Abstract

Allergic rhinitis (AR), a chronic inflammatory disease of the upper airway, is one of the most common chronic diseases in the United States and is estimated to affect up to 60 million people. Pediatric Allergies in America is the largest and most comprehensive survey to date of pediatric patients and parents of patients with allergy, as well as health care providers (HCPs), regarding AR in children and its treatment. The goals of the survey were to determine the prevalence of AR in the US pediatric population and to collect information on what effect the condition has on patients in terms of symptom burden, quality of life, productivity, disease management, and pharmacologic treatment. This national survey screened 35,757 households to identify 500 children with HCP-diagnosed nasal allergies and 504 children without nasal allergies who were between the ages of 4 and 17 years. Parents of young children, as well as children 10 to 17 years of age, were questioned about the condition and its treatment. In parallel, 501 HCPs were interviewed. This survey has captured previously unavailable data on the prevalence of nasal allergies and their most common and most bothersome symptoms, on the effect of nasal allergies on the quality of life of children, and on medication use, including both over-the-counter and prescription medications, and has identified factors affecting satisfaction with treatment. The Pediatric Allergies in America survey also identifies distinct areas for improvement in the management of AR in children. In fact, based on the results of this survey, it appears that HCPs overestimate patients' and parents' satisfaction with disease management and the benefit of medications used for the treatment of nasal allergies in children. Findings from this national survey have identified important challenges to the management of AR, suggesting that its burden on children in the United States has been significantly underestimated. Allergic rhinitis (AR), a chronic inflammatory disease of the upper airway, is one of the most common chronic diseases in the United States and is estimated to affect up to 60 million people. Pediatric Allergies in America is the largest and most comprehensive survey to date of pediatric patients and parents of patients with allergy, as well as health care providers (HCPs), regarding AR in children and its treatment. The goals of the survey were to determine the prevalence of AR in the US pediatric population and to collect information on what effect the condition has on patients in terms of symptom burden, quality of life, productivity, disease management, and pharmacologic treatment. This national survey screened 35,757 households to identify 500 children with HCP-diagnosed nasal allergies and 504 children without nasal allergies who were between the ages of 4 and 17 years. Parents of young children, as well as children 10 to 17 years of age, were questioned about the condition and its treatment. In parallel, 501 HCPs were interviewed. This survey has captured previously unavailable data on the prevalence of nasal allergies and their most common and most bothersome symptoms, on the effect of nasal allergies on the quality of life of children, and on medication use, including both over-the-counter and prescription medications, and has identified factors affecting satisfaction with treatment. The Pediatric Allergies in America survey also identifies distinct areas for improvement in the management of AR in children. In fact, based on the results of this survey, it appears that HCPs overestimate patients' and parents' satisfaction with disease management and the benefit of medications used for the treatment of nasal allergies in children. Findings from this national survey have identified important challenges to the management of AR, suggesting that its burden on children in the United States has been significantly underestimated. Allergic rhinitis (AR) is a chronic inflammatory disease of the upper airways that is characterized by the symptoms of nasal congestion, rhinorrhea, sneezing, and nasal itching. AR is estimated to affect approximately 60 million people in the United States, and its prevalence is increasing.1Bloebaum R. Managing allergic rhinitis: the role of pharmacotherapy; sound treatment can improve your patient's quality of life.J Respir Dis. 2002; 23: 370-376Google Scholar, 2Nathan R.A. The burden of allergic rhinitis.Allergy Asthma Proc. 2007; 28: 3-9Crossref PubMed Scopus (384) Google Scholar, 3Settipane R.A. Rhinitis: a dose of epidemiological reality.Allergy Asthma Proc. 2003; 24: 147-154PubMed Google Scholar The Agency for Healthcare Research and Quality estimates the prevalence of AR in adults to be between 10% and 30%, and several studies have estimated the prevalence of AR in children to be closer to 40%.4Berger W.E. Allergic rhinitis in children: diagnosis and management strategies.Paediatr Drugs. 