Table 1 Statements included in the Delphi Consensus on the pediatric allergic rhinitis management in Italy and relevant answers expressed as percentages of participants voting score 4 or 5, and means ± standards deviations (SD) of the scores 4 and 5

1) Allergic rhinitis is a disease caused by a dysregulation of the immune system that is characterised by type 2 inflammation.

97.2

2) Type 2 inflammation of the nasal mucosa is mainly represented by infiltration by eosinophils.

94.5

3) Type 2 inflammation is closely correlated with sensitisation/re-exposure (inhalation) to the causative allergen, even in the absence of symptoms (minimal persistent inflammation)

91.7

4) As part of the World Allergy Epidemic, allergic rhinitis is a condition that affects more than 20% of the paediatric population and its prevalence is steadily increasing.

97.2

5) Allergic rhinitis can no longer be considered a trivial disease, as it is accompanied by asthenia, irritability, depression of mood, anxiety, poor concentration and sleep disturbances, all annoying symptoms that cause a significant negative impact on quality of life.

97.2

6) Allergic rhinitis is often associated with other conditions such as atopic dermatitis, allergic conjunctivitis, rhinosinusitis, bronchial asthma, eosinophilic oesophagitis, food allergy and sleep disorders. In addition, in paediatric age it can cause altered development of the craniofacial massif and normal development of the dental arch.

100

7) Allergic rhinitis is the main risk factor for the onset of bronchial asthma and, if already present, the main risk factor for poor asthma symptom control.

97.2

8) From these considerations, the concept emerges that allergic rhinitis deserves a specific PDTA (Diagnostic Therapeutic Care Pathway) with particular attention to the search for comorbidities (especially asthma).

100

9) The typical symptoms of allergic rhinitis are nasal itching, sneezing (blanks), watery rhinorrhoea and nasal obstruction. The first three depend mainly on the abundant release of histamine during the allergic reaction (histamine-dependent symptoms), whereas nasal obstruction is mainly an expression of allergic inflammation.

100

10) It follows from this statement that histamine-dependent symptoms are more responsive to the use of antihistamines, whereas nasal obstruction is more responsive to the use of topical corticosteroids.

94.4

11) Topical antihistamines are quicker and allow a lower dosage than the systemic route. They may also be effective on possibly associated ocular symptoms.

80.5

12) Topical corticosteroids are effective and safe drugs at the recommended dosage. They effectively reduce the degree of type 2 inflammation and consequently relieve nasal obstruction and can also act on comorbidities such as rhinosinusitis or eye symptoms or asthma (if associated). At the recommended doses, they are safe even when used for long periods of time.

100

13) Topical corticosteroids must be administered appropriately, considering the symptomatology and mode of application.

100

14) A fixed combination antihistamine/corticosteroid (azelastine/fluticasone) available as a nasal spray has been available for some time. Existing literature highlights its high efficacy, rapid action and safety even in paediatric age.

97.2

15) The azelastine/fluticasone combination acts with a dual effect on both the histamine response and inflammation with greater speed and efficacy than the non-combined administration of the two drugs on all symptoms of allergic rhinitis.

100

16) The combination of azelastine/fluticasone should be considered in children/adolescents when maximum results are to be achieved in a short time.

91.7

17) It is preferable to use the azelastine/fluticasone combination for appropriate periods of time (at least one to two weeks) to ensure prompt resolution of symptoms and adequate control of type 2 inflammation.

88.9

18) However, the combination azelastine/fluticasone can also be used in symptomatic mode in the case of sporadic but nevertheless intense rhinitis episodes

81

19) These considerations give rise to the notion that the combination of azelastine/fluticasone could result in a saving of inhaled corticosteroids when using topical corticosteroids for asthma therapy

80.6

20) The combination azelastine/fluticasone can lead to savings in the use of oral antihistamines with lower economic costs and greater adherence to treatment, which is particularly relevant in adolescence.

83.4

21) In both seasonal and perennial allergic rhinitis, the nasal anti-H1/steroid combination may act more rapidly and therefore be preferred.

86.1

22) In any case, it is essential to take the time to explain well to children/adolescents and their families what allergic rhinitis is, what causes it, and the use of the most appropriate medication, in order to achieve maximum patient engagement in the correct management of the condition.

100