 Thank you so much for having me. I actually did do my P's rotation here during medical school So I was here a long time ago also, so some maybe I don't know if people recognize me But it's good to be back. So thank you all for having me and yes My talk today will be about pediatric allergy with a focus on Allergic rhinitis as that's primarily what I help manage but just you know kind of touching on all parts of allergy So allergic rhinitis is really something that has implications and a lot of other medical problems that kids have We know that it can be a sign of something else and it is has a lot of other concomitant comorbid symptoms and diagnoses In children one thing and so these are the things that I always try to ask about whenever I have a kid coming in with a runny nose or a stuffy nose Primarily, you know atopic dermatitis eczema asthma allergies those things always tend to run together and we'll talk about that in a little bit More detail. I always ask about sinusitis and sinus infections because obviously having Chronic congestion in the nose can ultimately lead you to go on to have more formal infection Chronic cough is actually something that is common in kids with allergy. Sometimes it's their presenting symptom like dry persistent cough So if a kid has allergic rhinitis I also ask about chronic cough chronic cough can then also lead to like chronic throat irritation and laryngitis and things like that so Those things kind of also lump together and then sleep disorder breathing I know that's something that most of us screen for all the time But if you can't breathe out your nose most likely you're gonna have some issue with your sleeping too so I try to touch on all of these every time I see somebody coming in and I think it's just a good reminder that allergic rhinitis does sort of reach into multiple different aspects of what what kids may have So this is something that I think we're all familiar with or have seen at some point It is the atopic March or the allergic March and it's just trying to show how different parts of allergy Manifest over time across different age groups So in infancy and you know under age one the most common thing kids will have is skin conditions So a topic dermatitis eczema high of dry skin things like that that tends to be what happens first Soon thereafter around age one they start the most common thing next to happen is food allergy It's not as common to have the formal allergic rhinitis that early on and so early early It's a topic dermatitis and food related allergies Allergic asthma does sort of start to take off You know a little bit around that time to age one But really starts to hit its stride around you know between four and five around age three And then allergic rhinitis is the one that does kind of take a little bit to get started It starts a little bit later we think and as you can see it kind of hits its deep incline closer age five six seven And unfortunately allergic rhinitis is the most common one to last into adulthood So once that kind of starts that can be a hard one to kind of get rid of We know that about 50% of children who have eczema will go on to develop asthma and that 33% of them will also go on to have food allergy We also know that children who have eczema are at risk of developing allergic rhinitis Food allergies in children are also a risk factor for allergic rhinitis and asthma So all of these things tend to overlap And once they start they can be kind of hard to to get on top of again So how does allergy actually start what is the process at least with regards to allergic rhinitis? This is a kind of a busy slide, but I think it goes through it pretty well So the first step in developing allergies you have the allergy sensitization phase So what happens is is you're exposed to the allergen usually obviously through the nasal mucosa That takes it up the antigen or the you know the allergen pollen whenever it is And it is taken in by an antigen presenting cell That antigen presenting cell then breaks it down and presents it to T cells at this time they're considered naive T cells. They haven't decided like what kind of T cell they're going to be But with this allergic response they kind of turn into this TH1 and TH2 helper response Which causes them to release the pro-inflammatory cytokines IL4 IL3 Those cytokines then cause the B cells to turn into plasma cells that make antibodies and the plasma cells in this case Make IgE and IgE is what we know is implicated and starting off the allergy So at this point then you have IgE being made and it's binding to the mast cells So the mast cells are kind of ready to go next time you see that allergen So that's how the allergy sort of starts The next time you see that allergen we kind of move over towards the right side of the screen And you have two phases of the allergic response There's a primary action phase which happens really quickly. That's the one, you know immediate response that antigen comes back in It gets broken down again. So that that mast cell now with the IgE coating it can then just sort of automatically be activated Mast cells and vasophils then will release all their mediators like histamine serotonin Lucotrines and you end up getting allergic rhinitis So ultimately you have mucous gland stimulation most accretions to cause the rhinorrhea You have your sensory nerve stimulation to cause the sneezing and the itching Basal dilation causes you to have nasal congestion and pressure in the nose and the sinuses and then you have increased Vascular permeability that causes ultimately tissue edema In the secondary reaction phase Because you've had this is you've even independent of the persistence of the antigen But because you've had the primary reaction phase all of those Originally released mediators that we talked about recruit other kind of like stronger immune system cells to the area like the neutrophils and Acinophils macrophages and then those become activated and release their mediators. So this whole process is perpetuated So that's sort of how allergy happens. It's a little bit complicated, but you know that it kind of makes