Rhinitis

Allergic rhinitis is an extremely common health problem affecting up to 40 million in the United States and between 10–25% of the World’s population1 with the actual prevalence varying within and among countries.2,3,4,5

Typical symptoms of rhinitis include nasal congestion, runny and itchy nose, and sneezing. The eyes, ears, sinuses, and throat can also be involved.

The impact of rhinitis and how it negatively affects the quality and quantity of sleep is underrecognised and undertreated. “Nasal congestion, which is one of the most bothersome and prevalent symptoms of AR (allergic rhinitis), is thought to be the leading symptom responsible for rhinitis-related sleep problems.”1

This section examines nasal congestion and its effect on sleep and ADHD. I have cited quite a number of studies to alert readers to the widespread recognition of this relationship.

Craig et al. notes that “nasal congestion is associated with sleep-disordered breathing and is thought to be a key cause of sleep impairment in rhinitis. The end result is decrease in quality of life and productivity and increased daytime sleepiness.”7

Other researchers observe that “patients with chronic diseases, including chronic respiratory diseases, usually have considerably impaired sleep quality that may increase the frequency of exacerbations and severity of symptoms, lead to difficulty in patient management, and reduce quality of life (QOL).”8

In a paper entitled, “A practical approach to allergic rhinitis and sleep disturbance management,”9 Davies et al. comments that “sleep quality can be significantly impacted by nasal congestion. This may lead to decreased learning ability, productivity at work or school, and a reduced quality of life.”9

This is further summed up by Ferguson, who states that allergic rhinitis “can lead to impaired nocturnal sleep, and this impairment results in daytime fatigue and somnolence, reducing both learning and work efficiency and decreasing quality of life.”10

Treatment of children with ADHD and problem behaviour is commonly done with medication or stimulants. An opportune question to ask is whether this is the correct approach given the potential benefits from addressing allergic rhinitis and improving the quality of sleep?

Researchers found that 28.1% of Singaporean children snored and 6% habitually snored.11 “Atopy such as asthma, rhinitis, and eczema was the strongest risk factor for habitual snoring in Singapore, and the effect was cumulative.” The paper also noted that “children attending psychiatric services in Singapore may also have sleep disorders, the highest prevalence being in children with attention deficit hyperactivity disorder.”11

In a paper entitled, “Pediatric allergic rhinitis: physical and mental complications,”12 Blaiss noted that allergic rhinitis has a far more negative impact on the health of the child than just a simple sneeze. “There are numerous complications that can lead to significant problems both physically and mentally in the child who suffers with allergic rhinitis. Under physical complications, recurrent and/or chronic sinusitis, asthma, and snoring impact children with AR. Sleep disturbances, poor school performance, and hyperactivity are all mental complications seen in many children related to their nasal allergies.”12

In a study by Gottlieb et al., parent questionnaires from 3019 children were analysed to assess the prevalence of sleep-disordered breathing symptoms in five-year-old children and their relation to sleepiness and problem behaviours. Sleep-disordered breathing was defined as frequent or loud snoring, trouble breathing or loud, noisy breathing during sleep, or witnessed sleep apnea.13 The study found “parent-reported hyperactivity (19%) and inattention (18%) were common, with aggressiveness (12%) and daytime sleepiness (10%) reported somewhat less often. SDB symptoms were present in 744 (25%) children.”13 Authors concluded that “children with sleep disordered breathing symptoms were significantly more likely to have parent-reported daytime sleepiness and problem behaviors, including hyperactivity, inattention, and aggressiveness.”13

Brawley et al. analysed data from 30 children to determine the prevalence of allergic rhinitis in patients with physician diagnosed ADHD.14 The paper concluded that “most children with ADHD displayed symptoms and skin prick test results consistent with allergic rhinitis. Nasal obstruction and other symptoms of allergic rhinitis could explain some of the cognitive patterns observed in ADHD, which might result from sleep disturbance known to occur with allergic rhinitis.”14

Authors of the paper entitled, “Attention deficit hyperactivity disorder and sleep disorder,” note that “there is a clear correlation between ADHD and sleep disorders”15 and “by improving these children’s sleep, the symptoms of ADHD are diminished and thus avoid the need to administer psychostimulants, which have undesirable side effects that produce a great deal of anxiety in the parents of these children.”15

