Allergy in childhood: Need for early detection and treatment Ondřej Rybníček Allergy unit, Paediatric Dept., FN BRNO ANICKA Sensitization •allergic rhinitis •atopic eczema •bronchial asthma 60th 90th 3 - 10 times INCREASE IN ALLERGY PREVALENCE •Sequential and progressive occurrence of atopy symptoms in childhood –Food allergy –Atopic dermatitis –Bronchial asthma –Allergic rhinitis „Atopic march“ ATOPIC SENSITIZATION PREVENTION OF ALLERGY AND ASTHMA • No contact with tobacco smoke both pre- and postnatally • Encouragement of spontanneous delivery (contact with vaginal microflora) • Encouragement of breastfeeding (also other reasons than allergy prevention) • Avoiding broad-spectrum antibiotics and paracetamol prenatally and during the first year of life when possible •GINA2014 •History, physical examination •Skin tests •Laboratory evaluation •Functional evaluation •Elimination-exposition tests (provocation tests) •Involvement of different specialists ALLERGIC DISEASES: DIAGNOSIS •COMPLEX APPROACH • Environmental adjustments • In- and outdoor allergens, pollutants, dietary alterations • Specific allergen immunotherapy • Pharmacotherapy • Permanent patient education • Adjuvant methods • Physiotherapy, climato/balneotherapy, diet, psychotherapy, vaccination…. ALLERGY THERAPY - APPROACH ALLERGEN IMMUNOTHERAPY (AIT) •Treatment approach where •defined doses of therapeutic •allergen are being administered •to the allergic person in regular •intervals. •The therapeutic allergen must •be a cause of allergic problems •+ IgE mediated hypersensitivity •(Ist type) must be confirmed. quick_drink WHEN AIT IS INDICATED? •Allergic rhinitis and asthma caused by known aeroallergens •History of severe systemic reaction caused by Hymenoptera venom allergy. •AIT in urticaria, angioedema, atopic dermatitis and food allergy is up to now considered experimental and is not recommended for daily practice. Kočka s mouchou ALLERGENS SUITABLE FOR AIT •A/ Aeroallergens –pollen allergens –house dust mites –cockroaches –pet allergens –moulds •B/ Hymenoptera venom an57 ANTIALLERGIC DRUGS •ANTIINFLAMMATORY DRUGS §systemic and topical GCS §antileukotriens §antihistamines §suppressed adverse effects §broader spectrum of effects: §antihistaminic §antiinflammatory §antiallergic §theophylline §cromons FOOD ALLERGY mléko •History, physical exam •Skin testing •prick tests, i.d. tests •atopy patch test •Specific IgE antibodies •Component diagnostics •Elimination-exposition tests FOOD ALLERGY: DIAGNOSTIC APPROACH •Elimination of causal allergens from diet, incl. cross-reacting allergens •Nalcrom •Epipen •(Antihistamines) FOOD ALLERGY: MANAGEMENT •SKIN ALLERGY ALERGK~1 Basic therapy: topical treatment regimen adjustment pruritus antihistamines Delayed hypersensitivity ATOPIC DERMATITIS Diverse etiology: allergy (food, drugs...) physical factors (cold, pressure...) focal infections other diseases (hepatitis, diabetes, haemophilia...) C1-esterase inhibitor defect Degranulation of skin mastocytes Effects of histamine on tissue receptors •comprehensive evaluation is necessary MECHANISMS OF URTICARIA §Symptom control (itching) §Higher doses usually necessary §increase the dose of non-sedating antihistamine §add first generation antihistamine §Continue 2-3 weeks after symptoms disappear (relaps prevention) §Plus: Regimen adjustment Additional drugs according to clinical course (GCS, adrenaline) Drugs of the choice – non-sedating antihistamines CHRONIC URTICARIA THERAPY •BRONCHIAL ASTHMA KOCKA2 •http://ginasthma.org/2018-gina-report-global-strategy-for-asthma-management-and-prevention free download (pdf) 2018 UPDATE OF GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION (GINA): •GINA 2018 Early childhood asthma • Fernando D. Martinez •Childhood asthma: whole life importance –2/3 of all asthma cases start in the first 3 years of life –majority of severe asthma cases start in the first 3 years of life –hypothesis that the severity of asthma in children decreases with age has not been proofed correct A clinical index to define risk of asthma in young children •Major criteria: •parental asthma •atopic eczema •Minor criteria: •allergic rhinitis •wheezing apart from colds •eosinophilia (>4%) Castro-Rodriguez et al., Am J Respir Crit Care Med, Vol 162. pp 1403–1406, 2000 Early wheezer + at least 1 major criteria or at least 2 minor criteria Chronic inflammation Structural changes Acute exacerbation Time clinical