itself worse as time goes on So I will be referencing this article pretty frequently. It's the American Academy of Otolaryngology clinical practice guideline on allergic rhinitis It came out in 2015. So this is how we frame a lot of our management of allergy and allergic rhinitis this article just as a Overall definition of what we consider allergic rhinitis. You can see here It's basically it has to be an issue caused by IgE mediated inflammation like we talked about in the nasal mucosa mucous membranes due to an Exposure to an inhaled allergen and the symptoms that are related to this are the rhinorrhea nasal congestion itching and sneezing so that's what allergic rhinitis is by definition and Allergic rhinitis can be seasonal. It can be all year long It can be intermittent, which is if it's less than four days per week or less than four weeks per year It can be persistent, which is more than that And then it can also be episodic So if you're in a situation, you know, you know, you're allergic to cats you go to someone's house who has a cat you get allergic rhinitis But that's the only time that happens that is still allergic rhinitis, but it's considered episodic So allergic rhinitis has a big implication on multiple factors Throughout you know quality of life and day-to-day in people who have this so these Charts are from the paper cited at the bottom It was basically a paper that worked by surveys to determine the burden of allergic rhinitis in kids The top chart there is basically trying to show what the most common symptoms are and You know red is everyday orange is most days and as you can see it's a lot of times the issue is with the nose So nasal congestion is the most common sneezing runny nose. Those are the things that people have most of the time But then on the bottom you can see what is considered most bothersome either extremely bothersome versus moderately bothersome and again It's it's the nose. It's nasal congestion post-nasal drip runny nose Obviously a lot all of these things are at least moderately bothersome so nothing is like slightly bothersome, but The things that seem to bother people the most is their nasal symptoms and It has impacts also not just on how they feel but also cognitive function their productivity That same paper put that chart up number e that shows that kids who had allergies Accomplish less They cut down on the amount of work and activity they took on they had difficulty in their performance and the things They did start to do and Then on the bottom you can see here that kids who had rhinitis and rhinitis type symptoms as compared to those who were Asymptomatic basically did less activity didn't sleep as well. They had a lack of self-satisfaction So it really does have a big implication on quality of life You know if it goes kind of unmanaged and untreated, so I think it's pretty important So when you have a kid who comes in with a concern for allergic rhinitis These are the things that our Academy says we should basically look for and ask about So presenting symptoms again, I think the first thing they'll always say is they sound always very congested No matter what we do their nose is full. It's congested. They may have sneezing. They may have drainage in Allergic rhinitis the thing we're looking for is more of a clear drainage Color drainage might suggest something else. You can have that in allergic rhinitis, but typically If it's colored or opaque you have there's some other things we think about In addition to the allergic rhinitis itching of the nose post nasal drip throat clearing Cough is something also that can be a presenting symptom with just allergic rhinitis And we'll talk about that in another paper too Malays is something that's common and fatigue also is common. Malays and fatigue are more unique to children That's not as common in adults who are coming in with allergic rhinitis On history. We always want to ask about the nature of it. Is it seasonal all year round? Is it due to a certain exposure? What medicines are on what medicines they've tried what has helped what has not helped is our family history? We know that atopic Hp runs in families. So if parents or somebody siblings have really strong allergy Then it's very it makes it more likely that that kid will have it too And then I'll talk about a little bit of exam coming forward So the clear drainage like we talked about you look for eye findings allergic shiners watery eyes that nasal crease that allergic salute from itching the nose and And I always want to make sure you know, they don't have another reason to have drainage in their nose Like some something that shouldn't be up there So when we talk about the physical exam the one thing that in addition to all of those other things that we look for really Sorry, I just touched this we look for really Specifically in ENT as we look at the turbinates So you might remember that the turbinates are these Structures on the outside wall of the nose. They're on both sides They have a there's a bone and then they're covered in mucosa There's three of them on each side and they kind of act like the first line of defense in the nose They act to humidify the nose, but they can also they have a little bit of a filtration property as well So if you're allergic to something they kind of get hit really hard really fast usually because they are the first thing seeing the allergen So if you look here on the left side of the screen, this is looking in the left nasal cavity You see the septum there. I don't know if my this is the septum here and Then this here is the turbinate. This is the inferior turbinate. That's the middle turbinate So you see here that the mucosa is pink. It's normal healthy looking. It doesn't look swollen It doesn't look a deminus or anything and then you can also see here. Whoops. Sorry. I looked at my this screen Not that screen. This is the nasal airway, so you can see it's nice and open There's no drainage or anything over here on the right if you compare this turbinate to that turbinate That turbinate is a lot like more pale. We say maybe bluish in color sometimes It doesn't look as it looks