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    Seasonal Allergies: A Pediatrician’s Guide to Managing Rhinitis

    Seasonal allergies are a common concern in pediatric practice, particularly during the summer months. Even though you see them each year, it can be helpful to get a refresher to make sure you know the latest management strategies and guidelines. 

    For pediatricians preparing for board exams, a thorough understanding of the pathophysiology, diagnosis, and management of seasonal allergies is essential. Allergy & Immunology questions make up a significant (4%) portion of the exam of the ABP exam content outline—you’re likely to see rhinitis as a question on your upcoming exam. 

    In this excerpt, Dr. Patel brings you the latest guidelines for the management of seasonal allergies. She gives pearls of wisdom for speaking to parents and caregivers about the nature of allergies, treatment options, and avoidance strategies that can empower them to better manage their child’s condition. 

    This video is an excerpt from our 2023–2024 Pediatrics Video Board Review and gives a complete overview of Rhinitis. For a deeper review into Allergy & Immunology, plus 50 more hours of board-focused lectures, explore our Pediatrics Video Board Review.

     

    Rhinitis overview

    (0:03) So let's talk a little bit about allergic rhinitis. Allergic rhinitis can be seasonal, perennial, and you can have perennial with seasonal exacerbation. So there's all sorts of allergic rhinitis, right? And some of it also depends on where you live. I come from California where we have beautiful sunny weather. So things pollinate year-round, which is different than other parts of the country where they have snow, so things don't pollinate year-round. So sometimes your seasonal allergies can be year-round. So it again depends on where you're living. There's a vasomotor or nonallergic rhinitis and rhinitis medicamentosa. And we'll talk about all of these. 

    Allergic Rhinitis 

    (0:44) Seasonal allergies are usually due to things that have a season: grasses, trees and weeds, pollens. Perennial or year-round allergies are things that don't have a season: dust mite, indoor molds, and animal dander. There are four major symptoms of rhinitis: nasal congestion, rhinorrhea, sneezing, and nasal pruritus. Those are the four sort of cardinal symptoms of rhinitis. 

    Allergic rhinitis, as its name implies, is IgE mediated, there is some IgE-mediated sensitivity. Nasal smear can show eosinophilia, though no one I know does this other than study situations—but study situations are similar to test situations, right?

    Allergic Rhinitis — Physical Exam

    (1:38) So, what might you see on physical exam? Nasal mucosa will be swollen and pale—pale, boggy turbinates is what you'll see. Cobblestoning of the posterior oropharynx because that postnasal drip causes an irritation. So you get what's called cobblestoning of the posterior oropharynx when you look in the back of the throat. Nasal polyps are not common in children; In adults we see it a lot more. But if you see nasal polyps, you should start thinking of things like cystic fibrosis. But keep in mind, not every person, [not] every child with nasal polyps, has cystic fibrosis either. So you may have some nasal polyps as well, too, but that should at least start the ball rolling.

    Allergic Rhinitis — Rx

    (2:24) How do you treat allergic rhinitis? Avoidance, medications, and allergy shots. The first thing is avoidance. We want to test patients to figure out what they're allergic to, so you can give the appropriate advice on what to avoid. Blanketly avoiding things doesn't always help, so knowing what they're allergic to can help you to tailor that advice. Antihistamines are most commonly used, but keep in mind that antihistamines don't help with nasal congestion. And I mentioned the hallmark features: congestion, rhinorrhea, itching, and sneezing. Antihistamines will only help with three of those four symptoms; you really need intranasal corticosteroids to help with the congestion.

    And then what I do specifically is offer allergen-specific immunotherapy—allergy shots—to hopefully desensitize these patients. So that's something that's different that can be offered by an allergist. 

    Avoidance

    (3:28) First thing, like I said, is avoidance—avoid the things that you're allergic to. You do a skin test, or blood immunoCAP testing as it's really called. Even though everybody calls it RAST testing, it's not RAST testing anymore, no lab does that. RAST has to do with radioallergosorbent testing versus immunoCAP is immunofluorescence testing. It has to do with the way that it's looked at in the microscope. The common vernacular has been RAST test, but please keep in mind that it's not done that way anymore.

    So, things that you can advise: pollen allergies, depends on what they're allergic to. Trees pollinate in the spring, summertime is grasses, fall is weeds. If you know what they're allergic to, you know what time of year that they may have a problem. Keeping windows closed, having a HEPA air filter, showering if you've been outside, these may all be helpful things. We don't want patients to be limited in what they can do.  Should they not go outside and play sports? No, I don't believe in limiting children. My job is to better control and give you advice so that you can go and do all the things that you need to do.