2004; 6: 233-250Crossref PubMed Scopus (61) Google Scholar, 5McCrory D.C. Williams J.W. Dolor R.J. Gray R.N. Kolimaga J.T. Reed S. et al.Management of allergic rhinitis in the working-age population.Evid Rep Technol Assess (Summ). 2003; 67: 1-4PubMed Google Scholar, 6Wright A.L. Holberg C.J. Martinez F.D. Halonen M. Morgan W. Taussig L.M. Epidemiology of physician-diagnosed allergic rhinitis in childhood.Pediatrics. 1994; 94: 895-901PubMed Google Scholar Allergies in America, a recent survey of adults with nasal allergy in the United States, estimates that 1 (14%) in 7 adults is diagnosed by a health care practitioner with AR, nasal allergies, or “hay fever.”7HealthStar Communications, Inc, in partnership with Schulman, Ronca and Bucuvalas, Inc. Allergies in America: a landmark survey of nasal allergy sufferers. Executive summary. Altana Pharma US, Inc, Florham Park, NJ2006Google Scholar, 8Meltzer E. Blaiss M. Derebery M. Boyle J. Naclerio R. Hadley J. et al.Perspectives on allergic rhinitis and its treatment.Allergy Asthma Proc. 2007; 28: S1-S32PubMed Google Scholar Most (80%) individuals develop symptoms of AR before 20 years of age, with 40% of patients becoming symptomatic by age 6 years.9Skoner D.P. Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis.J Allergy Clin Immunol. 2001; 108: S2-S8Abstract Full Text Full Text PDF PubMed Scopus (658) Google Scholar AR can be categorized as seasonal or perennial depending on allergen sensitivity. Among US adults diagnosed with AR, 40% have perennial AR, and 20% have seasonal AR; an additional 40% have perennial AR with seasonal flare-ups.9Skoner D.P. Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis.J Allergy Clin Immunol. 2001; 108: S2-S8Abstract Full Text Full Text PDF PubMed Scopus (658) Google Scholar It is noteworthy that approximately 50% of adults with AR report that their symptoms last for more than 4 months of the year and that 20% report symptoms for more than 9 months.2Nathan R.A. The burden of allergic rhinitis.Allergy Asthma Proc. 2007; 28: 3-9Crossref PubMed Scopus (384) Google Scholar Although AR can be associated with significant morbidity, its effects are not limited to its physical symptoms. Often, the true effect of this disease involves the profound consequences it imposes on the patient's quality of life (QoL), emotional well-being, productivity, and cognitive functioning. Many of these health-related QoL issues appear to stem, in part, from sleep disturbances associated with AR.2Nathan R.A. The burden of allergic rhinitis.Allergy Asthma Proc. 2007; 28: 3-9Crossref PubMed Scopus (384) Google Scholar In addition to the physical and emotional toll that AR elicits in patients, it also places a considerable economic burden on the US health care system. This burden includes both direct costs to patients and insurance providers and indirect costs that include patient absenteeism (missed days at work/school) and presenteeism (decreased productivity at work/school).2Nathan R.A. The burden of allergic rhinitis.Allergy Asthma Proc. 2007; 28: 3-9Crossref PubMed Scopus (384) Google Scholar Although treatment of AR often begins with environmental control to reduce allergen exposure, pharmacologic intervention is often required for control of moderate-to-severe symptoms. Intranasal corticosteroid (INCS) sprays are generally considered the gold-standard pharmacotherapy for AR in both adults and children.10Dykewicz M.S. Fineman S. Skoner D.P. Nicklas R. Lee R. Blessing-Moore J. et al.Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology.Ann Allergy Asthma Immunol. 1998; 81: 478-518Abstract Full Text PDF PubMed Google Scholar Over-the-counter (OTC), as well as prescription, oral and intranasal antihistamines, oral and topical decongestants, and leukotriene receptor antagonists are also commonly used pharmacotherapies in both adult and pediatric patient populations.1Bloebaum R. Managing allergic rhinitis: the role of pharmacotherapy; sound treatment can improve your patient's quality of life.J Respir Dis. 2002; 23: 370-376Google Scholar Although these medications can be effective at controlling the symptoms of nasal allergies, they can be associated with adverse effects, such as local epistaxis, nasal dryness, and irritation from intranasal medications and drowsiness from antihistamines.1Bloebaum R. Managing allergic rhinitis: the role of pharmacotherapy; sound treatment can improve your patient's quality of life.J Respir Dis. 2002; 23: 370-376Google Scholar, 11Trangsrud A.J. Whitaker A.L. Small R.E. Intranasal corticosteroids for allergic rhinitis.Pharmacotherapy. 