Chapters Transcript Sneezing and Wheezing, and Hives, Oh My! How to Help Your Pediatric Patients with Allergies Dr. Rebekah Browning presents about common childhood atopic conditions, appropriate allergy testing and when to refer to allergy. All right. Um, good evening. Thank you so much for allowing me to talk to you a little bit about allergies tonight. Um, I did my MD PhD at Ohio State University, and then did my pes residency at University of Chicago, um, and then finally came here to wash you, uh, for my allergy immunology fellowship. So, I am a Midwest girl through and through, um, and I know how beautiful it can be here in the spring, um, but also how miserable it can be for those of us with allergies. Um, so this is definitely a good time of year, um, for this talk, I believe. All right. I have no relevant disclosures or any disclosures. I'm sorry, we lost your video. Oh, whoops. Here we go, thanks. OK, all right, sorry about that. Um, all right, so no disclosures. Um, and when I was trying to decide what I wanted to talk about, um, tonight, you know, obviously this is a limited time, and I can't address every aspect of allergy. Um, so what I was thinking about was, um, the questions that I often get from my pediatrician friends, um, as well as some of the things that, um, My allergist friends, uh, wish that PCPs knew when they were referring patients to us. Um, so we will review management of some common allergic conditions, um, which will certainly be, you know, just review for most of you. Um, but then we'll talk about some of the newer recommendations, and then we'll discuss, um, when to get allergy testing, what to get. Um, and then, you know, recognizing when to refer to allergy. So, um, you know, obviously, if you take care of kids, you are almost certainly taking care of kids with these conditions. Um, per the CDC, um, in 2021, more than a quarter of kids in the United States had at least one allergic condition, um, and this number is not going down, um. So certainly something that we all see. Um, All right. Um, so we'll start with allergic rhinitis and conjunctivitis. Um, we're all familiar with these common symptoms, um, you know, the sneezing, itchy, watery eyes, runny nose, um, some of these are more obvious than others. Um, kids who have chronic nasal congestion are actually often unaware that they have nasal congestion. Um, because that is just their normal, um, but then if you ask them, you know, plug one nostril and try to breathe in through your nose, they realize that they can't, um, and those kids often say, do you, do you know that a lot of people can actually breathe through their noses? They don't have to only breathe through their mouth, or they can breathe through both sides of their nose at once. Um. In addition to those commonly recognized symptoms, um, allergies can also contribute to these things here on the right. Um, so fatigue, snoring, poor concentration or poor school performance, um, it can cause headaches, it can cause ear infections, um, due to fluid trapping in the middle ear. Um, it can also contribute to oral allergy syndrome, which is when fresh fruits and vegetables cross react with pollen allergens and cause oral itching or tingling, or even swelling. So it can be pretty miserable, um. Especially during the peak of the allergy season, um, and these are, you know, these are probably all things that you have seen, but these are some of the signs that we see, um, in kids who have allergies. So you get the, the facial twitching or grimacing, um, due to eye and nose itching. I tend to think of this as, you know, the sort of like bunny nose where they're twitching their little nose or like the old um Bewitched TV show where she could uh kind of twinkle her nose. Um, then as far as the eyes, in addition to seeing redness and watering or swelling, we see these allergic shiners, um. Due to the vascular congestion around the nose and eyes, um, as well as these Denny Morgan lines, um, which we don't actually know exactly what contributes to that, but they are more common in kids with atopic disease. Um, they can also just be a normal genetic variant, um, but it, it's not uncommon to see those in kids with allergies, um. Are you, are you able to see my arrow? Yeah, yeah, OK, great. OK, um, so this here is the allergic salute, uh, you know, kids rubbing their hand up their nose because it's itching and running, um, often resulting in this, um, In the nasal crease here. And then um chronic mouth breathing can contribute to development of the so-called allergic feces. Um, so that can lead to a high arched palate, um, overbite, and then that sort of uplifted upper lip, um. And then if you look inside an allergic nose, this is pretty classic, um, instead of seeing that nice pink mucosa, um, it is pale, boggy, almost bluish white and um commonly there is um white or clear mucus stranding. So what do we do for these kids? Well, an ounce of prevention is worth £1 of cure, um, But allergy avoidance can be challenging. Um, obviously things like dust mite or pollen, those are everywhere, um, but you can reduce exposure. So, A big one for kids who are allergic to pets, keep pets out of the bedroom and if possible, off of furniture. There's no such thing as a hypoallergenic cat or dog. Um, cat dander in particular is extremely sticky and very hard to get rid of. Um, so we, you know, we don't tell, um, families to get rid of their pets because they're part of the family. Um, unless