Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Allergic Rhinitis and Conjunctivitis
ALLERGIC RHINITIS AND CONJUNCTIVITIS
An allergic response resulting in inflammation of the mucous membrane. It is characterized by chronic, thin, watery nasal discharge with or without concurrent conjunctival discharge, inflammation, and pruritus.
I. Etiology
A. IgE-mediated immunologic reaction to common inhaled allergens (pollens, molds, dust, animal dander). The mediators cause increased permeability of the mucosa and produce vasodilation, mucosal edema, mucous secretions, stimulation of the itch receptors, and a reduction in the sneezing threshold.
B. Seasonal allergic rhinitis is generally caused by non-flowering, windpollinated plants, and fungal spores.
Allergens vary seasonally and by geographic distribution and commonly include tree pollens in the early spring, grasses in late spring
and early summer, and weeds primarily in the fall. However, in many areas, various weeds pollinate from spring through fall.
C. Perennial allergic rhinitis is caused by allergens that are present year round such as animal dander, dust, cockroaches, and molds.
D. Food allergens are not a common cause of allergic rhinitis.
II. Incidence
A. Allergic rhinitis is the most common atopic disease and the most common chronic disease in children.
B. Usually seen after 3 to 4 years of age but can develop at any age
C. Affects approximately 10% of the population
D. 80% to 90% percent of children with asthma have concomitant allergic rhinitis.
III. Subjective data
A. Nasal stuffiness: Varies from mild to chronic obstruction
B. Rhinorrhea: Bilateral, thin, watery discharge
C. Paroxysms of sneezing
D. Itching of nose, eyes, palate, pharynx
E. Conjunctival discharge and inflammation
F. Mouth breathing
G. Snoring
H. Fatigue, irritability, anorexia may be present during season of offending allergen.
I. Allergic salute: Rubbing the tip of the nose upward with the palm of the hand
J. Recurrent nosebleeds
K. Persistent, nonproductive cough
L. Pertinent subjective data to obtain
1. History of associated allergic symptoms: Asthma, urticaria, contact dermatitis, eczema, food or drug allergies
2. Family history of allergy
3. Does child always seem to have a cold, or does it occur at specific times of the year (perennial versus seasonal)?
4. Are symptoms worse in any particular season?
5. Do parents or child notice that symptoms are worse after exposure to specific allergens, such as animals, wool, feathers, or going into attic or cellar?
6. Are symptoms worse when child is indoors or outside?
7. What do parents or child think causes symptoms?
8. Can child clear nose by blowing?
9. What makes child feel better?
10. How much do symptoms bother child and family?
IV. Objective data
A. Allergic shiners: Bluish cast under eyes
B. Allergic crease: Transverse nasal crease at junction of lower and middle thirds of nose
C. Clear mucoid nasal discharge
D. Pale edematous nasal mucosa
E. Nasal turbinates swollen and may appear bluish
F. Nasal phonation
G. Mouth breathing
H. Conjunctivae may be inflamed. “Cobblestoning” of upper lids may be present.
I. Tearing
J. Edema of lids
K. Laboratory test: Nasal smear positive for eosinophilia
V. Assessment
A. Diagnosis
1. Differentiate between the following:
a. Seasonal allergic rhinitis occurs seasonally as a result of exposure to airborne pollens: generally tree pollens in late winter and early spring, grass pollens in spring and early summer, and weeds in late summer and early fall.
b. Perennial allergic rhinitis occurs all year but is usually worse in winter due to increased exposure to house dusts from heating systems, pets, wool clothing, and other allergens.
2. Classify as:
a. Mild: No sleep interruption, no interference with activities, no troublesome symptoms
b. Moderate–severe: Involves sleep interruption and/or impairment of daily activities, troublesome symptoms
c. Intermittent: Symptoms less than 4 days/week or duration under 4 weeks
d. Persistent: Symptoms over 4 days/week or duration more than 4 weeks
B. Differential diagnosis
1. Infectious rhinitis or recurrent colds: Nasal discharge watery to thick yellow, low-grade fever, symptoms develop after exposure to cold virus, 5 to 7 days duration.
2. Foreign body: Unilateral purulent nasal discharge with foul odor
3. Vasomotor rhinitis: Symptoms precipitated by exposure to temperature changes or specific irritants (smoke, air pollutants, strong perfume, chemicals); symptoms appear suddenly and disappear suddenly.
4. Rhinitis medicamentosus: History of chronic use of nose drops
5. Acute or chronic sinusitis: Nasal mucosa is usually inflamed and edematous; discharge is generally mucopurulent; may have lowgrade fever.
6. Cystic fibrosis: Consult if nasal polyps are present.
VI. Plan: Involve child in treatment plan as much as developmental level allows.
A. Pharmacologic therapy
1. Antihistamines relieve rhinorrhea, sneezing, and itching.
2. Decongestants improve nasal congestion.
3. Intranasal steroids suppress the entire inflammatory process in the nose but do little for relief of ocular symptoms or systemic manifestations.
4. Optimal results may be obtained with a combination of nasal cromolyn or steroids and an antihistamine or decongestant.