    Dust mite allergies—dust mite covers, encasings for your mattresses and pillows can be super helpful. Decreasing the humidity, because dust mites love to grow in higher humidity. Washing your sheets weekly in hot water can get rid of the dust mites as well. So again, if you know what the patient is allergic to, you can tailor that advice. Blanketly telling someone to get dust mite covers if they're not allergic to dust mites isn't going to help them. HEPA air filters can be expensive, so is it something that's going to help them? HEPA air filters filter out smaller particles, things that are lighter, like pollens—not heavier things necessarily, like pet dander or dust mites all the time.

    Pet allergies. No one gets rid of their pets. They will get rid of me before they get rid of their pets. No one is gonna get rid of their pet. But if you find out that they are allergic to the pet, maybe you can get them to keep it outdoors or at least keep it outside of the bedroom. I tell patients, “Create at least an allergy-free zone in your bedroom. Maybe have a HEPA air filter in there. Keep your bedroom door closed. Keep the pet outside. So that 8 or 10 hours a day that you're sleeping in your bedroom, you're in your allergy-free zone.” Sometimes that's the best we can do.

    Interesting thing: Keep in mind that if you remove a cat from a household, it takes 4 months for that level of cat dander to go down to be equivalent to the level of a home that doesn't have a cat. Four months is a long time. Cat dander is very sticky. It's also very ubiquitous. So, you know, they may come back a week later and say, “Well, doctor, I got rid of my cat and I'm not any better. I should just bring it back.” No, tell them that it's gonna take a while.

    Antihistamines 

    (6:27) All right, treatment. Antihistamines are, again, commonly used—but keep in mind that I did say they don't help with nasal congestion. You do need an intranasal corticosteroid for that. Amongst your antihistamines, you probably know that there are the early first generation antihistamines—things like diphenhydramine, chlorpheniramine, and hydroxyzine that cross the blood-brain barrier. They can cause sedation, blurry vision, dry mouth… lots of studies that show that people might have a hangover effect the next day. I'm really super careful about not giving Benadryl unless it's needed. We have a lot of other choices nowadays that we don't need to use Benadryl for chronic conditions like allergic rhinitis.

    Second generation antihistamines are less likely to cross the blood-brain barrier, so they don't cause sedation. You have things like cetirizine, fexofenadine, loratadine, desloratadine. They cause little-to-no sedation.

    Allergen Immunotherapy

    (7:35) Allergen immunotherapy—or allergy shots, as it's called—works well for IgE-mediated conditions. Again, we need to know that they have some sensitivity for me to be able to desensitize them to something. What we're basically doing is giving increasing doses of the allergen in a very specific way: subcutaneously. What I'm trying to do is decrease their IgE to that antigen. We're increasing T-regulatory cells, increasing things like IgG4, you're blocking antibodies. So you're making an immune change in these patients, and that's why it's effective. The medications help to temporarily alleviate their symptoms, but they're not doing anything for the underlying pathogenesis of the disease, and this is something that allergen immunotherapy can do—it's disease modifying.

    Vasomotor Rhinitis

    (8:31) Vasomotor or nonallergic rhinitis. Many patients come to me because it's thought that they have allergic rhinitis, and you test them and they actually aren't allergic to anything. And this is probably why antihistamines were not helpful to them, because their problem is not histamine mediated. We think these patients have reaction to vagal stimuli, neurogenic stimuli, so you'll often see similar symptoms—sneezing attacks, followed by nasal congestion. It can be with exposure to cold, sunlight, spicy foods, smells, different things. Skier’s nose is an example—with exposure to cold water, their nose will just start to water and drip. Gustatory rhinitis can happen with food, which can be embarrassing if you're going out to eat. So knowing the history is important, again, these patients don't endorse a history usually of things like the itching that you get with allergies. And I told you itching is a hallmark feature of things that are allergic.

    Rhinitis Medicamentosa

    (9:45) Just a word about rhinitis medicamentosa. What you see is a rebound congestion after using topical decongestants. So, after using, you know, phenylephrine or other nasal decongestants for an extended period of time, you may see that rebound congestion has to do with depletion of norepinephrine from your nerve endings. So I usually never prescribe any topical decongestants unless I know that that patient is gonna be super compliant and not use it for more than 3 to 5 days at the most because they will start to get this problem, and it can be difficult to get them off of it because they use it and it helps them so much and then they wanna keep using it. So, probably just don't use it in the first place is the best bet. And patients don't often tell us what they're using over the counter, right? So you can get this over the counter, and so unless you specifically ask, they may not be telling you this.

     

    Managing seasonal allergies is a core part of every Pediatrician's practice. Understanding rhinitis and the latest guidelines not only helps with your practice, but also helps you prepare for questions on an upcoming exam.

    To dive deeper into Pediatric Allergy and Immunology topics, check out our Pediatrics Video Board Review.

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