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The Informed Parent

The Persistent Runny Nose

by Pediatric Medical Center
Published on Apr. 23, 1997

Young children never seem to be greatly bothered by a collection of mucus on their upper lip. They eat, sleep and play with the glistening liquid layer coating the skin under their nose. As they get older they are not so compliant; a "drippy nose" causes loud complaints. The parent, child or both are irritated by the presence of a snotty nostril.

We are not discussing the child who develops a fever, cough or nasal discharge that lasts five-to-seven days. The child-in-point is the one who has nasal discharge for weeks or months at a time. He does not appear ill and has no fever. A headache may come and go, but no acute problem is apparent. If antibiotics are used, a slight decrease in symptoms may occur but nothing significant or long-lasting. Is this a chronic cold? Is it an allergy? What can be done to alleviate the situation?

First, children do not have chronic colds as previously mentioned. A cold, meaning a viral infection of the nose and throat, lasts on an average of five days. The average elementary school child gets about three to five colds per year. Whether they are treated or not, they improve readily. What we are talking about is a chronic or recurrent watery discharge from the nose, with congestion. This is also known as serous (clear discharge) rhinitis (inflammation of the nose).

To digress for a moment: it disturbs me when I hear someone say that it is worthless to give parents or patients medical terminology because they cannot "handle it". I am convinced from my practice experience that they can "handle it" if we explain it to them. Thus,in this discussion I will refer to this condition as chronic serous rhinitis.

Let's look at this condition. The two most common causes are allergy and vasomotor over-reactiveness of the tissue lining of the nose and throat. The latter condition involves over-reaction to an irritating stimulus or environmental change.

In allergic rhinitis, the child has antibodies (specific proteins) in the blood stream that react with specific allergy substances. This provokes the body to release factors that cause the lining of the nose to swell, itch and produce excess mucus. In vasomotor rhinitis, the irritating substance affects the lining of the nose directly. No antibodies are present. Everyone is aware of allergies to airborne pollen, dust,fungus, animal dander, and food. The patient inhales, eats,or touches the substance he is allergic to; it enters the blood stream and the reaction occurs.

I find that many parents are not aware of the non-allergic vasomotor rhinitis. This condition is provoked by exertion,sudden changes in environmental temperature, changes in barometric pressure, chlorinated pool water, perfumes, flower scents, smoke, vapors from volatile liquids, as well as anxiety and fatigue. I am sure you have heard someone tell you, "I'm allergic to air conditioners", or "I'm allergic to perfume",or "Every time the weather changes I get allergies". These people are describing non-allergic, vasomotor rhinitis. The specific reaction they complain about has no relation to allergy.

When confronted with this type of patient the physician must separate allergy from non-allergy. Both conditions look and act the same. The treatment varies between the two diagnoses. The physician might resort to laboratory tests and allergy skin testing to separate the two conditions. At times the two co-exist in the same patient. Thus, your physician may find clear cut evidence of allergy, manage the allergy component perfectly, and still have some symptoms. To achieve complete control the vasomotor component must also be treated.

In the past, a child with this problem might have been given small shots of gamma globulin, but more recent studies have demonstrated these children are not deficient in gamma globulin. Before the advent of the newer test procedures all of these children were called "allergic children". As you would guess, they did not improve under the usual allergy treatments.

There is usually a strong family tendency to both types of rhinitis. Only after caring for the child does the parent realize he or she has non-allergic rhinitis.

Ignoring the problem is not wise,as these children tend to get secondary infections in the nose and ears due to the congestion. Furthermore, if allergy is the problem, not only the nose but the child's general well being may be affected. Irritability, headaches, poor school performance and mild behavior problems may also be associated with the allergy.

Treatment for the two conditions is not always the same. It is important to separate the allergic from the vasomotor type. For example, "allergy shots" would prove useless for the non-allergic patient.

In order to separate the two types, the physician will need a careful history with specific questioning on what triggers the attacks. All too often, cells in the nasal mucus are the same in both conditions. Blood counts and specific gamma globulin determinations are frequently not helpful.

The treatment for allergic rhinitis rests on the use of antihistamines or steroid nasal sprays. When it is non-allergic, best results seem to come from decongestants and sodium chromolyn nasal sprays. Since many patients have combined allergic and vasomotor types, the popular combination of antihistamine with a decongestant proves very helpful.

The management of these patients rests in a team approach. This team should be composed of parents, physician and patient. In the long run specific diagnosis and therapy decreases the number of infections, school days missed and child irritability. Remember, chronic nasal drainage does not always mean infection or allergy. Environmental changes can also provoke a "gooey nose."

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