Curriculum Vitae

WAHYUNI INDAWATI,MD
EDUCATION :
Medical Doctor and Pediatrician in Cipto Mangunkusumo Hospital Faculty of Medicine Universitas of Indonesia
Consultant Pediatric Respirologist in Cipto Mangunkusumo Hospital Faculty of Medicine Universitas of Indonesia
TRAINING :
Cystic Fibrosis : Sophia Children Hospital Rotterdam, Netherlands
Bronchoscopy : NUH Singapore and Hongkong University, Cipto Mangunkusumo Hospital
Pediatric TB : Stellenbosch University South Africa
POSITION : Medical Staff of Respirology Division Child Health Department
Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia
ORGANIZATION :
Secretary of Community Affair Indonesian Pediatric Society 2011-2014
Co chair of Respirology Working Group Indonesian Pediatric Society 2017-2020
Co chair of Pediatric Pharmacy Taskforce 2017-2020
Board Member of Asian Pediatric Interventional Pulmonology Association
Member of National Childhood TB Working Group- Ministery of Health
Member of American Thoracic Society and European Respiratory Society
Member of World Association Bronchology and Interventional Pulmonology
 DIAGNOSIS AND
MANAGEMENT OF ALLERGIC
RHINITIS IN CHILDREN
Dr Wahyuni Indawati SpA(K)
Divisi Respirologi Departemen Ilmu Kesehatan Anak
RS Dr Cipto Mangunkusumo Fakultas Kedokteran Universitas Indonesia
 LEARNING OBJECTIVE
To Understand Definition Allergic Rhinitis in Children

To Recognize Clinical Symptoms of Allergic Rhinitis in Children

To Know Diagnosis Criteria and Classification of Allergic

Rhinitis in Children
To Recognize comorbidity accompany Allergic Rhinitis in
Children
To Understand Comprehensive Management of Allergic
Rhinitis in Children
 OUTLINE

DEFINITION
CLINICAL SYMPTOMS
DIAGNOSIS CRITERIA
COMORBIDITY
MANAGEMENT
DEFINITION
• Allergic rhinitis (AR) is an inflammatory disorder of
the nasal mucosa induced by allergen exposure
triggering by IgE-mediated inflammation

• About 40% of the world’s population is atopic and

allergic rhinitis is the commonest of preservation of
this atopic tendency

• Incidence AR in western countriest is 1.4-39.7%

PATHOPHYSIOLOGY
CLINICAL SYMPTOMS
• Rhinorhoea
• Nasal blockage
• Postnasal drip
• Itchiness
• Sneezing
• Associated
health effects

‼ IgE
mediated
Allergic Rhinitis Symptoms
 • Conjunctivitis
• Postnasal drip
• Eustachian tube
ASSOCIATED dysfunction
SYMPTOMS • Otitis Media
• Sinusitis
• Dental malocclusions
 Domestic allergen : mites, domestic
animals, insects or of plant origin

Outdoor allergens : pollens and moulds

Occupational triggers : eg latex

TRIGGERS
Pollutant triggers : tobacco smoke,
automobile exhaust include ozone, oxides
of nitrogen and sulphur dioxide
Drugs : aspirin and other NSAID
SIGNS OF ATOPY AND RECURRENT
OR PERSISTENT RHINITIS
DIAGNOSIS

1 2 3
Detail history : history Physical examination : Evidence of IgE
of typical symptoms of sign of atopy and mediated : Skin prick
reccurent or persistent reccurent or persistent testing or serum-
rhinitis and/or rhinitis specific IgE testing
associated health effect
 Classification of Allergic Rhinitis
According to ARIA ( Allergic Rhinitis
and Its Impact on Asthma )

• Less than 4 days a week

Intermittent • Or for less than 4 consecutive
weeks

• More than 4 days a week

Persistent • And for more than 4 consecutive
weeks

Bousquet J et al. ARIA Update 2008.

