PEDIATRIC ALLERGYBrian 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 salute Nasal crease Allergic shiners

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

Allergen Specific IgE Serologic Testing

Skin Prick 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

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