A child’s personal best is the highest PEFR achieved over a2-week period when stable. Based on the child’s personal best, a written action plan can be established, which is divided into three zones, similar to a stoplight. The green zone indicates aPEFR 80% to 100% of the child’s personal best value. In thiszone, the child is likely asymptomatic and should continuewith medications as usual. The yellow zone indicates a PEFR50% to 80% of the child’s personal best value, which generallycoincides with more asthma symptoms. Rescue medications,such as albuterol, are added. A call to the physician may be warranted if the peak flows do not return to the green zone within24 to 48 hours or if asthma symptoms are increasing. The redzone indicates a PEFR below 50% and is a medical emergency.Rescue medication should be taken immediately. If the PEFRremains in the red zone or the child has significant airway compromise, a call to the physician or emergency care is needed.
Children with asthma should be seen not only when they are ill but also when they are healthy. Regular office visits allow the health care team to review adherence to medication and control measures and to determine whether doses of medications need adjustment.
Rhinitis describes diseases that involve inflammation of the nasal epithelium and is characterized by sneezing, itching, rhinorrhea, and congestion. There are many different causes of rhinitis in children, but approximately half of all cases of rhinitis are caused by allergies.
Allergic rhinitis, commonly known as hay fever, is caused by an IgE-mediated allergic response. During the early allergic phase, mast cells degranulate and release preformed chemical mediators, such as histamine and tryptase, and newly generated mediators, such as leukotrienes, prostaglandins, and platelet-activating factor. After a quiescent phase in which other cells are recruited, a late phase occurs approximately 4 to 8 hours later. Eosinophils, basophils, CD4 T cells, monocytes, and neutrophils release their chemical mediators, which leads to the development of chronic nasal inflammation.
Allergic rhinitis can be seasonal, perennial, or episodicdepending on the particular allergen and the exposure. Somechildren experience perennial symptoms with seasonal exacerbations. Seasonal allergic rhinitis is caused by airborne pollens,which have seasonal patterns. Typically trees pollinate in thespring, grasses in late spring to summer, and weeds in the summer and fall. The pollen, microscopic in size, can travel airbornehundreds of miles and be inhaled easily into the respiratory tract.Perennial allergic rhinitis is primarily caused by indoor allergens, such as house dust mites, animal dander, mold, and cockroaches. Episodic rhinitis occurs with intermittent exposure toallergens, such as visiting a friend’s home where a pet dwells.
Chronic rhinitis is one of the most common disorders encountered in infants and children. Overall allergic rhinitis is observed in 10% to 25% of the population, with children and adolescents more commonly affected than adults. The prevalence of physician-diagnosed allergic rhinitis may be 40%.
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Table 79-1 Classification of the Etiology of Rhinitis in Children ALLERGIC NONALLERGIC NONANATOMIC ANATOMIC Seasonal Nonallergic, noninfectious (vasomotor) rhinitis Adenoidal hypertrophy
Episodic Nonallergic rhinitis with eosinophilia Choanal atresia
CSF, Cerebrospinal fluid.