Transcript Dr. Brian Safier: Pediatric Allergies

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)
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RHINITIS
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Heterogeneous group of nasal disorders
characterized by 1 or more of the following
symptoms:
Sneezing
 Nasal itching
 Rhinorrhea
 Nasal congestion
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RHINITIS
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Causes include:
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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
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Early Response - within minutes of allergen exposure
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Preformed mediators:
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Rapidly generated mediators:
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Cysteinyl leukotrienes, Prostaglandin D2
More important in development of nasal congestion
Sensory nerve stimulation
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Histamine, Tryptase
Itch, rhinorrhea, sneeze
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
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ALLERGIC RHINITIS: PHYSICAL FINDINGS
Normal turbinate
Allergic salute
Nasal crease
Pale (allergic) turbinate
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
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ALLERGIC RHINITIS: TREATMENT
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Avoidance
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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
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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
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Pets
Wash pet often
 Keep pet out of bedroom
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ALLERGIC RHINITIS: TREATMENT
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Medication
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Must consider age, personal preference, tolerability, cost, response to
past medication use, severity of symptoms, associated conditions,
patient compliance, side effects
Oral antihistamines
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Nasal steroid spray (standard vs. dry aerosol)
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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
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
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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
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Medication
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Combination nasal steroid & antihistamine
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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
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ALLERGIC RHINITIS: TREATMENT
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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)
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ALLERGY TESTING
Skin Prick Testing
Allergen Specific IgE Serologic Testing
ALLERGY TESTING
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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
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Utility for food allergy detection
Confirm suspected diagnosis elicited by history
 Monitor for evidence of waning allergy on annual basis
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Unnecessary food allergy testing may lead to
unnecessary avoidance measures, nutritional
compromise, and family stress
ALLERGY TESTING
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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
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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
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Immunosorbent Allergen Chip (ISAC) component
testing
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Detects components of whole allergen
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Standard serologic testing detects IgE binding to whole allergen
Small quantity of blood required
 Currently not covered by insurance
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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
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FOOD ALLERGY
FOOD ALLERGY
FOOD ALLERGY MANAGEMENT
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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
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Referral to Food Allergy and Anaphylaxis Network
website
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www.foodallergy.org
In development
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Oral/Sublingual Immunotherapy for food allergy
ORAL ALLERGY SYNDROME
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Allergic reaction to fruits, vegetables, and nuts
that is limited to the mouth and throat
Itch (main symptom)
 Mild swelling
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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
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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
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VOCAL CORD DYSFUNCTION
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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
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Inspiratory loop on spirometry may be truncated
or flattened
 Referral to laryngologist for laryngoscopy, reflux
management, and speech therapy
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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
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Skin prick test, then intradermal testing (i.e.
needles), then oral challenge
 Takes approximately 2 hours
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