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| CLINICAL CASES |
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| Year : 2019 | Volume
: 21
| Issue : 1 | Page : 19-28 |
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Risk factors contribution to pediatric allergic rhinitis in Jeddah, Saudi Arabia
Talal A Al-Khatib1, Fathi M El-Gamal2
1 Department of Otolaryngology-Head Neck Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Department of Family Medicine, Ibn Sina College for Medical Studies, Jeddah, Saudi Arabia
| Date of Web Publication | 6-Feb-2020 |
Correspondence Address:
FRCSC Talal A Al-Khatib
Department of Otolaryngology, Faculty of Medicine, King Abdulaziz University, PO Box 80215; Jeddah 21589;
Saudi Arabia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/1319-8491.277842
Objectives/Hypothesis: To identify risk factors contributing to AR among preschool children in Jeddah (SAUDI ARABIA). Study design: Case control study.
Methods: The study comprised 128 children with ISAAC diagnosed AR, and 189 children as controls. Logistic regression was used. The odds ratio (OR) and 95% confidence intervals (95% CI) were calculated.
Results: The significant risk factors for AR were high socio-economic class (OR 3.08; 95% CI 1.69, 5.165), smoking of the father (OR 0.379; 95% CI 0.214, 0.674), age of the child (OR 2.665; 95% CI1.445, 4.910), formula feeding (OR 5.41; 95% CI 3.024, 9.679), family history of allergy (OR 4.27; 95% CI 2.74, 7.39), obesity (OR 2.234; 95% CI 1.18, 4.22), and respiratory tract infection (OR: 7.997; 95% CI: 4.019, 15.913).
Conclusions: Environmental, genetic, nutritional as well as life style factors are risk factors for development of AR, and should be considered when planning medical care services for preschool children.
Keywords: Allergic rhinitis, Preschool children, Risk factors
How to cite this article:
Al-Khatib TA, El-Gamal FM. Risk factors contribution to pediatric allergic rhinitis in Jeddah, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg 2019;21:19-28 |
How to cite this URL:
Al-Khatib TA, El-Gamal FM. Risk factors contribution to pediatric allergic rhinitis in Jeddah, Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2019 [cited 2023 Jun 4];21:19-28. Available from: https://www.sjohns.org/text.asp?2019/21/1/19/277842 |
| Introduction | |  |
Allergic rhinitis causes symptoms, such as a runny nose, nasal obstruction, sinus pressure, itchy eyes, nasal itching, and sneezing[1],[2],[3],[4],[5],[6],[7]. Allergy is the underlying cause in nearly half of the cases. AR is induced after allergen exposure by an IgE-mediated inflammation, such as inhalant allergens[8]. AR is common among young children, and may interfere with normal activities, and is a major burden for the health care system. AR is associated with poor control of asthma, and may underlie many complications[8],[9]. AR is mainly intermittent, but it could be persistent; it may be mild, moderate or severe[10],[11].
The occurrence of AR is increasing worldwide and may be as high as 40% in children in some developed countries. In developing countries the prevalence of AR is generally lower, but is tending to rise[12],[13].The incidence of AR is generally under estimated because large proportion of patients with AR does not see their physicians and use self-medication[14]. In USA, AR was reported by 9% to 16% of the population, and it is among the 16th common health office visits in primary health care[15],[16].In 2010, white children in the U.S. were more likely to have had AR (10%) than black children (7%)[17]. In the United States a study of more than 2000 children (ages from 13 to 14 years) from 1994 to 2002, found that prevalence of AR is on the rise[14]. In a research conducted in Madinah (Saudi Arabia) found that AR was common, affecting 24.2% of children[1]. In Jezan, Saudi Arabia, Hadadi et al, reported that the prevalence of AR was 27.1% (15.4% in male and 11.7% in female), which was close to the prevalence of AR reported by other study in Saudi Arabia (26.5%)[2],[4].
Risk factors for AR has not been as extensively studied as disorders such as eczema and bronchial asthma[18]. Thus the present study was conducted to study the possible risk factors contributing to AR in preschool children in Jeddah city.
| Methods | | |
Design: This is a case control study. Study setting: It was conducted in two outpatient clinics (in the economically developed North region of Jeddah city, and the other in the less economically developed South region) during the months of August and September, 2017. The subjects for this study were preschool children (1 - 6 years), who were accompanying their mothers during their visits to the clinics (not as patients),
Subjects: Out of all preschool children, who were surveyed (748 children), those aged 12 months to 72 months were included in the study (522 children). Children with AR were identified (number 128 children) and served as cases. Out of total children who were 1- 6 years old, and free of AR, asthma or eczema or any other allergic condition (289 children), a systematic random sample 189 served as control group. Thus the total number for this study was 317 preschool children; this number was more than the necessary minimum number needed for this study (220 children, as assessed by G*power software ['9], for α = 0.05, β = 0.95, effect size is 0.3, and degree of freedom = 5). Data were collected from child’s mother after taking an informed written consent.
| Data were collected through: | | |
- interview questionnaire to the mothers: Provided information on socio-demographic characteristics of the family, feeding and vaccination history of the child and clinical history of the child.
