1. P EDIATRIC A LLERGY Brian Safier MD

2. A LLERGIC R HINITIS

3. 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)

4. R HINITIS Heterogeneous group of nasal disorders characterized by 1 or more of the following symptoms: Sneezing Nasal itching Rhinorrhea Nasal congestion

5. R HINITIS Causes include: Allergic (most common) Nonallergic Infectious Hormonal Occupational 44-87% of rhinitis is mixed (allergic & nonallergic)

6. T YPES OF R HINITIS

7. C ONDITIONS T HAT M IGHT M IMIC R HINITIS

8. A LLERGIC R HINITIS 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 T H 2 cells & macrophages – similar mediators released as in early response Similar symptoms as early response but congestion is more prominent

9. A LLERGIC R HINITIS : P HYSICAL F INDINGS Normal turbinatePale (allergic) turbinate Allergic saluteNasal crease Allergic shiners

10. A LLERGIC R HINITIS : T ESTING 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

11. A LLERGIC R HINITIS : T REATMENT 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

12. A LLERGIC R HINITIS : T REATMENT 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

13. A LLERGIC R HINITIS : T REATMENT 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

14. A LLERGIC R HINITIS : T REATMENT 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)

15. A LLERGY T ESTING Allergen Specific IgE Serologic Testing Skin Prick Testing

16. A LLERGY T ESTING 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

17. A LLERGY T ESTING 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

18. A LLERGY T ESTING 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

19. F OOD A LLERGY

20. 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

21. F OOD A LLERGY

23. F OOD A LLERGY M ANAGEMENT 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

25. O RAL A LLERGY S YNDROME 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

26. V OCAL C ORD D YSFUNCTION 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

27. V OCAL C ORD D YSFUNCTION 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

28. D RUG A LLERGY 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