a little bit more full. It looks a little bit swollen and You know sometimes you can see the nasal airway is reduced in this case But sometimes you'll see the turbinate coming all the way over and touching the septum in which case you know You don't really have any nasal airway there. So this is a Good example of what an allergic turbinate might look like So then the question becomes you know how early or how young can you develop allergic rhinitis symptoms? So this was a it was a little bit of an older paper. It's from like the early 2000s looking at an allergic rhinitis and ATP and kids in South Africa and They had a bunch of people enrolled. It was over 700 and they followed them over eight and a half years And they evaluated them by questionnaires some imaging skin prick testing and then blood testing what they found was that Significant rhinitis was noted in almost 80% of them And in this paper interestingly their median age of onset was six months 30% of them had rhinitis at infancy. I don't know if it was technically like allergic rhinitis So I think there's a difference there, but you can have symptoms of rhinitis very early What they considered symptomatic rhinitis was nasal obstruction drainage itching sneezing and you can see on the right here The chart basically depicting the rates at of how severe it was by different age groups Every age group looks like the majority of them had moderate Disease, but you can see here that the highest number with moderate was actually newborns So they go ahead It seems super high Yeah, so I think it is a little bit skewed But I think that they're the point is that you can have kids who come in very early like earlier Then I think we typically think of on that atopic March with concern for possible allergic rhinitis This paper is one of those like landmark papers in the world I think of at least ENT allergies the Paris birth cohort So they started off with about 3,500 Children at birth all of them were healthy normal full-term normal weight no twins like everything normal And they followed them for the first 18 months and they questioned them about allergic rhinitis regarding sneezing Runny nose congestion independent of being sick, and they also did blood testing And what they found I think this is maybe more realistic more of like a ten nine percent ten percent of them ended up with allergic rhinitis symptoms and Again the most common thing here was the runny nose But they a lot of them had sneezing congestion and then watery eyes with nasal symptoms They counted not just watery eyes, but with nasal symptoms interestingly on the right side They found that infants who had allergic rhinitis symptoms didn't really have increased prevalence of wheezing Compared to those without but they did see a significant difference between having this dry cough So I think just a point again when you have a young kid with this persistent dry cough And we don't know what it's coming from and maybe they're a little too young to have asthma. It could be allergy So something I learned This is like the biggest one I found this was from 2016 it was a Epidemiology paper and it included almost 30,000 kids in the US looking to see the incidence of Auxema asthma allergic rhinitis out like all allergy stuff and basically What they found is on table two is looking up until age five or so and they found here that 17% of kids overall, you know from birth to 59 months We're gonna develop allergy, but the peak age range within the young age time frame up until age five was between age Like two and three so um around here It's when it kind of peaks. So they're saying under a year is pretty uncommon to have the allergic rhinitis And overall in all kids if you look over here, they go up until age 17 Incidents is similar at almost 20% but the peak over here is going to be more towards like age six to ten So even more so than this first three years the real peak of this is ages six to ten But you can have it as early as like two or three is kind of when it starts, okay? This slide is just trying to show the relationship between Developing asthma or rhinitis in the setting of having had food allergies. So again a point to how these things are all kind of related So if you had food allergy 35% of them went on to develop asthma and similarly 35% of them went on to develop allergic rhinitis. So it can be like a a sign of what might be coming if they develop a food allergy So then the question is, you know, when what should we do allergy testing? So this was a paper and an older paper again, but it was a prospective study trying to look at when Kids are showing signs of being sensitized by allergy testing So they had 200 or so kids and they looked at them almost every year until age six And so you can see on the left hand side is sensitization to food Allergens and you can see that that happens it peaks very early and then kind of slopes down as they get older So some of them obviously we know can grow out of it But then in the middle and on the right are what they call the arrow allergens or the inhaled allergens The middle one B is they only tested two outside allergens And then the right side is inside allergens and what you can see is that basically there was the incidence of sensitization increased with age and particularly with the outside allergens it happens after their third birthdays when they kind of really Take off in terms of what when they'll become more reactive with the outside allergens Inside allergens were similar and that they kind of did say they went up over time, but the big difference here Was the outside ones after age three or so This was a paper trying to see if kids who had already developed asthma symptoms might be more likely to have Sensitization patterns earlier So if you have a kid who's looking like they have asthma and they're younger than three should you still allergy test them? So they were looking at kids all under the age of two and they were Medium age of 1.2 years and they you can see all the allergens they tested here They're all none of them are food allergens and what you can see here ultimately is the sensitization rates