral vasoconstrictor, for nasal conge stion, and the anticholinergic nasal spray ipratropium bromide for rhinorrh oea. Sodium cromoglycate, a mast cell stabiliser nasal spray, may also be u seful in this population. For patients with more persistent, severe symptoms, intranasal corticostero ids are indicated, although one might consider azelastine nasal spray. whic h has antiinflammatory activity in addition to its antihistamine effect. Wi th the exception of fluticasone propionate for children aged 4 years and ol der, and mometasone furoate for those aged 3 years and older, the other int ranasal corticosteroids including beclomethasone dipropionate, triamcinolon e, flunisolide and budesonide are approved for children aged 6 years and ol der. All are effective, so a major consideration would be cost and safety. For short term therapy of 1 to 2 months, the first-generation intranasal co rticosteroids (beclomethasone dipropionate, triamcinolone, budesonide and f lunisolide) could be used, and mometasone furoate and fluticasone propionat e could be considered fur longer-term treatment. Although somewhat more cos tly, these second-generation drugs have lower bioavailability and thus woul d have a better safety profile. In patients not responding to the above programme or who require continuous medication, identification of specific triggers by an allergist can allow for specific avoidance measures and/or immunotherapy to decrease the allerg ic component and increase the effectiveness of the pharmacological regimen.