- Anthropometric measurements: Weight and length/ height were measured using standard techniques and equipment. Anthropometric analysis: The variables age, sex, weight and height were used. Indices of malnutrition were generated and standard reference values of WHO were used to obtain the Z-scores. Four indices of malnutrition were determined namely, stunting, underweight, wasting, and obesity. A child having a Z score below -2 or above +2 was diagnosed as having the corresponding type of malnutrition[20-22].
- ISAAC Allergy questionnaire was used to diagnose bronchial asthma, allergic rhinitis and atopic eczema[23-25.
Data analysis and statistical tests: Data were analyzed using the IBM SPSS, version 22. Multi-nominal logistic regression method was used to explore the significance between the response factor and explanatory risk factors (using OR, and 95Ú/0CI).
| Response variable: | | |
ISSAC diagnosed allergic rhinitis (no = 1, and yes = 2) Explanatory risk factors; (scored as 1, and 2)
- socio-demographic variables: area of residence, gender, age groups, nationality, education and occupations of the parents, monthly income, smoking of the father and mother, and family history of allergy.
- Environmental pollution variables: smoking of the father and mothers, keeping animals, plants, or birds at home; living nearby industrial city.
- Feeding and clinical history of the child: gestational age, feeding in infancy, types of food eaten, vaccination coverage, repeated respiratory tract infection, treatment for parasites or anemia.
- Nutritional assessment variables: Wasting, Underweight, Stunting, and overweight and obesity.
- Clinical variables e.g. repeated respiratory tract infection, doctor diagnosed asthma, rhinitis or eczema. Level of significance was considered 0.05[26].
| Ethical considerations | | |
Ethical clearance was obtained from the IRB of the College of Ibn Sina. The directors of the outpatient clinics approved the collection of the data on children. Informed consent was obtained from mothers’ of the children after providing information about the purpose of the study. Data collection procedure was anonymous.
| Results | | |
The present study was conducted on preschool children, 128 cases with AR and 189 children as control group. Children were selected from two different districts in Jeddah city; El-Safa district, which is characterized by high socioeconomic standard (SES), and Ghulail district at the south of Jeddah with relatively lower SES [Table 1]. | Table 1: Comparison of some Socio-Economic Standard variables between North and South districts of Jeddah City
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The mean age of children with AR was 36.6 ± 21.19 months, while that of the control group was 36.5 ± 15.00 months. Male gender was 52.3%, while females were 47.7% among children with AR, compared to the control children (42.3% and 57.7% respectively). Majority of children with AR had positive family history of allergic disorders (72.7%), and 46.9% had ISSAC diagnosed asthma, and 17.2% had ISAAC diagnosed eczema.
Majority of children with AR (85.9%) suffered from sneezing and runny nose in the past 12 months, and 42.2% suffered rhino-conjunctivitis. AR occurs mainly in winter months (51.6%), and AR was, mainly, intermittent (84.4%), while 15.6% of the children suffered from perennial symptoms. About one third of the children with ISSAC diagnosed rhinitis (31.3%) had little problems prevented the child from normal activities; while only 3.9% suffered from a lot of problems. AR symptoms were significantly more encountered among females compared to males [Table 2]. | Table 2: Frequency and severity of clinical symptoms among children with ISAAC diagnosed allergic rhinitis by gender
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Out of the 128 children diagnosed as having ISAAC diagnosed AR, a large proportion (36.7%) was not diagnosed by doctors as having AR. Children living in the high SES North region of Jeddah city were at more risk to develop AR than those living in the South region, with relatively lower SES (OR: 3.08; 95% CI 1.69, 5.165 and p < 0.000), when adjusting for other factors. Children older than 4 years were 2.6 folds risk of having AR compared to younger children (OR 2.665; 95% CI1.445, 4.910; p <0.002), controlled for confounding factors [Table 3]. Preschool children with history of father smoking had 2.6 times the odds ofhaving AR than those whose fathers do not (OR 0.379; 95% C 0.214, 0.674; p<0.001), when adjusting to other factors. Children who were fed on formula milk during infancy (OR 5.41; 95% CI 3.024, 9.679; p<0.000), had five times the odds of having AR than those who were breast fed [Table 4]. [Table 5] revealed that: preschool children who suffered from overweight or obesity had 2 times the odds of having AR than those with normal BMI/Age (OR 2.234; 95% CI 1.18, 4.22; p< 0.013) after adjusting for other factors. Children with Repeated respiratory tract infection had 8 times the odds of having AR than those without repeated respiratory tract infection (OR 7.99; 95%CI 4.019, 15.913; p< 0.013), when adjusting for other factors. | Table 3: Multi-nominal Logistic regression of the socio-demographic variables on the dependent variable ISAAC diagnosed Rhinitis
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 | Table 4: Multi-nominal Logistic regression of the environmental pollution factors and feeding pattern of the child and ISAAC diagnosed AR.
