Pediatric Allergy

Pediatric Allergy Brian Safier MD

Allergic Rhinitis

Allergic Rhinitis • Affects 10% to 25% of the population • Can significantly decrease quality of life, aggravate comorbid conditions (e.g. asthma), & predispose to respiratory infection (e.g. sinusitis)

Rhinitis • Heterogeneous group of nasal disorders characterized by 1 or more of the following symptoms: • Sneezing • Nasal itching • Rhinorrhea • Nasal congestion

Rhinitis • Causes include: • Allergic (most common) • Nonallergic • Infectious • Hormonal • Occupational • 44-87% of rhinitis is mixed (allergic & nonallergic)

Types of Rhinitis

Conditions That Might Mimic Rhinitis

Allergic Rhinitis • Early Response - within minutes of allergen exposure • Preformed mediators: • Histamine, Tryptase • Itch, rhinorrhea, sneeze • Rapidly generated mediators: • Cysteinyl leukotrienes, Prostaglandin D2 • More important in development of nasal congestion • Sensory nerve stimulation • Perception of nasal congestion & itch • Paroxysmal sneeze • Late-Phase Response – 4-8 hours after exposure • Eosinophils, some neutrophils & basophils, and eventually TH2 cells & macrophages – similar mediators released as in early response • Similar symptoms as early response but congestion is more prominent

Allergic Rhinitis: Physical Findings Normal turbinate Pale (allergic) turbinate Allergic shiners Allergic salute Nasal crease

Allergic Rhinitis: Testing • Important to confirm diagnosis & guide avoidance measures, particularly with perennial rhinitis in which history alone is often insufficient to distinguish between allergic & nonallergic • Necessary when allergen immunotherapy is being considered • Skin testing is preferred over in vitro testing for its simplicity, ease, rapidity of performance, & high sensitivity

Allergic Rhinitis: Treatment • Avoidance • Dust mite • Dust mite covers for pillow, mattress, box spring • Wash bedding in hot water every 1-2 weeks • Keep humidity below 50% (35-45% is ideal); also important for mold control • Pollen • Keep windows shut in home & in the car • Limit outdoor activity when pollen counts are high • Change clothing & bathe after outdoors for extended period of time • Pets • Wash pet often • Keep pet out of bedroom

Allergic Rhinitis: Treatment • Medication • Must consider age, personal preference, tolerability, cost, response to past medication use, severity of symptoms, associated conditions, patient compliance, side effects • Oral antihistamines • Generally well tolerated vs. nasal sprays which children sometimes resist • Good option for mild to moderate symptoms, particularly with associated allergic conditions such as conjunctivitis & asthma • Nasal steroid spray (standard vs. dry aerosol) • Must be used every day • Indicated for ages 2 years old and up • Likely more effective than nasal antihistamines for nasal congestion • May cause nosebleed • Nasal antihistamine spray • Bitter taste may affect tolerability • Indicated for ages 6 years old and up • May be used on as needed basis • Similar efficacy to nasal steroid spray for most symptoms • Potential for nosebleed less than nasal steroid

Allergic Rhinitis: Treatment • Medication • Combination nasal steroid & antihistamine • For moderate to severe symptoms incompletely controlled by solo therapy • Leukotriene receptor antagonists • Typically not as effective as other treatments • Good option for mild allergic rhinitis with mild allergic asthma/exertional asthma • May provide additional relief when other medications incompletely treat symptoms

Allergic Rhinitis: Treatment • Allergen immunotherapy • Only disease modifying modality for the treatment of allergic rhinitis • No minimum age per practice parameters, however safest use of this treatment necessitates child’s ability to report subjective symptoms (~7 years old) • Typically relieves dependence on medication • Decreases development of additional allergy • Effective treatment for allergic asthma & may prevent the development of asthma in patients with allergic rhinitis without asthma • Option for dust mite allergic eczema • Risks: reaction at injection site (common), anaphylaxis (rare)

Allergy Testing Skin Prick Testing Allergen Specific IgE Serologic Testing

Allergy Testing • Should only be performed when indicated by detailed history! • Useful for detection of environmental and food allergy • Utility for environmental allergy detection • Confirm suspected diagnosis elicited by history • Guide avoidance measures • Allow for the option of allergen immunotherapy • Utility for food allergy detection • Confirm suspected diagnosis elicited by history • Monitor for evidence of waning allergy on annual basis • Unnecessary food allergy testing may lead to unnecessary avoidance measures, nutritional compromise, and family stress

Allergy Testing • Mean serum IgE levels progressively increase in healthy children up to 10 to 15 years of age and then decrease from the second through eighth decades of life • Sometimes testing in young children with allergic symptoms is initially negative and repeat testing within the following years is positive • Seasonal allergy is typically not evident clinically or on testing until there have been at least 3 seasons worth of pollen exposure

Allergy Testing • Immunosorbent Allergen Chip (ISAC) component testing • Detects components of whole allergen • Standard serologic testing detects IgE binding to whole allergen • Small quantity of blood required • Currently not covered by insurance • Out of pocket cost is approximately $150-300

Food Allergy

Food Allergy • Adverse immune responses to foods affect approximately 5% of young children and appear to have increased in prevalence • Diagnosis is complicated by the observation that detection of food-specific IgE (sensitization) does not necessarily indicate clinical allergy. Therefore diagnosis requires a careful medical history, laboratory studies, and, in many cases, an oral food challenge to confirm a diagnosis. • Of the patients whose food allergy resolves, 80% resolves by the age of 16 years old

Food Allergy

Food Allergy Management • Strict Avoidance • Food Allergy Action Plan • Epipen/Epipen Jr. to be available at all times • Epinephrine is the only life saving treatment for an anaphylactic reaction • Fatalities are primarily from reactions to peanuts/tree nuts, are associated with delayed treatment with epinephrine, & occur more often in teens/young adults with asthma & a previously diagnosed food allergy • Referral to Food Allergy and Anaphylaxis Network website • www.foodallergy.org • In development • Oral/Sublingual Immunotherapy for food allergy

Oral Allergy Syndrome • Allergic reaction to fruits, vegetables, and nuts that is limited to the mouth and throat • Itch (main symptom) • Mild swelling • Occurs in pollen allergic patients because of cross-reactivity between the pollen and the food • 1.5% of these patients will develop a serious allergic reaction if the patient continues to eat the offending food • Avoidance is recommended

Vocal Cord Dysfunction • Symptoms include dyspnea, wheeze, tightness in the neck, shortness of breath, inability to breathe deeply or satisfactorily, and coughing • Some patients have concurrent asthma & chronic rhinosinusitis with postnasal drainage or reflux • Can be intermittent and might not be present when the patient is distracted, sedated, or asleep

Vocal Cord Dysfunction • Suspect when difficulty breathing surpasses the physical findings • Clear chest on auscultation • Wheeze over the neck, not over the chest • Whispering instead of talking loudly • Refusal to inspire to total lung capacity • Inspiratory loop on spirometry may be truncated or flattened • Referral to laryngologist for laryngoscopy, reflux management, and speech therapy

Drug Allergy • Often difficult to distinguish between drug allergy and rash triggered by acute illness • The only reliable drug allergy testing available is for penicillin • Skin prick test, then intradermal testing (i.e. needles), then oral challenge • Takes approximately 2 hours

Pediatric Allergy