Allergic rhinitis (AR) is a globally prevalent, IgE-mediated inflammatory disorder of the nasal mucosa, characterized by sneezing, nasal congestion, rhinorrhea, and nasal itching. The condition significantly impacts quality of life, academic performance, and sleep in children, and it is also a recognized risk factor for the development of asthma and other atopic conditions 1,2.

In recent years, there has been a notable rise in AR prevalence, particularly among urban pediatric populations, likely attributable to increased exposure to pollutants, allergens, and changing lifestyles 3. Despite the widespread nature of the disease, AR remains substantially underdiagnosed in India, particularly in rural and semi-urban settings where access to specialists is limited and clinical suspicion remains low.

Children with AR are frequently misdiagnosed with recurrent upper respiratory tract infections and are often treated empirically with antibiotics or antihistamines, especially by informal or unqualified healthcare providers. This leads to inappropriate treatment, increased healthcare burden, and unnecessary antibiotic exposure 4. Moreover, misconceptions among caregivers regarding the use of inhaled corticosteroids, fear of dependence on nasal sprays, and the social stigma associated with inhalers further limit effective management 5.

This study was undertaken to assess the true burden of allergic rhinitis in pediatric and ENT outpatient settings over a six-month period, examine its associated risk factors, delineate its clinical profile, assess seasonal patterns, and explore barriers to diagnosis and treatment in a real-world setting.

Methods: Study Design: This was a cross-sectional, observational study conducted in the pediatric and ENT outpatient departments (OPDs) of a tertiary care hospital in North India.

Study Duration: Six months (October 2024 to March 2025).

Study Population: Children aged 2 to 14 years presenting to the OPDs with symptoms suggestive of allergic rhinitis, including recurrent sneezing, nasal congestion, rhinorrhea, nasal itching, or sleep disturbances.

Exclusion Criteria: Children with known chronic sinusitis, nasal polyposis, craniofacial anomalies, immunodeficiency, or any syndromic illness were excluded.

Sampling and Data Collection: Of approximately 9039 children seen during the study period, 486 were diagnosed with allergic rhinitis based on clinical history and ARIA guidelines 6. A structured data collection form was used to gather information on demographics, residence (urban/rural), family history of atopy, environmental exposures (pets, smoke), symptom severity, comorbid asthma, prior diagnosis, treatment history, quality of life (10-point Likert scale), and caregiver-reported reasons for non-adherence.

Diagnosis and Classification: Diagnosis was based on ARIA criteria (symptoms >4 days/week and >4 weeks). Severity classification was based on nasal obstruction, sleep quality, and functional impairment.

Data Analysis: Data were analyzed using Microsoft Excel and SPSS. Descriptive statistics (percentages, means) and temporal trend analysis were used. Month-wise case distribution was plotted. Caregiver response analysis was thematically clustered.

Ethical Considerations: Informed consent was obtained from parents or legal guardians. Institutional Ethics Committee approval was secured.

Out of 9039 children seen during the study period, 486 were diagnosed with allergic rhinitis, yielding a prevalence of 5.38%.

Demographic Characteristics: The mean age of children was 8.1 years (SD ±2.9), with 63% being male. Urban residence was noted in 76% of cases. Family history of atopy was reported in 60%.

Table 1: Demographic and Clinical Features

Table 1: Demographic and Clinical Features of Children Diagnosed with AR

Clinical Profile: Seasonal symptoms were reported by 71% of children. Nasal congestion was moderate in 52% and severe in 22%. Average sneezing episodes were 4.4 per day. Sleep disturbance was noted in 48%. The mean quality of life score was 5.1. Comorbid asthma was identified in 21% of patients.

Table 2: Symptom Burden and Comorbidities in Children with AR

Diagnosis and Treatment Gaps: Only 52 children (10.7%) had been previously diagnosed with AR. None were on ongoing treatment. At the time of consultation, all were advised therapy.

Reasons for Non-Adherence: Key themes included fear of steroids (44%), cessation after symptom relief (25%), denial of diagnosis (20%), and financial burden (11%). These trends were consistent across months.

Table 3: Reasons for Non-Adherence to Allergic Rhinitis Therapy

Seasonal Distribution: A clear seasonal trend was observed. Case numbers peaked in November and again in February, coinciding with post-monsoon allergen exposure and spring pollens. Lowest numbers were seen in December and March.

This six-month cross-sectional study reinforces that allergic rhinitis (AR) remains substantially underdiagnosed and undertreated in pediatric outpatient practice. With a point prevalence of 5.38% among over 9000 children attending OPD services, AR emerges as a common yet under-recognized clinical entity in North Indian children, echoing findings from earlier regional and global studies. Our data corroborate trends noted in previous Indian research, which reported AR prevalence ranging from 4–10%, particularly among urban school-aged children with atopic backgrounds.

A key contribution of this study lies in its integration of symptom burden, treatment adherence barriers, and seasonal variation—a combination rarely explored in a single investigation. The demographic profile of affected children (male predominance, urban residence, positive family history of atopy) aligns with well-established risk factors. The high prevalence of sleep disturbance (48%) and moderate to severe nasal obstruction in nearly three-quarters of children indicates significant functional impairment and highlights the impact of AR on quality of life, which remains underappreciated in routine pediatric care.