were pretty low for both inside and outside Allergens so ultimately, you know again this paper is arguing that under age two Probably not going to get a great yield on doing allergy testing The overall the data is mixed there are papers for doing early allergy testing There are papers against doing early allergy testing. I don't think there's a perfect answer You know our guidelines say that you can technically do skin testing at any age But you have to be mindful of the fact that in infants and young kids their wheels might be smaller and their Positive controls might look like they're negative controls which makes it all kind of it can be indeterminate So ours say that you shouldn't really do allergy testing really probably until at least two youngest But I still think that might be I think that might be a little early This was a review paper by actually one of my attendings in Dallas and Dr. Vealing who primarily does pediatric allergy now And she basically says her thoughts she always said like you don't do allergy testing before age four So I think somewhere maybe three might be the earliest where you might get some good data But really four or five is probably more commonly where people start doing skin-prick testing in kids So what are the types of allergy testing? Obviously the goals of allergy testing are to confirm your suspicion that a child is allergic and then to try to figure out what exactly they're allergic to and Also in addition to confirming that they have allergy we want to figure out how allergic they are to those things So those are like the three main goals all three of those can be accomplished with the in vivo testing meaning like skin-prick testing Not as easy to do this with the blood testing, but we'll talk about that next so This again is from our guidelines about the types of allergy testing So as we mentioned skin-prick testing, there's two main types shown here on the right is the skin-prick testing So you have these little cassettes. They have little points on the end of those little arms there You dunk that whole tray into Different allergens on each spot and then you put that onto the skin it pricks into the skin and you end up getting like this Baby has underneath and I think this was a good example because if you look here on the bottom right See how they're positive and negative don't look that different So that's a that's an example of one that you know You're you're testing you can tell what's definitely positive, but you can't necessarily tell what's negative in that sense So that's why I think doing it younger can be harder, but that's what you're looking for You're looking for the wheels and you measure the size of the wheels compared to the controls The other so that's the skin-prick testing it allows you to basically give a good sense of how much they're reacting to something It's considered more sensitive than the blood testing because you get kind of real in-time reactive information if you have something that's Indeterminate or you think a child is really sensitive to something But they're not really showing it's unclear on the skin-prick testing. You can do interdermal testing That's more like it feels like a PPD It goes in the dermis there And so you get basically more exposure to the the blood than you would from just a skin-prick testing So you theoretically should have a stronger response The problem with doing either of these skin tests are that they can Lead you to have a really bad allergic reaction and potentially anaphylaxis And also there are some meds that you have to stop ahead of time So I and I have a list of that coming up blood testing is Safe and that there's no risk of anaphylaxis. You can be on any of the medicines that are not affected by the medicines You're really testing for IgE levels This is what you have to do this in a kid who has dermatographism or who has really severe eczema Because you can't do the skin-prick testing in those cases But the problem is that sometimes you get false positives on the skin on the blood test So for example, you can have a kid who comes back is having like a terrible Grass allergy or something on their blood work, but they just played soccer yesterday And they were totally fine and their allergy symptom is in the winter or their season is winter So you kind of you don't always know what to make of that So I think that's why technically we usually prefer the skin-prick testing But if you have to obviously blood testing is fine They don't recommend doing the IgE levels IgG levels anymore And then there's some of these other like funky things like acoustic rhinometry, which they don't recommend So it's usually either skin some type of skin test or blood work You can I think it's a lot less likely to get false positives with the skin test But similarly that you would expect for example if you have those IgE circulating that come up on the blood work That you might have them come up also on skin-prick testing, but I think it's a lot less likely And I think the other thing too is it has to come you have to take like the clinical history about like one There's season is you know Yeah, I think you you can see it, but I think it's a lot less common I think this is it's more like I don't know what the word is Realistic I guess and that says huh. Yeah, it's more reliable, and I think it also is just more Genuine to what they're actually is feeling and like having happened Arrow allergen So these are the medicines that if you're gonna do skin-prick testing you're supposed to hold off on so red is stop Green is go those are fine So interestingly any antihistamine H1 like the obviously allergy meds, but also we're in it eating H2 blockers You have to stop beforehand And other topical antihistamines if you have eye drops that are have antihistamines in them or a nasal antihistamine that has to be stopped TCA's have to be stopped as well because they have antihistamine properties Also, you cannot be using Topical corticosteroids on the area that's gonna be used for skin-prick testing So I think if you're you know if you have a rash like on your belly or something But you're