Allergic Rhinitis in Children with Asthma: A Questionnaire Based Study in Lebanon

Introduction: Allergic rhinitis and asthma frequently coexist but has rarely been evaluated in Lebanese children. Conclusion: Allergic rhinitis is prevalent in children of the Lebanese population, the severity of asthma was found to be clearly associated with allergic rhinitis. The SFAR modified for children was found to be a simple and reliable tool to detect allergic rhinitis in asthmatic children.


INTRODUCTION
The prevalence of allergic disorders, allergic rhinitis and asthma, have increased over the last decades [1][2][3].
These two conditions share the physiopathologic links that need to be clarified further.
The allergic rhinitis prevalence varies from one epidemiological study to another mainly because there is no standardized assessment of allergic rhinitis [4]. Furthermore, the actual distribution of allergic rhinitis in patients with asthma is not well defined.
Asthma and rhinitis are influenced by the inflammatory process taking place in the two parts of the respiratory tract, the upper and the lower respectively [5]. An alteration of the upper airway function could therefore affect the function of the lower airway. Improvement of allergic rhinitis symptoms can be associated with resolution of asthma symptoms. On the other hand, deterioration of allergic rhinitis symptoms may exacerbate asthma symptoms. Consequently, appropriate management of allergic rhinitis could decrease the risk of asthma developing or asthma exacerbations [6].
In order to ensure optimal management it is important for primary care physicians to recognize the presence of rhinitis in patients with asthma, similarly patients with rhinitis are evaluated for the presence of asthma.

Support from Guidelines
The concept of an inter-related relationship between asthma and allergic rhinitis is endorsed by the Allergic Rhinitis and its Impact on Asthma (ARIA) 2007 updated guidelines [7]. This ARIA Workshop Report was in collaboration with the World Health Organization (WHO), the Global Allergy, and the Asthma European Network (GALEN). The ARIA guidelines were published as a state-of-the-art reference for physicians to update their knowledge of allergic rhinitis and to highlight the impact of Allergic Rhinitis on asthma [8]. The revised Global Initiative for Asthma (GINA) guidelines also recognizes rhinitis as a special consideration in managing asthma.

Study Population and Questionnaire
This study has been approved by the Institutional Review Board (IRB). During the period of July 2008 and March 2009, 124 asthmatic children were studied prospectively, with age ranging from 1-13 years old. All parents were informed and aware of their children's participation in the following study, and they filled in questionnaires at pediatric floor in MGH.
The questionnaire was modified from the adult form of the score for the allergic rhinitis (SFAR). Each item was assigned a number of points. The final score ranged from 0 to 17 (Table 1).
Allergic rhinitis and asthma were classified according to ARIA and GINA 2004 recommendations, respectively. Furthermore, the onset ages of allergic rhinitis and asthma, the treatment of allergic rhinitis were also recorded. Associations with other allergic conditions as well also recorded such as: Atopic dermatitis, conjunctivitis and / or food allergy.
The diagnosis of allergic rhinitis was based on a pediatric questionnaire taken from a study done at FRANCE (with the association with Paris Descart University Necker Hospital and public assistance of Paris Hospitals), this was approved to be valid against medical diagnosis by comparison of calculations for sensitivity, specificity and positive and negative predictive values for each score.
Asthma severity was assessed according to GINA guidelines.

Statistical Analysis
Statistical analysis was performed with the use of sigma stat software (SPSS Inc) version 13.0. For comparison of categorical data, chi-square.

RESULTS
A total of 124 patients were admitted to MGH with the diagnosis of asthma during the study period. All patients were between 1 and 13 years. No exclusion criteria.
The prevalence of allergic rhinitis in asthmatic patients studied was found to be 54% (67/124 patients).
The higher prevalence has found to be between 3 and 5 years 31 patients (46.3%) ( Table 2).
Males were more commonly affected with a sex ratio of 2.35 (Table 3).
Severity of asthma was classified in our patients as mild intermittent 40.3%, mild persistent 52.4%, and moderate to severe 7.25% (Table 5).
Allergic rhinitis was highly correlated to asthma severity in our study which revealed 20%, 74%, and 100% in mild intermittent, mild persistent, and moderate to severe groups respectively (Fig.1).
Allergic rhinitis was mostly stimulated by house dust mites (51, 3%) and 43% of children having both asthma and allergic rhinitis had a third disease atopic dermatitis (37%).
Skin prick test was performed in 36 patients (29%), but the results could not be collected because most were lost by parents. Parents' perception of allergy was very high 103/124 (83.1%) at the same time a strong family history of allergy found to be as high as 109/124 (87.9%).

DISCUSSION
These findings clearly contribute to further understanding of the association between AR and asthma in childhood. This study assessed the prevalence of AR in asthmatic children through a specific questionnaire.
A pediatric score cutoff value ≥9 allowed optimum discrimination between children with AR and those without [4] and therefore, this can be used in daily basis at all asthma Lebanese clinics.
This score was studied by Hammouda et al. and published in the journal of compilation done in FRANCE (with the association with Paris Descart University Necker Hospital and Public Assistance of Paris Hospitals) and was approved to be valid for medical diagnosis by comparison of calculations for sensitivity, specificity and positive and negative predictive values for each score.
Our study provides additional information regarding the clinical signs and the burden of allergic rhinitis on the asthmatic child. In contrast to the study done by Lack [9], who suggested that children with allergic rhinitis rarely complain of nasal stuffiness, we found that the main manifestations of allergic rhinitis were sneezing (61,19%), runny nose (56,7%), nasal itching (56,7%), and blocked nose (31,34%). We observed that the higher prevalence of allergic rhinitis in our population is between 3 and 5 years of age. Furthermore, it could manifest early at a younger age groups, as found in our study beginning from 1year of age as compared to Hammouda study starting from 3 years of age.
As asthma was more severe as allergic rhinitis was highly correlated demonstrated by our study 20%, 74%, and 100% in mild intermittent, mild persistent, and moderate to severe groups respectively. Thus in order to ensure optimal management it is important for primary care physicians to recognize the presence of rhinitis in patients with asthma; similarly patients with rhinitis are evaluated for the presence of asthma. A high percentage rate of perception of allergy is related to strong family history of the same disease.
As asthmatic patients do not overtly complain about nasal symptoms and / or these symptoms are not routinely sought by doctors, the allergic rhinitis frequency is underestimated in this group [10]. A retrospective study in Italy found that children complaining of persistent wheezing were 10 times more likely to have a personal history of allergic rhinitis than the control group [11].
Allergic rhinitis is not an independent risk factor for the severity of asthma as found in our study that 43% of children having both asthma and allergic Rhinitis had a third disease, atopic dermatitis (37%).
Our study may add a new simple score to Lebanese children that could be attached to asthma chart, being the two diseases are highly correlated in this population.

STUDY LIMITATIONS
Because of limited time the treatment measure and follow up of these patients were lost.

CONCLUSION
Allergic rhinitis and asthma are frequently associated (54%), in children in the Lebanese population. The severity of asthma was found to be positively correlated with that of AR. In this study, allergic rhinitis was found to be manifested in the early age group of children 1-2 years of age. The SFAR modified for children was found to be a simple and reliable tool to detect allergic rhinitis in asthmatic children.

CONSENT
It is not applicable.