The diagnostic gap is striking: only 10.7% of diagnosed children had a prior diagnosis, and none were on ongoing treatment. These findings point to a critical shortfall in both awareness and primary care screening. Contributing factors include limited specialist access, poor caregiver knowledge, and misconceptions regarding intranasal corticosteroids—a theme echoed in Indian and Southeast Asian studies.

An important and novel component of this study is the thematic clustering of caregiver-reported reasons for non-adherence, which revealed a consistent pattern of steroid fear (44%), cessation after symptom relief (25%), diagnostic denial (20%), and financial burden (11%). These insights offer contextual targets for public health messaging and provider education, particularly in semi-urban and rural areas. Interventions such as visual prescription aids, simplified education leaflets, and structured counseling protocols can be developed based on these findings.

Seasonality plays a prominent role. Bimodal peaks in November and February suggest environmental allergens and pollutants—such as post-monsoon mold spores, pollen, and stubble burning—as key triggers. This aligns with prior Indian data linking symptom flares to airborne particulate matter and allergen levels. Incorporating anticipatory guidance strategies—such as preemptive medication initiation during high-risk months and dissemination of air quality alerts—may help reduce AR morbidity and healthcare utilization.

The 21% comorbidity rate with asthma reinforces the 'united airway disease' concept, underscoring the need for integrated respiratory care in children with persistent nasal symptoms. Early identification of AR can potentially prevent asthma progression through timely initiation of therapy and allergen avoidance strategies.

Unlike prior Indian studies focusing primarily on symptom profiles or prevalence estimates, this study offers a holistic, practice-oriented perspective. By leveraging high-volume tertiary care data across two outpatient specialties (Pediatrics and ENT), it enhances the generalizability and clinical applicability of its findings. Moreover, the study's cross-sectional snapshot provides a realistic view of real-world adherence barriers, thereby laying a foundation for behavioral and system-level interventions.

Implications for Practice and Policy

This study highlights the urgent need to:

- Sensitize frontline healthcare providers (including general practitioners and community pediatricians) on AR recognition and rational pharmacotherapy.

- Develop community-based awareness campaigns targeting common myths around steroid use and chronic treatment.

- Include AR screening tools as part of school health programs.

- Utilize seasonal disease alerts via mobile apps and public health platforms to prompt anticipatory care during peak months.

Limitations

This study is not without limitations. The cross-sectional design precludes long-term follow-up on treatment outcomes. Diagnosis was clinical, based on ARIA criteria, without allergen-specific IgE or skin prick testing. Also, recall bias in caregiver responses may have influenced adherence reporting. Being a single-center study, findings may not fully generalize to all geographic settings in India.

Over six months, allergic rhinitis was diagnosed in 486 children attending a tertiary care OPD, revealing a considerable symptomatic burden with clear seasonal peaks. Persistent underdiagnosis and caregiver-driven treatment discontinuation reflect the critical need for awareness programs, training for frontline providers, and robust counseling strategies. Integration of seasonal trends into anticipatory pediatric care may enhance control and prevent escalation to asthma. Pediatricians should consider AR in all children with persistent cold symptoms and integrate seasonal alert systems into anticipatory guidance

1. Bousquet J, Khaltaev N, Cruz AA, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update. Allergy. 2008;63(Suppl 86):8–160.
2. Brożek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines – 2010 revision. J Allergy Clin Immunol. 2010;126(3):466–476.
3. Pawankar R. Allergic diseases and asthma: a global public health concern and a call to action. World Allergy Organ J. 2014;7(1):12.
4. Sharma A, Meena RS, Singh V, et al. Clinical profile of allergic rhinitis in children: A hospital-based study in North India. Indian Pediatr. 2020;57(6):543–546.
5. Patra AC, Tripathy MR. Knowledge, attitude, and practices of parents regarding inhalation therapy in children with asthma. Indian J Pediatr. 2020;87(10):781–785.
6. Brożek JL, Bousquet J, Agache I, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines – 2016 revision. J Allergy Clin Immunol. 2017;140(4):950–958.
7. Arora N, Gaur SN, Pawankar R. Allergic rhinitis: an Indian perspective. Indian J Otolaryngol Head Neck Surg. 2011;63(2):137–142.
8. Singh AB, Mathur C. An aeroallergen spectrum in respiratory allergic patients in Delhi, India. Asian Pac J Allergy Immunol. 1992;10(1):45–48.
9. Dey AN, Bhalerao V, Dey S. Seasonal variation of allergic rhinitis in children in relation to airborne pollen and pollutants in Lucknow. Indian Pediatr. 2019;56(8):635–639.
10. Pawankar R, Canonica GW, Holgate ST, Lockey RF, Blaiss M. WAO white book on allergy: Update 2013. Milwaukee, WI: World Allergy Organization.
11. Katelaris CH, Lai CKW, Rhee CS, et al. Nasal allergies in the Asian-Pacific population: Results from the Allergies in Asia-Pacific Survey. Am J Rhinol Allergy. 2011;25(Suppl 1):S3–S15.