your pet is landing you in the emergency room or the hospital, um, but there are certain accommodations that you have to make, so, um, Keeping the pet out of the room, um, having covers on the furniture that you can remove, um, before you sit down. Um, and then as far as, um, you know, pets can bring outdoor allergens inside, so, um, having, ideally somebody who is not allergic to those things, brushing or washing the pet, but again, realistically speaking, um, the interventions that work best are the ones that families will actually do, um. So, also during pollen season, keeping windows closed, running the air conditioner, um, and changing that that filter regularly, um, can be beneficial. For dust mite allergies, you want to remove their feeding grounds, so, you know, dust mites feed off of dust and dead skin cells, um, so you want to put covers on the bed, the dust mite covers, um, remove carpet when possible, no stuffed animals on the bed. Um, my children have a an insane collection of squishmallows that they are not allowed to keep on the bed. Um, but, you know, some kids look at me like I'm crazy when I tell them that they have to remove the stuffed animals, but unless you are regularly washing them in hot water, that is a breeding ground for dust mites, um. Linn should be washed regularly in hot water as well. And then you can take some measures to remove allergens after exposure, so showering after playing outside, um, if you've been around, you know, if you've been outside or you've been around pets or something that you know you're allergic to, using a nasal saline rinse, um, or artificial tears can sort of help rinse those mucous membranes, um, and then air purifiers can help with. Pollen, dust, irritants, um, as single interventions, none of these are really spectacular, um, they have limited benefits, but in combination, they can um have some benefit for kids with allergies. And beyond just prevention, um, So when it comes to medication, The nasal steroid sprays are really the most effective option. Um, unfortunately, kids don't like to hear that, families don't like to hear that, um, because it can be difficult to convince a squirming child to let you spray a nose spray, um, up their nose regularly. And these meds do really need to be used consistently. This is not an as needed medication. Um, to really get the benefit of a nasal steroid, it should be used ideally daily, but, you know, realistically speaking, at least every other day. Um. Now, I will say there have been some studies that show prolonged high dose can lead to slowed linear growth, but typically at the doses that we're using for kids, that's not really much of an issue. Um, they do also make a gentler sensitive mist formulation. Um, kids do tend to tolerate that better, but it, of course, is also more expensive. Um, I, I always tell families when they start this, please give it a couple weeks of regular use before you decide that you're going to stop it. It's hard to convince a kid to use a medication that they don't feel an immediate benefit from, but for some kids, this could be a life changing medication. They have to give it a chance to kick in and actually work. Families do tend to like oral antihistamines better. Um, they work quickly, they can be taken as needed. They come in a lot of different forms, usually with, you know, grape flavor or something a little more kid friendly. Um, They're not as effective as the the nose spray, um, but they can be beneficial, especially, um, you know, if you have littler kids that just really aren't going to tolerate a nose spray. Um, or in situations where you know it, um, you're anticipating a limited allergen exposure. So if you're going to your aunt's house and she has 12 cats, and you know you're allergic to cats, you can take that antihistamine before you go, um, and you don't have to build up on a schedule to get that to work. Excuse me. A small percentage of patients do find them sedating, um, and some people complain that it causes dry eye or dry mouth, but for the most part, um, the 2nd and 3rd generations, um, oral antihistamines are, are well tolerated. Uh, for eye symptoms, the nasal steroid can actually provide a lot of benefit with those as well. Um, but for kids who are still getting breakthrough symptoms, despite using the nose spray, um, there are antihistamine, um, eye drops available. They, again, these work quickly, um. If you use them consistently, you can see even more benefit, but they do provide some immediate relief, and you can keep them in the fridge so that they're nice and cool. Um, I find that despite that, a lot of kids still don't think that's very soothing. Anything coming at their eye, they don't super love that. Um. They also typically need twice daily dosing, and they can sting or burn. Um, and again, this is something that can be difficult to do with um uncooperative kids on a regular basis. Uh, an alternative to the nasal steroids is, um, the nasal antihistamine spray. Um, these Unlike the steroids, they, they do work quickly, they can be used as needed, and in some studies, um, they may actually be as effective as the intranasal steroid, um. The the biggest con to these, other than the fact that it is still a nose spray, which a lot of kids don't love, um, is that some of the preparations taste really bad. They're extremely bitter, um. What I tend to say is, you know, if you're using a nose spray properly, and that is you are, you