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 | Table 5: Multi-nominal Logistic regression between AR and clinical history and malnutrition variables
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[Table 5] revealed that: preschool children who suffered from overweight or obesity had 2 times the odds of having AR than those with normal BMI/Age (OR 2.234; 95% CI 1.18, 4.22; p< 0.013) after adjusting for other factors. Children with Repeated respiratory tract infection had 8 times the odds of having AR than those without repeated respiratory tract infection (OR 7.99; 95%CI 4.019, 15.913; p< 0.013), when adjusting for other factors.
| Discussion | | |
Allergic rhinitis is not a severe disorder, but it interferes with the subject’s quality of life. It thus disturbs the quality of life and integrity of psychological heath. So strategies, planned and implemented to discover AR early, and mange it can reduce, to a great extent, its adverse effects. The current study for the first time reported a large number of risk factors of AR in the preschool children in Jeddah, the second biggest city in Saudi Arabia.
Jeddah is a coastal city with high relative humidity, and several industrial activities, which impose an environmental pollution burden on the children living in this area. Thus, this study is important to highlight the problem of AR among 1 to 6 years children.
Several factors are implicated in the pathogenesis of allergic disorders. Among these are, environmental factors (such as in door and outdoor pollution, infections, and smoking, and allergens), and host factors (such as gender, nutritional status, and genetic predisposition)[27],[28],[29],[30]. Thus in the present study 33 trigger and risk factors were studied to assess its relative importance in the occurrence of AR.
Diagnosis of AR and other allergic disorders in the present study, was made using a validated widely used ISAAC core questionnaire on the asthma and allergic disorders, which make results of the present study comparable to previous studies[31].
The present study revealed that intermittent AR among preschool children predominated the persistent one (84.4% and 15.6% respectively). This is in line with other study, which revealed that AR was mainly of the intermittent type ]32]. Similar findings were also reported in Europe where occurrence of intermittent and persistent AR in Northern regions (53.8% to 24.8% respectively) was higher compared to rates in Southern areas (32.4% to 21% respectively). The percentage of persistent AR subjects was higher in Europe than in Jeddah[33].This could be due to the differences in the climatic condition, and sensitization to seasonal plants grew in Europe.
With regard to allergic multi-morbidity, the coexistence of “rhinitis and asthma” (46.9% of children with AR) was the most common allergic multi-morbidity in the current study, which is supported by the “one airway, one disease” notion[34]. This was followed by the coexistence of “rhinitis and eczema” (17.2% of children with AR). This is consistent with a European study carried out in Italy[35] . Normal subjects with rhinitis are at a greater risk of developing asthma, in different ages. Although, asthma in children with AR is dependent on allergy, in adults, it is not[36],[37]. The present study is in line with this finding.
It was reported that females predominated males in all types of atopic disease and in certain age groups[38]. In line with this study, in the present study AR symptoms were significantly more encountered among females compared to male preschool children. However, this is contradicting to findings by a previous study[39].
Several studies pointed out that repeated upper respiratory tract infections (RURTI) were significantly associated with allergic rhinitis[26],[40],[41].The present study confirmed this association where RURTI was reported by 35.2% of the children with AR compared to 6.3% among control children (X2 = 42.9; p < 0.000). Logistic regression confirmed this association where children with RURTI were almost 8 folds at increased risk of having AR than those without RURTI. In addition, susceptibility of the upper airways due to allergic inflammation may predispose to frequent URTI[42],[43].
Thus, it is important to differentiate between AR and infectious rhinitis/URTI in conducting a survey, and in treatment of children with rhinitis symptoms in clinic visits.
Genetic predisposing is a strong risk factor for AR. The present study revealed that family history of allergy (genetic factor) turned to be a strong risk factor for AR. This is consistent with findings by previous studies[44],[45]. Chromosomes 2, 3, 4 and 9, in chromosome association study, were demonstrated to have the most repeated regions[46]. Polymorphism was detected in genes from lekotrienes/receptors, interleukins/ receptors, and chemokines/receptors, which are functional groups contributing to AR[46].
The prevalence of allergic disorders was more common in families keeping animals in the home than in those who do not[47],[48].Therefore, avoidance of exposure to pets at home benefit children with allergy[12] However, in the present study, we failed to find such an association, which is consistent with other study[25].