manifestation •Zone for rescue drugs effect: • inhaled beta-2 agonists • inhaled anticholinergics CLINICAL COURSE OF ASTHMA •No chronic symptoms incl. nocturnal problems •No asthma exacerbations •No need for ED visits •No need for rescue beta-2 agonists use •No limitation of daily activities including physical activities and sport •Physiological circadian PEF variability •Normal lung function •No adverse effects of medication FULL ASTHMA CONTROL •Two key parts of asthma therapy: •Preventive (antiinflammatory) medication •Rescue medication (SABA) • •Stepwise treatment approach ASTHMA PHARMACOTHERAPY •GINA 2014 ALLERGIC RHINITIS MITE4 ALLERGIC RHINITIS CLASSIFICATION with regard to the quality of life intermittent persistent symptoms symptoms <4 days/week >4 days/week or <4 consecutive weeks and >4 consecutive weeks mild moderate/severe (all of the following) (one or more items) normal sleep sleep disturbed no impairment of daily activities, impairment of daily activities, sport, leisure sport, leisure no impairment of work and school impairment of school or work symptoms present, not troublesome troublesome symptoms •History, physical exam •Skin testing, specific IgE •Component diagnostics •Functional tests (flow-volume) •ENT, sinus X-ray (diff. dg.) •Ophthalmology (diff. dg.) ALLERGIC RHINOCONJUNCTIVITIS: DIAGNOSTIC APPROACH •GINA 2014 Symptoms: itchy eyes conjunctival injection lacrimation conjunctival oedema usually together with AR Ist type allergic reaction (immediate reaction) ALLERGIC CONJUNCTIVITIS ALLERGIC RHINITIS PHARMACOTHERAPY • TREATMENT GOAL •block of pathophysiological mechanisms that induce chronic inflammation •prophylaxis of allergy symptoms •Allergy 1998:53(suppl 41)7-31 •Rachelefsky GS. J Allergy Clin Immunol 1998;101:2, part 2, 367-69 RHINITIS – PRINCIPLES OF PHARMACOTHERAPY •When choosing a suitable and effective •medication, consider: •aetiology •pathophysiology •main symptoms •safety (side effects, drug interactions) •age •other specific conditions (pregnancy, athletes…) •coexisting airway disease (sinusitis, asthma) •patient preference and compliance PHARMACOTHERAPY •Glucocorticosteroids (GCS) –Intranasal GCS are considered drugs of choice when nasal congestion is the leading symptome (persistent rhinitis) •Decongestive drugs –Topical –Systemic •Antihistamines •Decongestant/antihistamine combination •Mast cell stabilizers •Leukotriene receptor antagonists •Corey et al. Ear Nose Throat J. 2000;79:690. •American Academy of Allergy, Asthma and Immunology. The Allergy Report. Volume 2: Diseases of the Atopic Diathesis. •Milwaukee, WI: American Academy of Allergy, Asthma and Immunology; 2000:13–50. Sneezing Rhinorrhoea Itching Blocked nose Intensity variation during the day Conjunctivitis Paroxysmal Watery secretion Anterior + posterior Yes Sometimes Daytime worsening, nighttime improvement Often Not common Thick mucus Mainly posterior No Common, intense Permanent problems often worse at night Not common •„sneezers/secretors“ •„blocked nose“ •Preferred therapy: antihistamines topical nasal steroids CLINICAL FEATURES OF RHINITIS •symptoms •asthma •* changes almost always detectable on the other organ •* intensity of nasal and bronchial symptoms correlate •* bronchial reaction after nasal provocation •* primary worsening usually on nasal mucosa •rhinitis UNITED AIRWAY DISEASE DEFINITION OF ANAPHYLAXIS •PATHOPHYSIOLOGY • Anaphylaxis is an acute allergic reaction based on Ist type, IgE mediated immunopathologic reaction •CLINICAL DEFINITION • - Multiorgan involvement - No generally accepted clinical definition exists Ch. Richet, 1850-1935 MANAGEMENT OF ANAPHYLACTIC REACTON •check vital functions •adrenaline i.m. 0,1 ml/10 kg •oxygen, maintain adequate oxygenation, relieve bronchospasm, intubate •I.V. fluids, maintain adequate blood pressure (noradrenaline, dopamine) •antihistamine •systemic GCS intubace Holgate ST, Church MK 1993 MANAGEMENT OF ANAPHYLACTIC REACTON •Adrenaline - effective in the early phase of anaphylactic reaction. Administer if in doubts, do not wait! •In fully developed anaphylactic reaction administration of I.V. fluids is necessary (up to 50% of vessel content can become extravasated within 10 minutes) Sampson et al., JACI, 2005, Lieberman et al., JACI, 2005 ANAFYLAX ENT, DERM., OPHTHAL. SPECIALIST ALLERGIST GENERAL PRACTITIONER OTHER SPECIALISTS PULMOLOGIST ALLERGIC PATIENT - CARE PETROV •Thank you for your attention!