5. Antihistamines for seasonal rhinitis
a. Ages 6 to 12 years
(1) Benadryl, 5 mg/kg/d in four divided doses (>10 kg, 12.5–25 mg tid–qid)
(2) Tavist syrup, 0.5 mg/5 mL: 1 tsp every 12 hours
(3) Zyrtec syrup, 5 mg/5 mL: 1 to 2 tsp daily depending on severity of symptoms
(4) Allegra suspension (recently FDA-approved for ages 2–11 years): 15 mg bid
b. Ages 12 and over
(1) Claritin, 10 mg/d
(2) Zyrtec, 5 to 10 mg once daily, depending on severity of symptoms
6. Decongestant-antihistamine combination
a. Pseudoephedrine (Actifed, Sudafed): 2–6 years, 5 mL qid; 6–12 years, 10 mL qid
b. Rondec: 2–6 years, 1.25 mL every 4–6 hours, max 7.5 mL/d 6 –12 years: 2.5 mL every 4–6 hours, max 15 mL/d
More than 12 years: 5 mL every 4–6 hours, max 30 mL/d
7. Intranasal corticosteroids: Believed by many experts to be the most effective pharmacologic therapy for allergic rhinitis.
a. Vancenase AQ: 1–2 sprays each nostril once daily for children over 6 years of age
or
b. Nasacort AQ: 2 sprays in each nostril once daily for children over 12 years of age, 1 spray each nostril once daily for children ages 6 to 12 years
or
c. Rhinocort Aerosol: 1–2 sprays each nostril q 12 hours for children over 6 years of age. May increase to 2 sprays each nostril once daily. Over 12 years, maximum 4 sprays each nostril once daily.
or
d. Flonase, one spray in each nostril once daily for children over 4 years of age; may increase to 2 sprays once daily
8. Ophthalmic preparations:
a. Patanol ophthalmic: 1 gtt in each eye twice daily at 6to 8-hour intervals for children over 3 years of age; indicated for all signs and symptoms, including itching, erythema, lid edema, and tearing
or
b. Alocril ophthalmic: 1 to 2 drops in each eye, every 12 hours for children over 3 years of age
or
c. Alomide ophthalmic: 1 to 2 drops in each eye, qid for up to 3 months, for children over 2 years of age
or
d. Optivar ophthalmic: 1 drop in each eye, bid for children more than 3 years of age
B. Avoidance: Identify and avoid offending allergens (see Environmental Control for the Atopic Child, p. 291).
1. Seasonal allergic rhinitis: Ragweed, trees, grasses, molds
2. Perennial: House dust, feathers, animal dander, wool clothing or rugs, mold
3. Environmental stimuli: Cold air, paint fumes, smoke, perfumes
C. Desensitization: Referral, indicated if
1. symptoms are severe and cannot be controlled with symptomatic therapy.
2. recurrent serous otitis occurs with resultant hearing loss.
3. symptoms become progressively worse or asthma develops.
4. allergen avoidance is impossible.
VII. Education
A. Advise parents that this is a chronic problem, although symptoms may sometimes decrease with age and then disappear. Exacerbation of symptoms may occur, particularly as child approaches puberty.
B. Discuss indications for hyposensitization.
1. Inability to suppress symptoms with conservative treatment
2. Inability to avoid allergens
3. Severe symptoms affecting child’s normal lifestyle (school, sleep, play)
4. 30% to 50% of children with allergic rhinitis who are not treated develop asthma
5. Desensitization is a lifelong process.
C. Discuss specific allergen control (see Environmental Control for the Atopic Child, p. 291).
D. Advise child and parents of possible hearing loss due to serous otitis.
E. Notify school of child with hearing loss.
F. Inadequate symptom control may contribute to learning impairment.
G. Side effects of antihistamines.
1. Sedation (often resolves with continued use); nightmares
2. Excitation, nervousness, tachycardia, palpitations, irritability
3. Dryness of mouth
4. Constipation
H. Antihistamines relieve nasal congestion, itching, sneezing, and rhinorrhea. Continuous therapy is more efficacious than sporadic use.
I. Topical anti-allergic ophthalmics also have a positive effect on nasal symptoms by draining into inferior nasal turbinates.
J. Intranasal corticosteroids
1. Reduces nasal stuffiness, discharge, and sneezing
2. Maximum benefit achieved in 1 week
K. Child should not wear soft contact lenses when using ophthalmic drops.
L. Ophthalmic preparations may cause transient stinging or burning.
M. Child with allergic rhinitis is more prone to upper respiratory and ear infections.
N. Child cannot clear nose by blowing it.
O. Child may not be able to chew with his or her mouth closed.
P. Epistaxis may be a problem because of nose picking and rubbing. Control nosebleed by compressing lower third of nose (external pressure over Kiesselbach’s triangle) between fingers for 10 minutes.
VIII. Follow-up
A. Return visit or telephone follow-up in 2 weeks for reevaluation. Contact sooner if adverse reaction to medication occurs.
B. If no response to medication, increase dosage to control symptoms. Reevaluate in 2 weeks. Change type of antihistamine if indicated.
C. If symptoms under control, continue medication until suspected allergen no longer a threat. Medication may then be used as needed to control symptoms.
D. Return visit at any time that child or parent feels symptoms are worse or medication has ceased to control symptoms.
IX. Complications
A. Bacterial infection
B. Recurrent serous otitis media
C. Malocclusion
D. Psychosocial problems
X. Consultation/referral
A. Symptoms have not abated after a trial period of 4 weeks on antihistamines.
B. Parent or child sees symptoms as a major problem and requests skin testing.
C. Recurrent serous otitis affecting hearing or school progress