2002; 22: 1458-1467Crossref PubMed Scopus (78) Google Scholar, 12Waddell A.N. Patel S.K. Toma A.G. Maw A.R. Intranasal steroid sprays in the treatment of rhinitis: is one better than another?.J Laryngol Otol. 2003; 117: 843-845Crossref PubMed Scopus (89) Google Scholar The systemic effects of INCSs are of particular concern in children because of the absence of weight-based dosing, as well as reports of cortisol suppression and growth slowing during treatment with INCSs.13Skoner D.P. Gentile D. Angelini B. Kane R. Birdsall D. Banerji D. The effects of intranasal triamcinolone acetonide and intranasal fluticasone propionate on short-term bone growth and HPA axis in children with allergic rhinitis.Ann Allergy Asthma Immunol. 2003; 90: 56-62Abstract Full Text PDF PubMed Scopus (79) Google Scholar, 14Skoner D.P. Rachelefsky G.S. Meltzer E.O. Chervinsky P. Morris R.M. Seltzer J.M. et al.Detection of growth suppression in children during treatment with intranasal beclomethasone dipropionate.Pediatrics. 2000; 105: e23Crossref PubMed Scopus (277) Google Scholar, 15Wihl J.A. Andersson K.E. Johansson S.A. Systemic effects of two nasally administered glucocorticosteroids.Allergy. 1997; 52: 620-626Crossref PubMed Scopus (42) Google Scholar, 16Wilson A.M. McFarlane L.C. Lipworth B.J. Effects of repeated once daily dosing of three intranasal corticosteroids on basal and dynamic measures of hypothalamic-pituitary-adrenal-axis activity.J Allergy Clin Immunol. 1998; 101: 470-474Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar In addition, currently available INCSs and other prescription nasal sprays might not provide complete or long-term symptom relief in children. Limitations in the extent and duration of action of INCSs or other prescription nasal sprays might decrease patient satisfaction with treatment, thereby reducing adherence. Oral and intranasal antihistamines, although clinically effective for the treatment of both seasonal and perennial AR as a monotherapy, are generally considered to be less effective than INCSs for control of nasal allergy symptoms; as a result, antihistamines are frequently paired with either a decongestant or leukotriene receptor antagonist to improve their efficacy.17Spector S.L. Overview of comorbid associations of allergic rhinitis.J Allergy Clin Immunol. 1997; 99: S773-S780Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 18Wallace D.V. Dykewicz M.S. Bernstein D.I. Blessing-Moore J. Cox L. Khan D.A. et al.The diagnosis and management of rhinitis: an updated practice parameter.J Allergy Clin Immunol. 2008; 122: S1-S84Abstract Full Text Full Text PDF PubMed Scopus (856) Google Scholar In contrast, topical decongestants are very effective for improving nasal congestion but are inappropriate for daily use because of the potential for rebound of symptoms (rhinitis medicamentosa).17Spector S.L. Overview of comorbid associations of allergic rhinitis.J Allergy Clin Immunol. 1997; 99: S773-S780Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar Much of the data available in the adult literature regarding prevalence, burden, and QoL effects of AR have not been available with regard to children. Information regarding how side effects from treatment affect the daily lives of children and their adherence to medication is not known. Therefore the Pediatric Allergies in America national survey was conducted to gain insights into the prevalence of AR in children, its symptoms, its effect on QoL, its comorbidities, the use of OTC and prescription treatments, patient satisfaction with symptom relief from treatment, and the side effects from AR treatment and their role in the adherence and discontinuation of AR treatment in children. Because current practice guidelines for AR and AR with comorbid asthma recommend the use of INCSs as first-line agents over other approved therapies, this supplement places an emphasis on INCSs and nasal sprays in general when reporting patient satisfaction with symptom relief, side effects of treatment, and treatment adherence and discontinuation rates (Allergic Rhinitis and Its Impact on Asthma Guidelines; 2008 Practice Parameters). Pediatric Allergies in America, a comprehensive national telephone screening of 35,757 households in the United States, was conducted to identify subjects with nasal allergy between 4 and 17 years of age. This national survey was designed to use a credible data-collection approach to determine the prevalence of AR in the US pediatric population. This survey interviewed the parents of children 4 through 9 years of age and both the parents and children 10 years of age and older and collected information on what this condition means to those who have it in terms of morbidity and management of the disease. During the interviews, an adult member of each household was asked to report the number of children in the household between 4 and 17 years of age who had been diagnosed with AR, nasal allergies, or “hay fever.” The survey identified 500 children who were diagnosed with AR by a health care provider (HCP) and who had symptoms and had taken medication in the previous 12 months. A comparison group of 504 children without nasal allergies was also identified (Table I). The calculation of overall prevalence of the disease in children was based on all children who were reported by parents to have been diagnosed with nasal allergies of all households surveyed that had children younger than 18 years. All other calculations were based on children with (n = 500) and without (n = 504) nasal allergies, as specified above.Table ISurvey demographicsAR (n = 500), no. (%)No AR (n = 504), no. (%)Sex Male263 (53)251 (50) Female235 (47)253 (50)Age (y) Mean (range)7.9 (4-17)10.4 (4-17) ≤7133 (26)166 (33) 8-12168 (34)157 (32) 13-17197 (40)181 (37)Race∗Represents race of parent responder. White367 (73)381 (76) Black51 (10)44 (9) Asian/Pacific Islander10 (2)14 (3) Hispanic19 (4)29 (6) Mixed35 (7)13 (3) Other16 (4)8 (2) Refused10 (2)6 (1)Percentages do not equal 100% within columns as a result of rounding.∗ Represents race of parent responder. Open table in a new tab Percentages do not equal 100% within columns as a result of rounding. The telephone survey lasted an average of 36 minutes (269 questions) in the AR parent group and 18 minutes (123 questions) in the allergy-free parent group. When parents consented, children 10 to 17 years of age responded to a subset of up to 98 questions in addition to the parents' responses. Where relevant (ie, outcomes different), data from parents' responses are reported separately from those of the children's responses. The average interview length of 36 minutes at a rate of approximately 4 questions per minute meant that a respondent answered about 140 questions. However, many of the questions were contingent on a gatekeeper question (eg, “Have you taken an OTC medication for your AR in the past 4 weeks?”), and subsequent questions would only be asked of those who answered in the affirmative. Hence respondents were only asked the subset of all possible questions that were appropriate to their condition and treatment. A parallel survey was conducted among 501 HCPs, including 100 physicians in family practice, 101 allergists, 100 otolaryngologists, and 100 pediatricians, as well as 50 nurse practitioners (NPs) and 50 physician assistants (PAs), to determine HCP's perspectives on children's nasal allergies and their treatment. Physician survey participants were drawn as probability samples from the American Medical Association and the American Osteopathic Association Master List of physicians in the United States. The samples were restricted to physicians in 4 specialty strata who were in active practice and in direct patient care in an outpatient setting. The NP sample was drawn from state licensing board lists, and the PA sample was drawn from the membership list of the American Academy of Physician Assistants. HCP interviews were approximately 20 minutes in length and were composed of 76 questions. Physician respondents were compensated $50, and NPs and physician assistants were compensated $25 for their time. Parents were not compensated; however, children aged 10 to 17 years who agreed to participate in a follow-up questionnaire were compensated $10. Schulman, Ronca and Bucuvalas, Inc, a national public opinion research organization and leading physician experts in the field of AR, collaborated to develop the Pediatric Allergies in America questionnaire. Survey questions were developed through analysis of the relevant literature and identification of questions used to study similar diseases in other accepted health surveys, including the adult Allergies in America survey conducted in January 2006.7HealthStar Communications, Inc, in partnership with Schulman, Ronca and Bucuvalas, Inc. Allergies in America: a landmark survey of nasal allergy sufferers. Executive summary. Altana Pharma US, Inc, Florham Park, NJ2006Google Scholar The AR patient questionnaire focused on general health, AR triggers, AR symptoms, the effects of allergies on QoL and productivity, AR comorbidities, and the effectiveness and side effects of nasal allergy medications in children. The surveys were conducted by Schulman, Ronca and Bucuvalas, Inc, between March and April 2007. Sampling was conducted by using list-assisted random-digit dialing within a geographically stratified design for the US household population. List-assisted random-digit dialing samples are based on a sampling frame that includes all hundred-series telephone banks (eg, 123-456-78xx) with listed telephone numbers to which 2-digit randomized numbers are appended to complete a full telephone number. Although the restriction of the sampling frame to banks with listed numbers excludes an estimated 4% of US households with landlines, it permits an efficient way to generate a simple random sample of telephone numbers. For a simple random sampling of 500 respondents (ie, the sample of children with AR and the sample of children without AR), the maximum expected sampling error would be ± 4.4% at the 95% CI. For the comparisons between