getting skin-prick tested on your arm that could be okay, but you can't put the antihistamine on the area That's gonna have the skin-prick testing You can take systemic steroids. That's the green one. It's interesting. It's bizarre Um, I don't fully also understand like why that is. I think it would make sense that you couldn't but you can I think it has to do with the fact that the systemic Steroids don't necessarily impact your antibody levels. They work more so on your neutrophil reactivity and stuff like that So I think for that reason it's okay, but that's just my that's what I think. I'm not totally sure Um, and interestingly if they're on Montelucas, they can keep taking that So those are the main ones I think that probably kids are on regularly to think about So if and test is negative like say for example, you do this early and it comes up with nothing Like is it worth doing again later? Like does this change over time? So this was a study. It was a worldwide study about it was the phase three of the international study on asthma and allergies So worldwide pretty big study included over five hundred thousand kids And they basically looked across the world and gave a questionnaire twice So it was at age six to seven and then again at 13 and 14. So when they were basically twice as old basically what they found is that About eight and a half percent of the kids who were younger had positive symptoms of allergy and then that almost doubled when they were 13 and 14 so the incidence of allergy Tended to increase with age Similarly, this was another paper looking to assess the predictive value of positive skin pre-testing early on On allergic symptoms into adulthood. So they had 200 kids followed for the 20 years Which is amazing that they kept that many of them that long But they did skin pre-testing at five eleven and twenty and what you can see here on the bottom Is that the skin pre-testing positives? The percentage of those went up every instance and every time point as did the allergic symptoms So within this cohort even kids became more allergic over time What they found is that the people who had a positive skin pre-test at five years old that same Allergen remained positive all Subsequent times the difference was that new sensitivities developed over time So once they were positive for that at five it stayed positive, but they found new ones as they tested when they were older so what they found up here is that in terms of how well the five-year one did to relate to the 20-year testing in terms of Any allergic symptom it still had a significant association, especially when you look at respiratory symptoms in particular That was significant But what they also showed was that 70% 77% of patients who had allergic symptoms at age 20 had originally been negative at age 5 so I Think it just shows that people develop allergies a little bit older Maybe than age 5 and as you get as you go along you can be sensitized to more things and then you become Potentially more allergic. So that's sort of what they're trying to show over here You can see that this these are the different things that they tested for And the dark black bar is five years testing and then the gray bar is 11 years and the dark gray bar is 20 years and can see that most of them had the highest incidence at age 20 So new sensitivities over time, but I think the main thing is once you're positive for something at five that stayed positive So how do we treat allergies in children? There are three main categories Avoidance, which may or may not be possible also doesn't really work that well There's pharmacotherapy, which is the first line treatment and pretty much everybody will need some type of allergy medicine forever, probably or at some point and And then the last option is immunotherapy, which we'll talk about in a little bit and immunotherapy is really the only one that can Potentially be curative, but it's a really big commitment and we'll talk about that too so in terms of avoidance They have shown that if you are able to be successful in your avoidance measures that that does reduce the Allergy levels in your environment, but that doesn't always translate to reduction in symptoms and Obviously if you have one of those Allergies that is specific to one type of animal or pet and you get rid of that pet then that does work But if you wash that pet you do end up reducing their allergen level, but that doesn't actually affect your symptoms so Some of these things work better than others, but ultimately I think this can be a huge challenge And most people are not super able to to do this totally successfully This is a busy slide and I'm going to zoom in on this part of it These are all of our guidelines basically in one table When it comes to treatment Our guidelines say that we should recommend intranasal steroids for anyone who has a diagnosis of the allergic rhinitis And the symptoms affect their quality of life As we've talked about they pretty much a hundred percent of the time will affect the quality of life and Can affect the quality of life in multiple different arenas? So I think most people will start with a intranasal steroid And we'll talk about oral antihistamines intranasal histamine antihistamines and lagoetriene receptors Another one that I want to mention here is the international consensus statement on allergy and rhinology This updated one came out in 2018. That's another one that we go by pretty regularly It's a really long paper, but when it talks about pharmacotherapy They say that basically medications are the primary modality for control of allergic symptoms. So multiple Societies talking about allergy recommend giving them some type of allergy medicine as first line So we recommend doing intranasal corticosteroids as first line treatment. How do these work? They really work to reduce the mediator cytokine release and they so that is talking about that The first phase that early phase of allergy that we talked about earlier that they kind of can help reduce that They also Inhibit recruitment of those strong inflammatory cells to the nasal mucosa So that's that prolonged or second