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CLINICAL REVIEW: Hans de Groot, Paul L P Brand, Wytske F Fokkens, and Marjolein Y Berger Allergic rhinoconjunctivitis in children BMJ 2007; 335: 985-988 [Full text]

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Two remarks on the review on allergic rhinoconjunctivitis

Hugo P. Van Bever, Hugo P. Van Bever, Lee Bee Wah, Lynette Shek   (13 November 2007)

Some practical points on intranasal steroid sprays

F. Carl van Wyk   (15 November 2007)

Two remarks on the review on allergic rhinoconjunctivitis 13 November 2007
Hugo P. Van Bever, Professor in Pediatrics 119074 Singapore, Hugo P. Van Bever, Lee Bee Wah, Lynette Shek Send response to journal: Re: Two remarks on the review on allergic rhinoconjunctivitis	Dear Sir, We read with great interest the review article by de Groot et al. (BMJ2007; 335:985-8) on allergic rhinitis (rhinoconjunctivitis) in children. The review is enjoyable to read, giving a very comprehensive status on our current knowledge of childhood allergic rhinitis, stressing also the limited number of studies in children. Although we largely agree with the text, we would like to comment on two strict statements of the authors. 1. It was mentioned that intranasal corticosteroids (INC) should be the first drug of choice for allergic rhinitis in children, because in studies their effectiveness and safety is proven, and because INC seem to be more effective than antihistamines. We completely agree with this theoretical statement, but in daily practice INC are very difficult to administer, especially to young children, because they dislike intranasal medication very much and some may also complain of nasal irritation. If a doctor prescribes an INC, he may force the parents to have one or two daily “fights” with their children. It is therefore our experience that compliance with INC in young children is very low, because parents give up trying to administer this treatment. For reasons of compliance, we suggest that the 1st drug of choice for allergic rhinitis in young children (or in children who dislike intranasal drugs) should be an oral antihistamine (pleasant taste, and administered only once a day). The new antihistamines (levocetirizine, desloratidine) have been shown to be effective and safe in young children. 2. The authors very strictly advise not to give immunotherapy to children with allergic rhinitis. They claim that no studies have been published that show effectiveness of immunotherapy. However, to our knowledge a large number of studies have been published showing effectiveness of subcutaneous immunotherapy (SIT) (old studies) and sublingual immunotherapy (SLIT) (new studies) and a large number of references are available in the literature (Penagos M, et al. Ann Allergy, 97, 141-8, 2006). Sure, there are negative studies too (as an example: there are even negative studies of inhaled corticosteroids), but it is a bit unfair to mention explicitly one negative study. Furthermore, in a limited number of studies it was shown that immunotherapy can prevent new sensitizations to allergens in children (Pajno et al. Clin Exp Allergy 2001, 31, 1392-7) and that immunotherapy has an important carry-over effect that can last for more than 5 years (Di Rienzo et al. Clin Exp Allergy 2003, 33, 206-10). Yet other studies have shown that it reduce the risk of asthma (Moller C et al, J Allergy Clin Immunol 2002; 109: 251-256; and Novembre E, et J Allergy Clin Immunol. 2004; 114: 851-7). These “extra” effects have never been shown of any drug. We feel that immunotherapy (SIT and SLIT) has a place in the treatment of certain children with severe allergic rhinitis who are mono-sensitized to an allergen, and in whom medications are ineffective. However, we agree that more studies are needed, especially in young children. Hugo Van Bever Lee Bee Wah Lynette Shek Department of Pediatrics, National University Singapore. Correspondence to: Prof. Hugo Van Bever, Dept of Pediatrics, National University Hospital, 5 Lower Kent Ridge Road, 119074 Singapore, Singapore e-mail: paevbhps@nus.edu.sg Competing interests: None declared
Some practical points on intranasal steroid sprays 15 November 2007
F. Carl van Wyk, Specialist Registrar in ENT St. George's Hospital, London, SW17 0QT Send response to journal: Re: Some practical points on intranasal steroid sprays	Dear Sir, I note with interest the topical clinical review on rhinoconjunctivitis in children (BMJ2007; 335:985-8). The authors rightly cover the use of intranasal steroid sprays as part of first line management, but would do well in adding some practical points: 1. Mometazone nasal spray is licenced in the UK for use in children from the age of 6 upwards at the dose of 50 micrograms (1 spray) into each nostril once daily. Recently the manufacturers have removed the alcohol component, eliminating the unpleasant sensation and taste which should aid compliance in children. 2. Fluticasone nasal spray is licenced in the UK for use from 4 years at the dose of 50 micrograms (1 spray) each nostril once daily, which can be increased to twice daily if required. 3. The authors mention local trauma due to the nozzle of the nose spray could be the cause for epistaxis seen with using these sprays. A common sense approach would be to instruct the patient to apply the spray with the head forward, using the hand from the other side (to point the nozzle away from the septum). This should be followed by a gentle sniff only and then repeated for the other side. Yours sincerely, Carl van Wyk Competing interests: None declared