the samples of children with allergies and children without allergies, the maximum expected pooled error would be ± 6.2% (95% CI). For the survey of HCPs, in which the simple random sample consisted of 100 respondents (eg, pediatricians), the maximum expected sampling error would be ± 9.8% (95% CI). This survey approach allowed for a relevant and statistically accurate reflection of parents' and physicians' perspectives on the management of AR in the 4- to 17-year-old population of US subjects with allergy. Where appropriate, the comparisons of responses by parents of children with nasal allergies and parents of children without nasal allergies were conducted by means of ANOVA (SAS Institute, Inc, Cary, NC), and P values were reported. However, surveys such as the Pediatric Allergies in America telephone survey tend to obtain responses and opinions that cannot be formally verified. Much like the analysis of reported adverse events that occur in a clinical trial, results from surveys are typically reported by using descriptive measures. Therefore except where noted, most survey results have been reported descriptively. The questions in the patient survey relevant to this publication are detailed by chapter in Appendix 1. Although AR is currently estimated to affect approximately 60 million people in the United States and prevalence is increasing, it is still considered by many to be a nuisance condition of childhood rather than a serious disease.1Bloebaum R. Managing allergic rhinitis: the role of pharmacotherapy; sound treatment can improve your patient's quality of life.J Respir Dis. 2002; 23: 370-376Google Scholar, 2Nathan R.A. The burden of allergic rhinitis.Allergy Asthma Proc. 2007; 28: 3-9Crossref PubMed Scopus (384) Google Scholar, 3Settipane R.A. Rhinitis: a dose of epidemiological reality.Allergy Asthma Proc. 2003; 24: 147-154PubMed Google Scholar Many children become symptomatic and are given diagnoses of AR by age 6 years; 80% of all individuals with AR have symptoms before age 20 years.9Skoner D.P. Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis.J Allergy Clin Immunol. 2001; 108: S2-S8Abstract Full Text Full Text PDF PubMed Scopus (658) Google Scholar According to the Agency for Healthcare Research and Quality, the self-reported prevalence of AR in adults is estimated to be between 10% and 30%, whereas in children numerous studies estimate the prevalence of AR to be nearer to 40%.4Berger W.E. Allergic rhinitis in children: diagnosis and management strategies.Paediatr Drugs. 2004; 6: 233-250Crossref PubMed Scopus (61) Google Scholar, 5McCrory D.C. Williams J.W. Dolor R.J. Gray R.N. Kolimaga J.T. Reed S. et al.Management of allergic rhinitis in the working-age population.Evid Rep Technol Assess (Summ). 2003; 67: 1-4PubMed Google Scholar, 6Wright A.L. Holberg C.J. Martinez F.D. Halonen M. Morgan W. Taussig L.M. Epidemiology of physician-diagnosed allergic rhinitis in childhood.Pediatrics. 1994; 94: 895-901PubMed Google Scholar Allergies in America, a recent survey of subjects with nasal allergy in the United States, estimates that 1 (14%) in 7 adults has a physician's diagnosis of AR, nasal allergies, or hay fever.7HealthStar Communications, Inc, in partnership with Schulman, Ronca and Bucuvalas, Inc. Allergies in America: a landmark survey of nasal allergy sufferers. Executive summary. Altana Pharma US, Inc, Florham Park, NJ2006Google Scholar Similar to the prevalence rate observed in Allergies in America for US adults, the Pediatric Allergies in America survey found that 13% of children had an HCP-confirmed diagnosis of AR and were symptomatic during the year before the survey. This value was based on parents' responses that of the 8,119 households surveyed with children 18 years of age or younger, 1,068 children had been diagnosed with nasal allergies. With the exception of this calculation of prevalence, subsequent analyses were conducted based on 500 children with nasal allergies and 504 children without nasal allergies, as noted in the Methods section. These estimates of symptomatic AR in children fall at the lower end of previous estimates of AR in the US pediatric population (10% to 40%).4Berger W.E. Allergic rhinitis in children: diagnosis and management strategies.Paediatr Drugs. 2004; 6: 233-250Crossref PubMed Scopus (61) Google Scholar, 5McCrory D.C. Williams J.W. Dolor R.J. Gray R.N. Kolimaga J.T. Reed S. et al.Management of allergic rhinitis in the working-age population.Evid Rep Technol Assess (Summ). 2003; 67: 1-4PubMed Google Scholar, 6Wright A.L. Holberg C.J. Martinez F.D. Halonen M. Morgan W. Taussig L.M. Epidemiology of physician-diagnosed allergic rhinitis in childhood.Pediatrics. 