In a paper published in the journal Pediatrics, researchers concluded that “inattention and hyperactivity among general pediatric patients are associated with increased daytime sleepiness and – especially in young boys – snoring and other symptoms of SDB. If sleepiness and SDB do influence daytime behavior, the current results suggest a major public health impact.”16 “Children undergoing evaluation for ADHD should be systematically assessed for sleep disturbances because treatment of sleep disorders is often associated with improved symptomatology and decreased need for stimulants.”17

Bearing the documented evidence, having a good night’s sleep is imperative to the health of every child and adult. Treating rhinitis is an absolute must in this regard. “Health professionals and school personnel need to increase their awareness of the ramifications of this disease and actively work to prevent deterioration in both academic achievement and workplace productivity.”6

• Storms W, Allergic rhinitis-induced nasal congestion: its impact on sleep quality.Prim Care Respir J. 2008 Mar;17(1):7-18.
• Sly RM. Changing prevalence of allergic rhinitis and asthma. Ann Allergy Asthma Immunol. Mar 1999;82(3):233-48; quiz 248-52.
• Von Mutius E, Weiland SK, Fritzsch C, et al. Increasing prevalence of hay fever and atopy among children in Leipzig, East Germany. Lancet. 1998;351:862.
• Romano-Zelekha O, Graif Y, Garty BZ, Livne I, Green MS, Shohat T. Trends in the prevalence of asthma symptoms and allergic diseases in Israeli adolescents: results from a national survey 2003 and comparison with 1997. J Asthma. Jun 2007;44(5):365-9.
• Lima RG, Pastorino AC, Casagrande RR, et al.Prevalence of asthma, rhinitis and eczema in 6 – 7 years old students from the western districts of Sao Paulo City, using the standardized questionnaire of the “International Study of Asthma and Allergies in Childhood” (ISAAC)-phase IIIB.Clinics. 2007;62:225.
• Borres MP.Allergic rhinitis: more than just a stuffy nose. Acta Paediatr. 2009 Jul;98(7):1088-92. Epub 2009 Apr 17.
• Lunn M, Craig T.Rhinitis and sleep. Sleep Med Rev. 2011 Feb 10.
• Muliol J, Maurer M, Bousquet J.Sleep and allergic rhinitis.J Investig Allergol Clin Immunol. 2008;18(6):415-9.
• Davies MJ, Fisher LH, Chegini S, Craig TJ.A practical approach to allergic rhinitis and sleep disturbance management.Allergy Asthma Proc. 2006 May-Jun;27(3):224-30.
• Ferguson BJ.Influences of allergic rhinitis on sleep.Otolaryngol Head Neck Surg. 2004 May;130(5):617-29.
• Chng SY.Sleep disorders in children: the Singapore perspective.Ann Acad Med Singapore. 2008 Aug;37(8):706-9.
• Blaiss MS.Pediatric allergic rhinitis: physical and mental complications.Rev Prat. 1996 Apr 15;46(8):975-9.
• Gottlieb DJ, Vezina RM, Chase C, Lesko SM, Heeren TC, Weese-Mayer DE, Auerbach SH, Corwin MJ.Symptoms of sleep-disordered breathing in 5-year-old children are associated with sleepiness and problem behaviors.Pediatrics 2003 Oct;112(4):870-7
• Brawley A, Silverman B, Kearney S, Guanzon D, Owens M, Bennett H, Schneider A. Allergic rhinitis in children with attention-deficit/hyperactivity disorder. Ann Allergy Asthma Immunol 2004 Jun;92(6):663-7.
• Betancourt-Fursow de Jiménez YM, Jiménez-León JC, Jiménez-Betancourt CS.[Attention deficit hyperactivity disorder and sleep disorders].[Article in Spanish]Rev Neurol. 2006 Feb 13;42 Suppl 2:S37-51.
• Chervin RD, Archbold KH, Dillon JE, Panahi P, Pituch KJ, Dahl RE, Guilleminault C. Inattention, hyperactivity, and symptoms of sleep-disordered breathing.Pediatrics. 2002 Mar;109(3):449-56.
• Domínguez-Ortega L, de Vicente-Colomina A [Attention deficit-hyperactivity disorder and sleep disorders].[Article in Spanish] Med Clin (Barc). 2006 Apr 8;126(13):500-6.