Majority of preschool children were covered with vaccines (99.1%), but this did not affect the occurrence of AR[25].The present study found that vaccination coverage was not protective or risk factor for AR.
Breastfeeding was found to be protective factor against allergic disorders[12],[25] .The present study supports these findings where formula feeding in infancy increases the risk of AR 5.4 times than those who were breast fed. Thus it is recommended that breastfeeding should be encouraged for prevention of allergic disorders.
Eating certain types of food such as seafood was linked to increased prevalence of AR in epidemiological survey, but not in clinical studies[25].The present study, as well, could not establish such an association of food being a risk factor for AR.
North region of Jeddah city, which is an economically developed area, was a risk factor for occurrence of AR compared to the less developed South region of Jeddah city (OR: 3.08). This is in agreement with other study, which found that AR was more common among the higher social classes and in urban compared to semi- urban areas[25] . This reveals that the environment plays a significant role in occurrence of allergy disorders. As most of the cities of Saudi Arabia are undergoing marked environmental changes and rapid urbanization, thus, it is expected that incidence of AR will increase in the coming years. This needs to be studied further, to assess the quality of the environment in different areas of Jeddah and study the under lying offensive factors.
In most countries, house dust mites are reported as most common inhalant allergens incriminated in incidence of allergic disorders[49],[50].In Saudi Arabia, rates of sensitization to house dust mites ranges from 26% to 87% in different cities of the kingdom[51]. Jeddah is characterized by a warm and humid environment (being a coastal city), which provide good medium for indoor mites to flourish.
The indoor life style (at home and work) of subjects in economically developed areas exposes them to mites. In the economically developed areas, air pollution, also, due to industrial activities may cause irritation of the airways and nasal passages predisposing it to allergic reactions[52-54].Increased frequency of AR in economically developed areas could be explained by the above-mentioned characteristics.
First and second hand smoking exposure is associated with IgE mediated allergic sensitization[55-57]. Smoking of the father yielded equivocal results on AR among exposed children[58],[59]. However, in the present study we found that after allowing for confounding factors, smoking of the father increased the risk of AR among preschool children by 2.63 times (OR: 0.379; 95% CI 0.214, 0.674; P<0.001).
The occurrence of excess weight among children has reached an epidemic proportion globally. Several studies revealed that excess weight was a significant risk factor for asthma in children[60],[61],[62],[63]. However, studies evaluating relation between excess weight and AR yielded equivocal results[64],[65]. In the present study we found that overweight and obesity among preschool children was a significant risk factor for having AR in the preschool children. Various studies had shown that rhinitis symptoms are already prevalent in the first 6 years of life. Two birth cohort studies monitoring the natural history of childhood rhinitis[66],[67] showed a trend of increasing prevalence over time from infancy to adolescents. In these studies, symptoms of rhinitis were already observable from preschool age. The present study, revealed that symptoms of AR increased with increased age among preschool children where we found that children 4 - 6 years were 2.6 folds risk of having AR compared to 1- < 4 years children (OR 2.665; 95% CI1.445, 4.910; p <0.002), after adjusting for other factors. This is in line with other studies[66],[67]. Primary and secondary prevention of AR are recommended in guidelines[68]. Several studies conducted in United Kingdom and Denmark revealed that AR among children is under diagnosed and under treated by physicians[69],[70].The present study confirmed these findings where we found that about one third of the children with AR (36%), did not consult a physician because of AR symptoms, or received medications for it. In conclusion, this study was undertaken to assess the risk factors contributions to AR among the critical age group 1 - 6 years. The present study found that seasonal AR was the most prevalent type, and AR was underdiagnosed in almost one third of the preschool children with AR. It re-confirmed, also, that genetic factors e.g. family history of allergy and history of other allergic disorders, are risk factors for AR among preschool children. Smoking of the father, formula feeding in infancy, excess weight and lifestyles are risk factors for occurrence of AR. These factors should be considered when trying to develop policies for primary and secondary preventions for AR in Jeddah, and even other cities in Saudi Arabia. Limitations and strengths
This study has several strengths. First, it is a case control study (appropriate design to calculate odds ratio and 95% CI); the multi-nominal logistic regression was used to allow for confounding risk factors. Secondly: the total number of the cases and controls exceeded the minimum number required to make it powered.
However, the study has some limitations. The data were obtained retrospectively, and parents completed the questionnaire. No objective assessment of AR was done.
Acknowledgements
We would like to thank mothers and children who participated in this study. We would like to thank also, Drs (M Al-Sheikh, J Al-Kaf, A Al-Harbi, R Babader, and W Al-Kaf) who participated in collection of the data. Our appreciation will also go to the College of Ibn Sina, and directors of Al-Gadany Hospitals for their material support.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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