1994; 94: 895-901PubMed Google Scholar Among households having children diagnosed with AR, 80% of parents reported that their children had used medication to control nasal allergy symptoms during the previous 12 months. More than half (61%) of all children were diagnosed with AR by age 6 years (Fig 1, A), and the plurality of diagnoses (43%) were made by the child's pediatrician (Fig 1, B). Interestingly, the pediatricians surveyed estimated that among 95 patients (4-17 years of age) seen on average each week (Fig 1, C), 24% (n = 23) of patients had AR. These physician estimates of AR prevalence are similar to those reported by family practice physicians (29%), as well as by NPs and PAs (27%). Ear, nose, and throat specialists estimated that 44% of their patients 4 to 17 years of age had AR; allergists estimated that 67% of patients seen each week had AR (Fig 1, D). Although pediatricians see more patients, make more AR diagnoses, and provide the bulk of the general management and treatment of pediatric AR, only 44% reported that they are familiar with professional guidelines for the diagnosis and management of nasal allergies (Fig 1, E).Fig 1Diagnosis of AR in children. A, Age at diagnosis of children with AR. B, Diagnosing HCP. C, Mean number of patients aged 4 to 17 years seen per week by the HCP. D, Percentage of patients diagnosed with AR by the HCP. E, HCP's awareness of professional guidelines. ENT, Ear, nose, and throat specialist; OTO, otolaryngologist.View Large Image Figure ViewerDownload (PPT) The survey found that, with the exception of allergists, few HCPs routinely use skin or blood tests to confirm a diagnosis of AR. In order of decreasing frequency of diagnostic test use, allergists (99%); ear, nose, and throat specialists (28%); NPs/PAs (12%); and pediatricians and family practitioners (7%) say they perform skin tests all or most of the time. Even fewer (≤17%) HCPs use blood tests to confirm an AR diagnosis. Despite the relatively low percentage of HCPs who reported that they routinely used diagnostic tests to confirm AR, 24% of parents said that their child with nasal allergies had a skin test, 11% said that their child had a blood test, and 13% said that their child had both to confirm a diagnosis of AR (Fig 2). Nasal allergies are commonly diagnosed as either seasonal or perennial, although many patients had both types of allergy triggers. When asked whether their nasal allergies were seasonal or persisted throughout the year, 313 (62%) parents reported that their children's allergies were seasonal only, whereas 183 (37%) indicated that their children's allergies occurred throughout the year (Fig 3, A). Similarly, most (54%) HCPs agreed that their pediatric patients primarily had seasonal rather than perennial allergies. Among parents of patients who reported seasonal AR, 76% said that their child's allergies were worse during the spring season, whereas 34% reported that their children's allergies were worse during the fall season (multiple answers were permitted; Fig 3, B). More parents report that their children's nasal allergy symptoms were worse outside (44%) rather than inside (3%), although the remaining 52% of parents reported that the severity of their children's allergies was about the same inside and outside (Fig 3, C). Triggers of nasal symptoms can be divided into allergic and nonallergic types, and most patients reported multiple sensitivities. In keeping with the high percentage of seasonal allergies reported, the most common triggers of nasal symptoms in the allergic children were pollen (54%; including grass [25%], as well as tree and weed allergens), dust (29%), and animal dander (15%). In addition, nonallergic triggers, such as weather (19%), fumes and odors (7%), and exercise (6%), are commonly reported (Fig 3, D). The results of the Pediatric Allergies in America and Allergies in America questionnaires indicate that diagnosed nasal allergies are equally prevalent in children and adults in the United States; however, because they do not include adults or children without a formal HCP-confirmed diagnosis of AR, these surveys likely underreport the overall population prevalence of the disease. Most diagnoses in children are made by a pediatrician who is likely also the child's primary care physician. Most parents and physicians report that children appear to have seasonal allergies, although many also have perennial allergies. In contrast, the Allergies in America survey of US adults found that most adults had perennial allergies, with a slightly lower prevalence of seasonal allergies. When seasonal exacerbations occurred in children with AR, the majority of parents reported that their child's worst allergy symptoms occurred during the spring season, followed by fall. Adults also reported that spring, followed by fall, was the worst time of year for allergy symptoms. AR is characterized by nasal congestion, rhinorrhea, repeated sneezing, and nasal itching, common symptoms brought on by the body's immunologic inflammatory response to allergen exposure.19Bousquet J. Van Cauwenberge P. Khaltaev N. Allergic rhinitis and