 Classification of Allergic Rhinitis According to ARIA
(Based on Symptoms Severity Impact on social school
and work)

• Sleep disturbance
• Impairment of daily activities, leisure
Mild
and or sport
(None of the Folowing items
are present) • Impairement of school or work
• Symptoms present but not
troublesome
Moderate-Severe • Sleep disturbance
(One or more of the • Impairment of daily activities, leisure and or sport
Following items are present) • Impairement of school or work
• Troublesome symptoms

Bousquet J et al. ARIA Update 2008.

Allergic Rhinitis Classification

Bousquet J et al. ARIA Update 2008

COMORBIDITIES

Hardjojo A et al. Asia Pac Allergy 2011;1:115-22

UNITED AIRWAY CONCEPT
RESPIRATORY TRACT
Upper Airways Lower Airways

Lack of opportunity to view the comprehensive and integral function

of the airway

Share many similar anatomic and histological features

Imunologically related

AllergicUNITED
RhinitisAIRWAY
and its Impact on Asthma
DISEASES (ARIA) &
(UAD):
World
OneHealth Organization
airway, (WHO
one disease
Upper and lower airways form a single organ continuum  co-occurence of upper
and lower airway diseases as a different manifestation of a single disease process

Marseglia GI et al. Int J Immunopathol Pharmacol. 2011;24:7–12

Licari A et al. Int J Immunopathol Pharmacol. 2014;27:499–508
Yii AC et al. Allergy. 2018;73(10):1964-78
INTERACTION MECHANISM OF
ALLERGIC RHINITIS AND ASTHMA
Asthma affects up to 40% of
AR patients
Many patients have both AR
and asthma
AR affects up to 80%
of asthma patients

Upper airway symptoms of AR Treatment of AR can improve

can exacerbate asthma asthma in some patients

AR patients without asthma

Treatment of AR can reduce
often have bronchial hyper-
bronchial hyper-reactivity
reactivity

Source: South Med J © 2009 Lippincott Williams & Wilkins

MANAGEMENT OF ALLERGIC
RHINITIS

Gentile et al. J Allergy Clin Immunol in Practice.2013;1:214-26

 MANAGEMENT OF ALLERGIC RHINITIS
Diagnosis of allergic rhinitis
Intermittent
symptoms
Check for asthma especially in patients with
severe and/or persistent rhinitis
Persistent
symptoms

Mild Moderate-
Mild Moderate- severe
Not in preferred severe In preferred order
order
Intranasal CS
Oral H2-blocker
or intranasal H2- Not in preferred order H1-blocker or LTRA
blocker Oral H2-blocker
or LTRA* or intranasal H2-
blocker Review the patient after 2-4 weeks
or LRTA (or
chromone)
ARIA GUIDELINES In persistent
Improved Failure
Review the diagnosis
2010 rhinitis review the
patient after 2-4 Step-down and Review the compliance
weeks continue treatment Query infections or other causes
for >1 month
If failure: step up Add or increase Rhinorrhea Blockage and decongestant
If improved : continue intranasal CS dose Add ipratropium or oral CS (short term)
for 1 month
Allergen and irritant avoidance may be appropriate
If conjunctivitis
Add : oral H-1 blocker or intraocular H-1 blocker, or intraocular cromone (or saline)
Consider specific immunotherapy

Bousquet J et al. Allergy. 2012;63(Suppl 86):1049–62

ANTIHISTAMIN FOR ALLERGIC
RHINITIS

Gentile et al. J Allergy Clin Immunol in Practice.2013;1:214-26

INTRANASAL CORTICOSTEROID

Gentile et al. J Allergy Clin Immunol in Practice.2013;1:214-26

J Allergy Clin Immunol. 2011;127:927-34
Allergic Rhinitis Approach in Children
SUMMARY
• Allergic rhinitis (AR) is a common atopic disease occurs in
children
• It is an inflammatory disorder in nasal cavity induced by
IgE mediated
• Clinical manifestation include rhinorhea, nasal blockage,
itchiness and sneezing
• Diagnosis based on clinical history, physical signs of atopy
and recurrent/persistent rhinitis and evidence of IgE
mediated
• Classification based on ARIA Guideline consist of
frequency and severity of symptoms
• Comprehensive management should comprise of
avoidance of potential triggers, pharmacotherapy,
immunotherapy and treating comorbidities
THANK YOU FOR YOUR ATTENTION