Addressing Kids’ Seasonal Allergies | MedPage Today

Seasonal allergic rhinitis isn’t always easy to identify in children, but treatment options are on fairly solid ground.

Distinguishing seasonal allergies from the multitude of childhood infections can be a challenge, acknowledged Purvi S. Parikh, MD, a pediatric asthma and allergy specialist with Allergy & Asthma Network and NYU Langone Health in New York City. Stuffy nose, watery eyes, and sore throat can be either from allergies or an infectious cause.

Suspicion for seasonal allergies should be raised when symptoms last more than the 7 to 10 days a virus takes to typically run its course, or if symptoms last weeks or months and occur with a seasonal component. “Parents will come in saying, ‘Oh, my child is sick like all of the spring and fall,'” noted Parikh in a conversation monitored by Allergy & Asthma Network media relations.

Itchy eyes, nose, or ears are also usually indicative of allergies, whereas a body temperature at 100.4°F or higher and a cough that produces mucus is more likely viral.

“Sometimes the main way we can differentiate is with allergy testing, and so that’s why it’s important that they come see an allergist,” Parikh said. “If we find they have zero allergies, then we know that likely this is viral. And then we need to investigate why they’re getting so many viruses or bacterial infections or getting sick so often.”

Family history is helpful, as having one parent with any type of allergy is associated with a roughly 50% greater risk that the child will develop allergies as well, she added. However, “I wouldn’t say it’s like one of the most important features in figuring out if a child has allergies or not just because of how things are changing epidemiologically.”

She pointed to environmental shifts as climate change intensifies the pollen season and as societal forces have reduced exposure to animals and other protective factors on farms and in gardens.

Age matters too, as seasonal allergies are not common before age 2 years.

Addressing Asthma

The most common cause of asthma attacks in both kids and adults are airborne environmental allergies, including seasonal aeroallergens. But starting appropriate controller medication rather than just rescue inhalers, for these patients who may present with frequent coughing as a key symptom, is too often missed, Parikh said.

“Primary care is getting better at treating allergies in terms of antihistamines, nasal sprays, things like that,” she said. But, “there’s a hesitancy to treat asthma aggressively, and that is a big disservice to the patient because that’s actually the most dangerous consequence of a seasonal allergy.”

In a 2002 study of Medicaid-insured children with persistent asthma, 49% reported no controller use and 24% were prescribed controller medication but reported less than daily use. In a 2023 study of commercially or Medicaid-insured individuals, 41% of children ages 4 to 11 years with moderate to severe asthma had not filled their maintenance inhaler prescription in the 30 days prior to an exacerbation, although nearly 95% did so in the 30 days afterward.

One fear is impacting children’s growth, but inhaled and nasal steroids do not affect growth. “I’m not hesitant to use those because those are the things that work and actually help treat both the allergies and asthma more appropriately,” Parikh said.

Treatment Considerations

Data on seasonal allergy treatments support their efficacy for children 2 years of age and up, with less data in younger children. The only antihistamine indicated for children under age 2 years is levocetirizine (Xyzal), which is approved down to 6 months of age.

“However, in the real world, allergist pediatricians use all of them under age 2, because we know that it’s safe and effective,” even if the trials haven’t been done, Parikh said.

Oral medication doses are typically lower for children, although inhaled medication doses are not. Inhaler doses are targeted to symptoms.

What clinicians should steer away from is diphenhydramine (Benadryl), she argued. “That’s like one of the worst antihistamines you can use, because it has a lot of side effects and it doesn’t work as well.” These side effects can include drowsiness and cognitive issues.

Another medication to be cautious with, due to adverse event risk in children, is oral steroids. These can be effective in acute settings but the most common risks are vomiting, behavioral changes, and sleep disturbance. In terms of severe adverse events, a 2021 nationwide study from Taiwan showed that corticosteroid “bursts” prescribed for 14 days or less in children carried 1.4 to 2.2-fold increased risk of gastrointestinal bleeding, sepsis, and pneumonia within the first month after initiation.

Allergy and asthma drug montelukast (Singulair) carries a boxed warning for reports of suicidality and other neuropsychiatric events, many of which occurred in children. Parikh noted that she uses it “very sparingly as a last resort” in children, although a recent Swedish study showed no elevated risk of depression, anxiety, suicidality, or behavioral problems for children, casting doubt on the causality of the risks.

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