phase of the allergy that we talked about so they can kind of work on Both ends of the allergic response They also reduce the hyper responsiveness of the nasal mucosa Therefore like raising the threshold before they're going to release histamine So they kind of work in in a lot of the ways that allergy happens. They work really well They work to reduce congestion sneezing itching rhinitis basically all of the symptoms of allergic rhinitis and they do so also by Reducing the nasoocular reflex. We know that you know if you think about when you sneeze and your nose is really Bothering you sometimes your eyes get watery. That's because we have this reflex through the nose and the eyes that they work on that too Between like in terms of which one to pick they have all been shown to be equal and same efficacy But I think probably the way I make my decision is based on how old the kid is and what's approved What's FDA approved so I have a chart for that in a minute What are the side effects usually the main thing is that they get local irritation in the nose One thing I think is interesting as I've had a few kids come to see me recently for nosebleeds And it sounds like someone told them that they should use like flonies for the nosebleed But actually flonies can cause a nosebleed. So that was interesting and They were funny about it But basically I think nosebleeds is probably the most common thing I see and sometimes that can be helped But by how they're actually applying the medication. So I have a picture of that next And so sometimes we can we can work on that and get by that There's not been any adverse effects proven in terms of if it you know having steroids long-term from the nose Actually will impact your hypothalamic pituitary axis. That's not been proven. The one thing that has been shown But the data is kind of not fully clear on this is its effect on growth So they have been shown if they're using them long term to have to potentially have an issue With their short-term growth But I think if they stop it typically that growth tends to catch up So in terms of like a long-term issue on growth that has not been super well-defined But it is something to take note of if you have a kid who's on it for a long time And you feel like they're not maybe growing appropriately it might be worth taking them off it and Seeing seeing if that helps So how to use it? Basically, we know that the part of the nose that it works on are those turbinates on the outside wall of the nose that we talked about earlier So I always tell people to try to aim the bottle towards the eye on the same side So in an older kid who's doing it themselves I try to tell them to use the opposite hand to the side They're gonna spray because it kind of inherently like aims the bottle out a little bit better We know but you know in younger kids we tell the parents that We know that it takes at least two weeks for this to really kick in and make a difference The reason for that is that the spray is thought to not really be systemically absorbed and it really is very localized But with that it's a fairly low dose per spray So it takes a little bit to build up to be a therapeutic level in the nasal mucosa We also know that if a patient has seasonal allergic rhinitis We recommend that they start using this before that season hits just to try to prevent that whole reaction So at least a couple days, I usually tell them at least a week or two before that season And again, we're trying to aim away from the septum So this is a chart. Sorry, I guess it's smaller over here than I thought it would be but Trying to basically show the age at which different sprays International corticosteroids sprays are approved by the FDA so the youngest one is nasal quart and Nays and necks are two years and older And the dose for that but up to age five is one spray on each side a day and then as they are over Six it can be two sprays on each side. So in the young kids, it's one spray per side per day Flow nays interestingly is not approved until age four And that is something that I think not a lot of us know about And I haven't yeah, I mean, I don't I don't it's used all the time and nothing bad has happened but technically it is and or has not been studied but So it happens all the time but just as a as an aside, it's not technically approved until age four But that being said we use it all the time and a lot of times all right for nasa necks and insurance says they can't do it Or whatever so they end up on flow nays anyway Here are the oral antihistamines. So these I think are something that we can start much earlier if we're concerned about allergy and Zyrtec and xyzol and Clarinix are each approved at six months of age. So I usually do Zyrtec I think most people are familiar with Zyrtec. Most parents may even have it at home already Interestingly claritin is not approved until age two. So it's a little bit older in that setting So therefore I tend to just use Zyrtec and I have them give it at night because it can be a little bit sedating But if you are concerned that they might be having allergies and things like that and they're younger than the two years old that you can start a spray I Oftentimes will start Zyrtec And then these are just a comment on the intranasal Antihistamines so the most common one is astaline right here this one is approved once they're age six and So this is something that there's a chart sort of at the end here that talks about like how you can add these things together But sometimes if you have a kid who's been on an intranasal steroid and it's not really doing it for them Then sometimes I'll add astaline if they're old enough that the combination seems to work really well together. Oh Here's that thing. So here's what our guidelines recommend on how to do allergy treatment They recommend doing the intranasal steroid as a monotherapy first If you don't have adequate control of the symptoms, they say that you can add an intranasal antihistamine like that Astaline that we talked about they say you can do Afrin for a few days. I think the point there is to try it in addition to the flonase I think