Hard to Control Allergies

Pediatric Allergy Basics

Many kids have seasonal allergies that get worse in the spring.
Many kids have seasonal allergies that get worse in the spring. Photo © Brian Hamilton

Allergies are easy to treat for many children, they simply take an allergy medication, such as Allegra (fexofenadine), Claritin (loratadine), Singulair (montelukast), or Zyrtec (cetirizine), and their allergy symptoms get under easy control.

Other children have more hard-to-control allergies though, and suffer either with their allergy symptoms or try many different allergy medicines without relief.

It is much better to get help to learn treat your child's allergies more effectively.

Hard-to-Control Allergies

To help treat your child's allergies, it can be helpful to:

  • avoid allergy triggers as much as possible
  • figure out what is triggering your child's allergies with a symptom diary or allergy testing
  • consider giving your child his allergy medicine every day, especially during his allergy season
  • make sure your child is taking the right medication for his allergy symptoms
  • consider a combination of medications, such as an antihistamine and a nasal steroid
  • try nasal washes to clear allergens, irritants, and mucus from your child's nose
  • consider allergy shots if you child has moderate to severe allergy symptoms that are hard to control
  • see a pediatric allergist to evaluate and manage your child's allergies

Allergy Triggers

Avoiding those things that trigger your child's allergies (allergens) would seem like the easiest and best thing to prevent and control allergies, unfortunately that isn't always easy to do.

It can be if you are allergic to things like cats or dogs, and you don't have any pets, or if you are only allergic to East Texas trees and you live in California.

But what if you are allergic to cats and you own a cat or if your are allergic to East Texas trees and you live in East Texas? Allergen avoidance becomes a little harder then.

How do you even know what is triggering your child's allergies and what allergens to avoid?

One technique is to simply try and avoid all of the most common things that trigger allergies, especially by controlling indoor allergens:

  • Dust Mites
    • place a zippered allergy proof cover on your child's mattress, box spring, and pillow to avoid dust mites that often live in beds
    • wash all bedding in hot water (130 degrees F) at least every two weeks
    • remove dust collectors from your child's bedroom, including carpets, heavy curtains, and stuffed animals, etc., and try to minimize the use of carpets and upholstered furniture in the rest of your house
    • avoid humidifiers and consider using a dehumidifier, as dust mites like humidity
    • use a vacuum that includes a HEPA filter, but only when your child is not in room
  • Pet Dander - don't get a pet if your child seems to be allergic to it, keep pets outdoors and off furniture and your child's bedding, use a HEPA air cleaner, and wash pets weekly. Keep in mind that it can take as long as four months to get pet dander out of a home when you find a new home for your pet if you find that your child is allergic to your cat or dog,
  • Mold - molds are allergens that can be present both inside and outside the home. You can avoid outdoor mold by checking mold counts (they are usually higher after it rains), and avoiding dark, wet areas around your home. Indoor mold can often be controlled by decreasing humidity and quickly cleaning areas damaged by water spills or leaks, to prevent the growth of mold in your home.
  • Pollens - pollens from trees, grasses, and weeds typically cause seasonal allergy symptoms. Although you can't avoid these allergens unless you never go outside, you can reduce your child's exposure by:
    • keeping windows closed in your home and car
    • avoid outdoor activities when pollen counts are very high and/or it is windy
    • take a bath or shower or at least change clothes and wash your child's hands and face after being outdoors on high pollen days
    • consider using a HEPA air cleaner insider your home
  • Cockroaches - controlling cockroaches inside your home, since their droppings are a common indoor allergen and can trigger both allergies and asthma symptoms, is a good idea if your are trying to avoid common allergy triggers.

Allergy Symptom Diary

If you aren't having much luck controlling your child's allergies by simply trying to avoid common allergy triggers, you can try to keep an allergy symptom diary to try and narrow down exactly what your child is allergic too.

As with other symptom diaries, just record all of the things that your child recently did around the time that his allergy symptoms worsened, and look for things like allergy symptoms that are:

  • worse on a rainy day (mold allergy)
  • worse on a windy day (pollen or mold allergy)
  • better on a rainy day (pollen allergy)
  • worse when your child mows the lawn or is around someone that is mowing the lawn (mold allergy)
  • worse after exposure to a specific pet, like your friend's cat, or simply after exposure to someone who owns a cat (pet dander)
  • worse when you vacuum in the house (dust mites)
  • worse when specific pollen or mold counts are high (pollen or mold allergy)

Over time, your child's allergy symptom diary may help you figure out what is triggering your child's allergies and what you need really need to try and avoid.