know, you put the tip in your nose and then you angle slightly out towards your ear, and you're not taking a big sniff, then you really shouldn't be getting a lot of nose spray down your throat, and so you shouldn't be tasting it. So if you taste it, you know, you're not getting it to your nose and sinus where it needs to be, you're actually just swallowing it. Um, so like I guess that could be sort of a pro and con. Um, it helps you know if you're using it correctly. Like all the antihistamines, um, some patients do report sedation with it, but again, not as common. So there are a few things here that I wanna mention, should not really be used as first line treatment of allergies. Um, so the big one is first generation antihistamines, um, you know, these have been extremely popular for a long time, but allergists are really moving away from this. Um, they cause, for a lot of people, they cause sedation, um, they can actually You know, like allergies can lead to cognitive impairment and poor school performance. Um, and then in some kids, we actually get paradoxical agitation. Um, so whether it knocks you out or it hypes you up, either way, it, it's, you know, it's not the best option. Um, and they are not more effective than the 2nd and 3rd generation. So there's, there's really not a big role for these in allergy treatment. Um, A certain brand used to have commercials where they would say, don't, don't miss out on life because of your allergies or something to that effect. Um, and I would always laugh and say, yeah, miss out on life because you're unconscious, um, there's no need to be knocked out by your antihistamine. There are better options that last longer work as quickly. Um, other things that I would say avoid for first line treatment. Don't go to the nasal decongestants, um, those can pretty quickly, um, cause tachophylaxis, and then you get that rebound congestion when you try to discontinue it. So not a good option for a chronic condition like allergic rhinitis. And then the leukotrian receptor antagonists, this has been an interesting one. my colleagues and I have noticed a, a definite uptick in kids getting these as a first line treatment for allergic rhinitis. This is not something that we would typically reach to, uh, reach for. For environmental allergies, um, especially given it, it does have that black box warning, um, for possible neuropsychiatric side effects. So, you know, this can cause mood disturbances, um, suicidal ideation, nightmares, night terrors. Um, it, it seems that this is potentially in a in a small percentage, but the The risks, you know, you, you really have to weigh those with the benefits, and if it's just for seasonal allergies, then this is maybe not the the best option. So it can be beneficial for kids, um, especially kids who have, say, asthma and allergies with a lot of congestion, um, but again, They should be discontinued if mood effects occur, and this is something that needs to be discussed with families before starting this. And then another treatment that we Typically don't recommend um would be. Eye drops that contain a redness reducing agent. So, the artificial tears are great, the antihistamines are great, um, but anything that says redness reducing, that has vasoconstrictors in it, you can get rebound redness when you discontinue it. So not, not a great option for a chronic condition. So a lot of people ask me, um, when do we test for allergies? Does it, you know, testing for environmental allergens, does it really make a difference? Does it really change management? And I will say, you know, for some families, probably not. They're just going to continue doing what they're doing, they'll give the antihistamine as needed, um, but there are some benefits to testing. Um, so it, it can help you to avoid, um, exposures to specific triggers or, you know, put mitigation measures in place. Um, it can also help you know the timing for your medications. Um, so if you have a kid who is only allergic to Tree and grass pollen, then you, you wanna make sure that they start their nose spray before the pollen season starts, but then they can likely discontinue that once you get into the fall. Um, for pollen allergies, we do typically recommend starting the nasal spray, um, mid-February and stopping around the first hard freeze. Um, so, Valentine's Day to Halloween, or as I had one patient say to me, chocolate to chocolate. Um, so that's how you know when, um, you know, if you, if you don't have the more year round, um, allergies like the dust mite and mold, if it's strictly just for pollen, then you can just use the nose spray during the time of year that, um, your allergens are around. A couple things to remember about allergy testing. Um, you know, families often interpret high IgE levels or large skin prick testing as severity of reaction, um, when actually with that test is really just your potential to be allergic. So, um, that can be confusing for families. They see a really huge skin prick test, and they say, oh my gosh, you know, the oak trees in our yard are gonna kill little Johnny, we need to cut them all down. Um, but again, you know, it, it doesn't indicate how severe their symptoms will be. It just indicates how likely they are actually to be allergic to that, um. Also cutting down your oak trees isn't gonna help because the wind is gonna bring all the pollen from every tree in the neighborhood anyway. Um, but this is just something to keep in