Referral guideline – Allergic rhinoconjunctivities (hay fever)

Introduction

Allergic rhinitis is very common and often missed, affecting around 1 in 5 children. It is caused by the nose and/or eyes coming into contact with environmental allergens such as pollens, dust mites, animal hair and moulds.

Symptoms of allergic rhinitis may include sneezing, itching, watering or rubbing of the nose.

Sometimes the nose is blocked and the child may be noted to be mouth breathing or snoring without any of the above symptoms. Symptoms may be similar to common URTIs but continue chronically or seasonally.

Think of the possibility of allergic rhinitis in children with continuous or recurrent URTIs, frequent sore throats, hoarse voice, persistent mouth breathing, persistent throat clearing, snoring, recurrent headaches, recurrent middle ear infections, coughing (particularly on lying down), halitosis, poor sleep or daytime fatigue.

Children with asthma frequently have co-existent allergic rhinitis. Treating the allergic rhinitis can have a significant impact on management of asthma. Some children with allergic rhinitis will also have allergic conjunctivitis but allergic conjunctivitis can also occur alone.

GP management

  • Examine the nose looking for swelling of the nasal turbinates, nasal airflow and mouth breathing.
  • Look also for “allergic facies” with an allergic crease, allergic “shiners” and swelling of the nasal bridge suggestive of chronic upper airway congestion.

Avoidance of recognised triggers

For example:

  • animal dander
  • house dust mite
  • grass pollen.

Corticosteroid nasal sprays

  • Nasal irrigation with saline, then blow nose and immediately follow with topical steroid spray e.g. fluticasone (Avamys), mometasone (Nasonex), ciclesonide (Omnaris) or azelastine/fluticasone (Dymista).
  • If one nasal steroid is ineffective, try another.
  • Use initially for a minimum of 4-6 weeks until symptoms resolve. Thereafter use as needed,commencing as soon as symptoms recur, for a minimum of a few days at a time, until symptoms resolve each time.

Regular daily non-sedating anti histamines

  • Provide symptom control, not anti-inflammatory effect.
  • Use either as monotherapy in very mild disease or children too young for nasal sprays, or, in addition to nasal steroids for symptom control.
  • Desloratidine is licensed from 6 months of age, cetirizine from 12 months, and loratidine and fexofenadine from 2 years. If one is ineffective, try another.
  • Sedating antihistamines such as Phenergan and Polaramine must be avoided due to the detrimental impact on learning and behavior, as well as the risk of respiratory depression and death.

When to refer

  • Refer to ENT if possible concomitant tonsillar or adenoidal swelling, or unresolved glue ear.
  • Refer to Allergy/Immunology if allergen desensitization may be required
    •  ongoing symptoms despite optimal topical nasal corticosteroid therapy and allergen avoidance for a minimum of 3 months.
  • Consider a referral to a private Australasian Society of Clinical Immunology and Allergy (ASCIA) member as waiting times through (LCCH) may be prolonged.

Essential referral info

  • Personal and family history of other allergic disease (e.g. atopic eczema, asthma)
  • Onset, duration and pattern of symptoms, including triggering and relieving factors and any systemic symptoms
  • Medication use, adherence and response
  • Any positive examination findings
  • Patient details
  • Medicare number
  • Parent/carer name and contact details
  • Referring clinician details (name, contact details, provider number, date and length of referral)

Helpful referral info

  • Height/weight/head circumference/percentile charts
  • Significant psychosocial risk factors