The present Delphi Consensus globally involved 47 Italian experts on AR management in the pediatric setting. Therefore, the present Delphi Consensus reflected how pediatric AR is managed in Italy’s real-world practice. The profile of participants also guaranteed an adequate standard of outstanding scientific profile.

There is good agreement (> 90%) among participants on the concepts that type 2 inflammation signs AR and leads to eosinophilic infiltration of the nasal mucosa. Namely, there is a body of evidence sustaining this concept [8]. In addition, large majority of participants believe that allergic inflammation depends on causal allergen exposure even without symptom occurrence, i.e., the concept of minimal persistent inflammation [9].

Most participants agreed about the increasing prevalence of AR as recently demonstrated by a meta-analysis [10].

Almost all participants (97%) shared the concept that AR should be not 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. The document ARIA and robust evidence confirmed these AR characteristics [11].

There was also full agreement (100%) about the notion that AR frequently presents comorbidity [12]. Namely, AR is often associated with other conditions such as atopic dermatitis, allergic conjunctivitis, rhinosinusitis, bronchial asthma, eosinophilic esophagitis, food allergy and sleep disorders [13]. In addition, in pediatric age, AR can cause altered development of the craniofacial massif and normal development of the dental arch [14].

A near full agreement (97.2%) concerned the idea that AR is the main risk factor for the onset of bronchial asthma and, if already present, the main risk factor for poor asthma symptom control. In this regard, there is large evidence supporting this statement and is widely shared [15]. As a result, all participants agreed about the need of thorough diagnostic pathways to early detect asthma comorbidity. There is evidence that adequately treating AR significantly affect asthma course [16].

There was also full consensus about the pathophysiological characteristics of AR symptoms. Nasal itching, sneezing (blanks), and watery rhinorrhoea 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 [17]. Instead, nasal obstruction is mainly an expression of allergic inflammation and intranasal corticosteroids efficaciously dampen type 2 inflammatory events [18].

However, an agreement (80.5%) was reached concerning the use of topical antihistamines, probably regarding the possible relief of ocular symptoms. Namely, there is a large pier of studies in fact that have shown that intranasal antihistamines allow significant dose reduction and are more effective than the systemic formulation [19]. In addition, there is also evidence about their efficacy in alleviating ocular symptoms as recently documented by a meta-analysis [20].

There was a full agreement (100) concerning the efficacy and safety of topical corticosteroids in treating patients with AR. There was shared awareness that 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 [21]. Consistently, all participants agreed on the fact that topical corticosteroids must be administered appropriately, considering the symptomatology and mode of application [22].

Almost full consensus (97.2%) regarded the statement declaring that a fixed combination antihistamine/corticosteroid (azelastine/fluticasone) has high efficacy, rapid action and safety even in pediatric age [23]. Similarly, there was full agreement on the concept that 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, as well documented in literature [24]. There was also high grade of consensus (91.7%) about the concept that the combination of azelastine/fluticasone should be considered in children/adolescents when maximum results are to be achieved in a short time. Namely, this fixed combination provides a quick symptomatic activity [25].

Most participants (88.9%) agreed that using the azelastine/fluticasone combination is indicated for appropriate periods of time (at least one to two weeks) to ensure prompt resolution of symptoms and adequate control of type 2 inflammation. This statement reflects the need of assuring a dampening of type 2 inflammation that usually requires one-two weeks [26]. There was also consensus (81%) about the combination azelastine/fluticasone can also be used in symptomatic mode in the case of sporadic but nevertheless intense rhinitis episodes. In this case, some participants preferred to prioritize inflammation control activities over merely symptomatic ones.

Moreover, there was an agreement about the notion that the combination of azelastine/fluticasone could result in a saving of inhaled corticosteroids when using topical corticosteroids for asthma therapy. Probably, some participants were doubtful that properly treating allergic rhinitis can also positively influence the anti-inflammatory treatment of asthma. In fact, there is a large body of evidence that instead shows how important it is to treat allergic rhinitis well to ensure adequate asthma control [27]. Consistently, some panelists expressed low agreement about 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. Actually, there is documentation that azelastine/fluticasone improves the AR management [28].

Also concerning the rapidity of action and consequently the preference for azelastine/fluticasone there was a wide agreement (86.1%). There is evidence that this combination is quicker than antihistamines alone in relieving complaints [25].

The last statement gathered full approval as to take the time to explain well to children/adolescents and their families what allergic rhinitis is, its causes and the use of the most appropriate medication, in order to achieve maximum involvement (patient engagement) in the proper management of the disease is crucial.

The present document had some limitations, including the collection of personal opinions, the lack of objective measures, and mostly the absence of clinical data. Moreover, the statements concerned only some aspects of AR management. However, this consensus involved outstanding pediatricians managing many children with AR with large experience. Thus, the results provided robust outcomes that also reflected what happens in the real world. Further studies should confirm these findings, adopting adequate methodology. In the future, this initiative could involve a wider audience of pediatricians involved daily in their clinical practice in the management of children and adolescents with AR. Moreover, the SIAIP is currently engaged and will be even more so in the future in initiatives aimed at updating knowledge on the topic through various educational initiatives (distance learning, meetings, courses, and congresses). The primary outcome should be to achieve a large application of these recommendations in clinical practice.

In conclusion, the present Delphi Consensus reported that a panel of Italian expert pediatricians considered the type 2 inflammation the leading characteristic of allergic rhinitis, so deserving adequate treatment. Contextually, this documented endorsed the concept that a rapid symptom relief represents a priority objective in managing children and adolescents with allergic rhinitis. In addition, safety should be always evaluated prescribing any therapy. In this context, the present Delphi Consensus underlined the experts’ opinion that the fixed combination of intranasal corticosteroid plus antihistamine (i.e., azelastine/fluticasone) may represent a valuable option for treating young people with allergic rhinitis. This issue reflects what the most recent guidelines advocate on AR management.