mind, um, when families see those test results, um, it often gets misinterpreted in that way. So when to refer um kids who have allergic rhinitis. Um, so if you prefer to have an allergist, do the testing and interpretation, then by all means send them to us, um, or if families prefer skin prick testing, um, we're able to do that. Um, if you've tried some of those first line interventions and the kids are still just miserable, um, send them our way. Um, if it's Difficult to tell if these are truly allergic symptoms or, you know, is, is this constant runny nose, just back to back to back viral infections from preschool, um, or is this chronic cough actually post-nasal drip from allergies, um, so we can help sort of parse that out. Um, if patients want immunotherapy, then yes, definitely send them to us. Um, and in, in those cases, you would definitely want to let us do the testing because we tailor the, um, the injections that vial is actually made specific for each patient, um, depending on our testing for them. And then if you have a kid who has a lot of multiple atopic conditions, um, then, you know, by all means send them our way. So I do want to briefly talk about urticaria or hives, um, and I love this picture from the American Osteopathic College of Dermatology. I use this in all my hives presentations, um, even though, you know, technically this is dramatic graphism or skin writing and not necessarily hives, but they are related, um. Just because hives are frustrating for families, they are miserable for the kids, um, you know, acute hives, so hives that have been present for less than 6 weeks, those, uh, it's scary, um, and then chronic hives, you know, kids are miserable, um. So I think the media has kind of trained us to see hives and think food allergy, you know, my child was exposed to something and there is a specific trigger, um, when in reality, the, the most common cause of acute hives in kids is infection, not an allergic reaction, and this is something that um Parents have a hard time um wrapping their heads around because they, they want to identify um a specific trigger that they can avoid and then help their kid feel better. So when you have a child um with new onset urticaria, first thing you wanna do is make sure that they're not They're not having an allergic reaction. They're not, you know, um, this isn't the beginning of anaphylaxis, um, so once you've ruled that out, then you wanna make sure, is this actually hives and what are potential triggers for the hives. Um, so you wanna make sure that these are the typical lesions, you know, the transient lesions, they resolve without leaving a mark, um, typically very itchy. Um, I often ask parents, like, do, do they look like mosquito bites? because some parents call everything that is a red rash, a hive. Um, a picture is worth 1000 words, um, if you are not face to face with them, tell them to get a picture and send it to you. Um, and then try to find out, you know, any sick symptoms, um, any new exposures. What was the kid doing when the hives appeared? Was there some kind of physical trigger like cold water or sweating? Um, does it follow that sort of dermatographic pattern where you could write on the skin? So once you've ruled out the scary things, um, you know, once you know that they're not anaplaxing to peanut or something like that, um, then you can And for, for most cases of acute hives, we're just treating the symptoms. Um, we give them antihistamines, so, um, I generally recommend cetirazine. It may take up to 2 to 4 times the typical dose given for, um, what we would give for allergic rhinitis. Um, so if it's a kid that usually would take 2.5 mg, they may need 5 mg twice a day. To actually resolve those hives. You can start low and and go up if you need to, um, but just don't be surprised if it takes more than the usual dose. Obviously, if there is an underlying infection, you treat that. Um, we do not typically recommend steroids because Steroids have side effects, and also once we discontinue them, we often see the hives rebound worse than they were before. The good thing is, is that with acute urticaria, um, they typically resolve within a couple of weeks, so about half of them resolve within the first week, and over 90% have resolved um within 3 weeks. Not fun to wait out, but, you know, the, the antihistamine should hopefully bridge kids to where they're resolving on their own. So, when would you refer a kid for hives? Um, obviously, if you think there is an allergic trigger, um, send them for testing. Um, if you are not able to get control of those hives, despite the increased doses of antihistamine, um, you know, those kids are miserable, um, definitely send them our way. Um, if it seems like The rash might not truly be urticaria, so if, you know, the, the lesions aren't the the individual lesions aren't transient, um, or if the lesions resolve and leave skin changes, um, like bruising. Then they need referral, um, and then that case more likely derm or rheumatology, um, because then we're worried about something like an urticarial, uh, vasculitis. And if it's been a few weeks and the hives are not resolving, um, you can send them our way, you don't have to wait for it to become chronic urticaria. Again, these families are very frustrated because they're expecting, um, They're expecting an isolated trigger to be identified, um, something they can avoid, like peanut, um, but in many cases, you know, an infection