the reason is to try to like kick them like get them kick-started Like get them feeling like you're doing something and that's working so that they'll stick with it They don't recommend adding an oral antihistamine or a leukotriene receptor antagonist for the purposes of nasal symptoms It's not been shown that the pills really work well on the nasal congestion and the nasal symptoms They work better for the more systemic symptoms like itching itchy throat itchy eyes that kind of stuff But doesn't really work super well for the nasal symptoms And then you know basically if you're gonna if they're younger or whatever And you want to start the oral antihistamine, but you don't get control of symptoms They say to you can add an oral decongestant briefly This is kind of a weird pathway. I don't think I've seen many people do this I think ultimately though the main point is they say don't add intranasal steroid because Either you're gonna do your if you do then you're gonna move to the intranasal steroid pathway You're not gonna stay with the combo and then in terms of an intranasal antihistamine You can use those as monotherapy But again, if that's not enough and you add the intranasal steroid So ultimately they tend to kind of all funnel back to the intranasal steroid if you can I think is the main point One thing they don't talk about in our guidelines though is saline And I think obviously saline is great. We love saline. Everybody should use saline probably Saline is not really a med. You can't be too young for saline And there's been a lot of really really good evidence that it works to help allergic rhinitis in adults But especially children so on the left here This is that chart from that international forum guideline that we talked about from 2018 the international one And there's a ton of research showing that saline is helpful in kids um One thing that they do suggest potentially is that hyper tonic solution might be more effective than isotonic solution The reason for that well, there's two folds I think the way saline works is two folds The first is that it acts like a shower and just flushes out all of the allergens from the nose So you're reducing the allergy burden But especially with the hyper tonic solution It kind of acts through osmosis to pull fluid out of the mucosa and cause it to shrink that way So in and of itself it can be a decongestant so um, I Try to put everybody on saline honestly I take I pick my battles like if you're only going to get one I'll pick the steroid but um, if you have a compliant kid and a compliant mom and they really are Determined to get this better. I'll do the saline as well If you're going to start saline, you just have to remind them to do saline first Because otherwise you wash out the medicine Which it makes sense when someone tells you that but until someone does sometimes you're like, oh, yeah So saline has to be first Other meds that you can use for allergy. There is pseudo ephedrine um Chromalin nasal sprays a mast cell stabilizer So it should theoretically block the degranulation in that early phase It's really hard to use though because you have to use it three or four times a day to work So I and most people don't use it. Um, itbutroporium is atravent And then montelucas like we talked about you can you can use that as a adjunct, but it shouldn't be used on its own So which of these actually work? Um, we have found that intranasal steroids as I'm sure you're not surprised to hear me say work the best For most of the symptoms if not all of them Or all antihistamines are pretty good for those more systemic symptoms like we talked about nasal itching sneezing Not as good for congestion though um Intranasal antihistamines are kind of the second best when it comes to the allergic rhinitis symptoms They have two pluses instead of one and then the leukotriene receptor antagonists there are kind of the least Effective and so they basically should not be the only thing someone is using for allergy Obviously if a kid has Like asthma or something there's other reasons to use them, but they shouldn't necessarily be used alone for allergy So now brief touch on immunotherapy. So it's pretty Involved so if a patient presents to you this is like a decision tree about when to or to not consider immunotherapy I think a lot of people end up falling into the no immunotherapy bucket. Um, just because there's a lot that goes into it So if someone comes to you with allergic rhinitis and all the symptoms Um, then you need to confirm that they have evidence of an IgE mediated issue So they need some type of allergy testing to confirm that If the testing doesn't show that then they shouldn't get out. They shouldn't get immunotherapy But if it does then you have to have a really in-depth discussion with the family about their risks the benefits The commitment that it takes that we'll talk about and if the family's not on board with that Then you shouldn't go forward with it. Um, if it if they are though and um, immunotherapies recommended Then you need to get like a really we need to get a really formal like informed consent process because again It's it's pretty involved and it has some real risks. Um, and if so then we move on to do immunotherapy So again prerequisites for immunotherapy. They have to have IgE mediated allergy Um, and then their allergic symptoms have to correlate to their testing So like we were talking about in those kids who may have something on their blood work But they don't actually have symptoms of that you wouldn't give them immunotherapy for that because it's not actually affecting them day to day And you also have to have proven that pharmacotherapy and everything has not been sufficient So what is it approved for it's approved for allergic rhinitis allergic asthma Atopic dermatitis if they also have an aero allergen sensitivity So I think atopic dermatitis in and of itself isn't but if you also have some nasal allergy and aero allergens you can allergic conjunctivitis and then some Beestings and insect stings It's sort of under investigation for food hypersensitivity and oral allergy syndrome Right now it is not