Allergy Testing

If you can't figure out what is triggering your child's allergies with an allergy symptom diary, and trying to avoid common allergens isn't working, then allergy testing may be helpful for your child.

Although many parents don't consider allergy testing because they think their child is too young or because allergy testing is too painful, it is an important tool that can be done relatively painlessly at almost any age.

In addition to the traditional skin prick testing that is usually done by an allergist, your pediatrician may be able to order the Immunocap CAP-RAST test, which is a blood test that can check for antibodies to many different allergens, including foods, pollens, mold, etc.

Allergy Medicines

In addition to avoid allergy triggers, your child with allergies will likely need to take one or more allergy medicines to help control his allergy symptoms, including some that are now available over-the-counter.

Keep in mind that for the child with hard-to-control allergies, choosing the right allergy medication can take a little more thought than choosing one off of the shelf at the pharmacy.

Allergy medicines include:

  • Antihistamines (first generation, meaning older) - usually very sedating
    • Diphenhydramine (Benadryl)
    • Chlorpheniramine (Extendryl, AH-Chew)
    • Brompheniramine (Ala-Hist)
  • Antihistamines (second generation)
    • Allegra
    • Clarinex (desloratadine)
    • Claritin
    • Xyzal (levocetirizine)
    • Zyrtec
  • Leukotriene Antagonists - Singulair
  • Nasal Steroids
    • Flonase (fluticasone)
    • Nasocort AQ (triamcinolone)
    • Nasonex (mometasone)
    • Rhinocort Aqua (budesonide)
    • Veramyst (fluticasone)
  • Nasal Antihistamines - Astelin (azelastine)
  • Allergy Eye Drops
    • Acular (ketorolac)
    • Optivar (azelastine)
    • Pataday (olopatadine) - once a day
    • Patanol (olopatadine)
    • Zaditor (ketotifen) - over-the-counter

With so many choices, how do you know which allergy medicine will be best for your child?

Your pediatrician will likely start with an age-appropriate allergy medication, either a second-generation antihistamine or Singulair. If that doesn't work, the next step will likely be to change to a different medication.

For the child with continued allergy symptoms, your pediatrician may add in a second allergy medication, typically a nasal steroid.

Keep in mind that some allergy medications do a better job of treating certain allergy symptoms than others. For example, antihistamines usually do not relieve congestion, while Singulair and nasal steroids do.

Allergy eye drops can also be helpful if your child's main allergy symptoms are red, itchy eyes.

A decongestant, either by itself, or in combination with another allergy medication, such as Allegra-D, Claritin-D, or Zyrtec-D, is also sometimes helpful for children with hard-to-control allergies.

Allergy Shots

Allergy shots are overlooked as an option to treat children with hard-to-control allergies. Some parents don't think that they are available for children, while others don't think that children will tolerate getting allergy shots every week.

Children can actually start getting allergy shots as young as age five and for those kids who need them, the benefits usually outweigh any possible downsides, such as side effects, the cost of therapy, the inconvenience of getting allergy shots once or twice a week, the high probability of a relapse of allergy symptoms when you eventually stop the allergy shots, and the fact that younger school-age children may not want to get shots at all.

On the other hand, your child likely doesn't want to suffer with allergy symptoms every day, especially if he has hard-to-control allergies that aren't responding to allergy medications and attempts to avoid allergy triggers.

And in the long run, the cost of allergy shots may be less than the cost of your child's allergy medications.

Allergy shots can also have the added benefit of preventing your child from developing new allergies or to keep simple allergies from progressing to asthma.

How often will your child need to get allergy shots? It depends, but children usually get allergy shots one or two times a week for three to six months during their initial build-up phase. The time between allergy shots is then increased to every two to four weeks during the child's maintenance phase, which can continue for three to five years.

Because your child will get allergy shots so often, it shouldn't be surprising that one of the biggest reason that some parents stop allergy shots early is that they are inconvenient to get. Taking a child out of school once or twice a week to get an allergy shot can be especially difficult. Seeing an allergist that is near your home can be helpful, especially one that gives allergy shots during after-school hours.



Sources:

Adkinson: Middleton's Allergy: Principles and Practice, 6th ed.

Allergen immunotherapy: a practice parameter second update. J Allergy Clin Immunol - 01-SEP-2007; 120(3 Suppl): S25-85

Allergic rhinitis and its impact on asthma update: allergen immunotherapy. Passalacqua G - J Allergy Clin Immunol - 01-APR-2007; 119(4): 881-91

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