just made those immune cells twitchy, um, and this is not an external exposure, um. The call is coming from inside the house, so to speak. Um, the good news is, is that with chronic hives, you know, even the chronic hives tend to burn themselves out eventually, um, and we do have tools beyond the antihistamines and the steroids, um, to treat the symptoms. So, um, including biologics, um, dilumab was just approved for kids 12 and older, um, for chronic urticaria. So, you do not have to wait to refer these kids, but I would ask that you tell families if they decide not to come. Because most of these just resolve on their own, that they would just let us know, um, and cancel their appointment, so. I probably my highest rate of no shows is kids who were referred for acute urticaria, by the time their appointment rolls around, they've forgotten, it's, you know, it's old history. They, they haven't had hives in weeks, and they forgot that they ever even needed to see me, so. And now we'll move on to my favorite topic, which is food allergy. Um, this is my jam, um, but also, I mean, this is unfortunately an area where, um, Doctors have actually done a lot of harm because we contributed to allergy development by telling families to delay um introduction of allergenic foods, um, but now we know better, so we're doing better, um, and this is really an area where pediatricians can play a role in allergy prevention. So, you've probably all heard of the LEAP study, um, that is 10 years old now at this point, um, but it showed that introducing allergenic foods, um, When developmentally appropriate, um, decreases the risk of developing food allergies. So this led to a huge paradigm shift in allergenic food introduction, and since then there have been multiple other studies looking at other allergenic foods, um, including eggs, milk, tree nuts, um, you name it, there's probably a study happening right now, um, with early introduction of those foods. The results have been somewhat mixed, um, some of them have shown trends at decreasing, um, food allergy, but not reaching statistical significance, and it would appear that this is something that um has a more powerful impact in kids who are at higher risk, um, to develop food allergy. So, for your non-atopic kid, it may not matter if you introduce peanut at 6 months or a year, um, but for the exhibitous kid who is at a higher risk of developing, those are the ones who really need to be seen that the allergenic foods earlier. Another result of all these studies, um, is that we have learned it's not enough to just introduce the food. Once it's in the diet, it needs to stay in the diet, so feed early, feed often. Um, introducing a food and then leaving a prolonged interval without the food can actually also contribute to allergy development. So if a kid eats egg at 6 months, and then you wait 2 months before you feed it again, um, they may actually be more likely to develop an egg allergy, um, whereas if you introduce it and then you're keeping it in the diet, um, at least weekly, ideally a couple times a week. Um, then that can reduce their risk of developing an allergy. Families often ask me what order they should introduce foods in, and I generally tell them prioritize the foods that you guys as a family eat most often, because one, they are more likely to give those foods regularly and keep it a regular part of the diet, but two, those are the foods that those kids are more likely to have accidental exposures to, if they did develop an allergy to that food. So this has raised the question, um, initially, the, the guidelines, um, you know, they All the organizations updated their guidelines, right, realizing, oh well, you know, we, we told people to wait and really they should be feeding early. Um, but now the question is, for those kids who are high risk, do we test for peanut before we feed it, or do we just feed it and test later if something happens? Um, and this is just the cover of um the, the updated guidelines from NIA. Um, and then I can show you here. These are different professional organizations and their recommendations on whether to screen or not before introduction of peanut. So you can see some of these organizations are still recommending that you screen um kids who are at higher risk, so kids with severe eczema or known egg allergy. Whereas other organizations are saying don't test, just feed. Um, the quad AI and the college are kind of hedging their bets, and they say, well, you know, you don't have to screen everybody, but talk about it with families and, you know, decide what you think is appropriate. So what I typically do is, um, I have a discussion with the families about the risk and benefit of testing. I generally only test if families are adamant that they will not introduce the food without prior testing. And why is that? Because, you know, a lot of people say, well, what's the harm? What's the harm in testing? Um, the problem is, is that food allergy testing has a really high rate of false positives. Um, it can be, you know, 50%. Um, so really not great, um, if you are screening for a food allergy. Um, especially in kids with eczema because they have poor skin barrier, they're more sensitive, they're more likely to wheel up if you do a skin prick test, and they have really high IgE levels typically. Um, so if you get a food specific IGE, it's really hard to interpret. We don't have good guidelines to say, well, you know, their, their peanut IGE was 10, but their total IgE is 2000. Um, can we safely assume that it's just elevated because their overall IGE is really high. Um, So families don't know what to do with this information, um, and then when families then avoid those foods, that can actually lead to a loss of tolerance, and then that child develops an allergy that potentially That food may have been tolerated if we had just fed it, um. Because when we're looking at food allergy testing, we're just looking at a part of the picture. It doesn't tell the whole story. Um, If you look at an IGE that might be elevated, and yes, that is an allergic antibody, it shows they have potential to be allergic, but there are other factors at play, and maybe that child has a neutralizing antibody that we don't know to test for. There are other immune cells and other serum factors that could be contributing to tolerance. So, The truest test is feeding the food, um, and for a patient who has a false positive and avoids that food, they can lose those tolerance mechanisms. So that, you know, that is a harm, that hurts kids when we are actually contributing to creation of an allergy. So when do we test? If a child has a reaction to a food that is consistent with an allergic reaction, so, you know, the classic hives, swelling, um, cough, wheeze, vomiting, typically within 15 to 30 minutes, you know, if it's Monday morning and parents say, um, That they they ate a peanut butter cup the day before, it, it's not a reaction to the peanut butter cup. Um, the exception to that would be alpha gal food allergy, which actually happens to you in my area of research, and if you want to know more about that, um, Find me and I will talk your ear off about it. Um, but for for most food allergy reactions, they happen fairly quickly, um, and parents aren't typically wondering what it was that caused the reaction. The food allergy testing is just confirming what they already very strongly suspect. And I'm sorry, I think I saw a question pop up, but I. I, I'm not sure how that works in here, so. Um, but I, I do have time for questions at the end. Hopefully, I'll go quickly. um, so when to send a food panel? And that is a trick question because the answer is never, never, never, never set a food panel. Um, I'm not talking about like a tree nut panel or a seafood panel, but I'm talking those broad panels that test everything from like wheat and egg and milk to tomato and chocolate. Um, when you send a mishmash of a whole bunch of common foods, odds are some of them are going to come back positive and then Families might avoid those foods, and again, you know, you're contributing to development of a food allergy that a child might otherwise have been able to eat. Um The worst is if a child has already been eating a food and tolerating it, and then they get a random panel, and then they eliminate it from their diet. And then when they get to me 6 months later, I mean, hopefully it doesn't take that long, but if it does, um, by then they may have actually developed an allergy to a food that they were previously tolerating. So please, no food panels, they should not exist. I said it, they should not exist, um, and I think most allergists would agree with me. But are there any exceptions? What about a kid with eczema? Um, So You know, they rarely foods can cause eczema flares. Um, I think it is probably rarer than people think. Um, but again, you know, if this is a specific food trigger, eliminating that food can actually lead to development of a more severe reaction on reintroduction of that food. So my preference is to treat the eczema, continue to feed the food. And try to find a threshold where the food is not worsening the eczema. And definitely no fishing expedition food panels because, as I said, these kids with eczema are more likely to have those random false positives. Again, kids with random hives, parents want to think it was a food, um, because that is what we are taught. Um, but if they can't point to a food they think is the culprit, it's probably not a food. And then kids with the sort of non-specific or non-classic IGE mediated symptoms, food allergy testing is not helpful in those instances. It, it detects your, it predicts your likelihood of an IG mediated reaction. does not tell you anything about food intolerances, and the IGG tests in the food sensitivity tests that you can get from some companies are not evidence-based or FDA approved. Um, we all make IgG to the foods that we eat. So those are basically expensive tests that tell you what foods you have eaten. So, I would not recommend those. If you truly think a child is allergic to multiple different foods, test those specific foods. Don't send a panel. Let the children eat. So, when would you refer? Um, any child with a suspected food allergy, honestly, because it's no longer just strict avoidance, we have options, we can do oral immunotherapy, um, we have biologics, you know, we can get bite protection to reduce the risk of a severe reaction. With OIT, um, or biologics with OIT we can even get kids to where they are freely eating their allergen. This works better in younger kids, so send them sooner rather than later. We really want families to know what their options are, so they can choose what works best for them. And obviously, don't forget the epinephrine. Um, I know you all know that, but I put this in here cause I do have to mention that there is intranasal epinephrine available now, um, and there is, it's now available for kids 4 and up who weigh at least 15 kg. Um, early Epi saves lives. Families often report they're hesitant to use it because they're scared of the needle. This is a great option for families who might be hesitant to use a needle. If you are thinking, should I use the epinephrine, the answer is probably yes. It's not going to hurt other than, you know, if there's a needle, there will be some physical pain, um, and, you know, it'll make their heart race, but In the long run, it is better to have used it and not needed it than to need it and not use it. And I'm just very quickly going to wrap up with some asthma, um. I suspect that, um, well, you see here, we, we kind of fall right in the middle with around 8% um pediatric prevalence of asthma in Missouri. Um, you have probably heard about these newer approaches, um, and Probably a lot of you are already incorporating this into your practice, but I did just want to mention them, um, because sometimes questions come up about these, um, but for the kids who have moderate to severe persistent asthma, um, smart therapy, um, the single maintenance and reliever therapy is now in the guidelines. Um, so I love this because it it allows kids to use the same inhaler for their controller and their rescue. Um, I have a lot of families that get confused between the two, and when you only have one for both, it, it just removes that complication. Um, the lava has to be for motorol because it has quick onset. You cannot use a slow acting or it's not giving you the benefit that albuterol would. Um, but studies have shown that this approach reduces serious asthma attacks, um, and reduces the need for oral corticosteroids. And then for our kids with intermittent symptoms, um, There has been an update that gives you the option of using, adding an inhaled corticosteroid in the yellow zone. So if you need to give albuterol, give the albuterol, give the um ICS or alternatively you can do a low dose ICS for Motterol um combined inhaler for rescue. Um you can also add the ICS for the little ones who have Those um wheeze associated with respiratory illness symptoms, um, so they would get the albuterol for their wheeze, but they also get that puff of the ICS. And then always, always spacers. Everyone should use a spacer. Adults should use spacers, people are resistant, but it, it makes such a difference. Um, it gets the medication to where it needs to go. You don't have to worry about timing your inhalation with the um dispensing, um. Dispensing of the medication, and you get less deposition of the medicine on your oral mucosa, so you're not swallowing it and getting those unwanted systemic effects, like, I mean, you, you'll still get some, but not um as much tachycardia or agitation. Um, it is as effective as using a nebulizer. Um, and it's faster, and it may actually get the medicine to the appropriate airways better. So families tend to think that nebulizers are better cause that's what they get in the ED, um, but really there's, there's no reason for families to not have spacers, um, and use an MDI at home. Um, there are some great videos, there are a lot of videos out there, but these are the AAP videos that address how to use it with a mask or with a mouthpiece. So if you've got the littles, um, or an older kid. And then when to refer, if you're not sure of the diagnosis, um, you know, is this cough bearing asthma versus postnasal drip or habit cough, um, if the kids are not getting good control despite, um, you know, the Despite optimizing their medication, um, regimen, if they're needing a lot of ED visits or oral corticosteroids, please send them. If you think that allergies are triggering their asthma, um, that would be another good reason to send them, or if they have other atopic conditions, um, definitely if you think a patient would benefit from a biologic. And honestly, any kid over 5 or 6 with asthma can do PFTs, and it's helpful to have those for monitoring. Um, especially because a lot of kids are poor perceivers of their symptoms, um, so while they might tell you that they are well controlled, um, the PFT show a different picture, um, so that can be helpful for guiding management. So, I know that was sort of a whirlwind tour, um, but these are just the main takeaway points that I would love for you to remember, um, you know, just, um, seasonal allergies can have a really significant impact on quality of life. It's really important to have shared decision making with families to find a regimen that works for them, um. With hives, infection is a common cause. Um, it's not always food allergy, um, with the allergenic foods, feed early, feed often, um, send us all of your food allergic kids, um, but never send a food allergy panel, um, and don't tell families to stop foods that kids are tolerating. Consider those newer yellow zone approaches and asthma treatment and make sure every kid has a spacer. And most importantly, no kid is too young to see allergy and immunology. You don't need to wait until there's a certain age to refer. I have heard this myth multiple times. We take all ages, we will test all ages. There, there's a window of immune plasticity in those little kids that for food allergy, it's really important to get in there early. Um, so please, please don't tell families that they need to wait until their kids are older, we will see them. Created by Presenters Rebekah Browning, MD, PhD Pediatric Allergy View full profile