indicated for kids who just keep like who get hives and we don't know why Those kids are not that's not a reason to do immunotherapy angioedema asthma. That's not allergy related or due to IgE Um emphysema drug reactions also are not reasons to do immunotherapy So both our guidelines and that international consensus statement guidelines do recommend immunotherapy in children um It's been The main things I think that we'll also talk about here that I thought was very interesting is that if you treat someone for allergic rhinitis with immunotherapy it can Delay or prevent them from progressing to developing asthma, which I think can be pretty big for kids So it is approved for kids What are the complete like total contraindications to doing immunotherapy? So if you have poorly controlled or uncontrolled asthma, that's an absolute contraindication If you have partially controlled asthma, that's a relative contraindication But I think typically we want the asthma to be Legit well controlled Autoimmune disorders if they're active that is an absolute contraindication But if it's if they're in remission, that's a relative contraindication to um Allergy immunotherapy for the aero allergens and then I also circled children below five years of age. Um I tried to box the ones that I feel like we run into most frequently in kids. Um, so basically Absolute contraindication if they're under age of two Um between two and five it's more of a relative contraindication So I think it it's case by case basis if they're under five But over five it is okay pretty much in anybody who doesn't have any of these other factors going on So most kids I think and I think part of that too is Um, they have to be old enough to like let you do the allergy therapy, you know and be okay with it Oh, yeah The It will be helpful to prevent you they've shown that it can so basically the and I think in a minute, I haven't yeah this slide talks about how it works and I think that that's why it works for that Um, so that's a great question But yes, they have shown that if you treat the allergy early with immunotherapy You're ultimately like altering the way the immune system responds to stuff. So in that way you can you just become less allergic So it does work. Um So when we talk about it's considering immunotherapy these are the things we have to discuss with the family So there is a big risk of anaphylaxis with the allergy treatment because you're actually giving them a shot of their allergen So that can put them into anaphylaxis. So that's dangerous So they have to know how to and be okay with using an epi pen and know what to do Should they have to use their epi pen? Um therapy is every week they have to come in for a shot and they have to come in for three to five years Every week for a shot. It's a big deal. So, um, they have to basically be okay with that big commitment Um, and you have to set real expectations You know, this is the only option that we have that can be considered potentially curative for allergy Um, but it may not be permanent. So you can get new sensitizations over time But they have shown that they're less if you treat the allergy So I don't think we understand it all the way to be honest. The immune system is kind of a big black box still but Um, they have shown that you reduce allergens and its sensitivities, but you still can get them So but usually you won't be sensitive to what you were treated for already So it it's I think it's still helpful So how does it work? This is another complicated slide ultimately what immunotherapy does is it works on the two different parts of the, um Allergic response that we talked about so the first thing that it does is if you remember in the early phase of the allergy You have the naive t-cell that kind of pushes itself towards the th one and th two response That's like the pro allergic response By doing immunotherapy you actually Change the proportion of th one to th two while also Increasing your t regulatory cells So your t regulatory cells are the ones that kind of suppress the immune response So you're increasing the t regulatory cells while also reducing your th one and th two proportions um So that's the first thing And then the second thing you're doing is if you remember we are in allergy. You're making a lot of IgE Using immunotherapy induces production of IgG for antibody which can basically Break down the IgE's so you end up reducing your proportion of IgE So your IgE to IgG for levels change with a basically you get more IgG for And those can help like prevent that allergic response So it does sort of alter how your immune system is functioning um So it's pretty cool. It's pretty complicated though, but that's like My level of understanding of how this works and it does seem to work Um, so there's two types of immunotherapy. There's subcutaneous immunotherapy and sublingual immunotherapy Both have been shown to be effective for allergic rhinitis um There I mean they're fairly safe as well Subcutaneous has been around for longer and has been better studied So they have had one per 2.5 million injections caused of death, but none so far with sublingual um, the rate of systemic reactions is similar Difference in dosing. So the subcutaneous is the one where you have to come into the office every week to get a shot um The sublingual ones are usually done at home The first one obviously you do in the office to make sure that nobody, you know has a horrible reaction But subsequently can do them at home. So theoretically that's a little bit easier to keep up with Um, right now all subcutaneous immunotherapy is FDA approved, which means we can get it Covered by insurance, which is great Sublingual some stuff is FDA approved now. There's a few allergens. I think dust mite is one of them and certain Um, like molds I think have a sublingual. Um, but most of them are not yet approved So because of that it's hard, you know, we can't really get them covered and therefore they that might be Like prohibitive to patients using them at home But they both work um And then the pat study Was another one of those landmark studies in allergy talking about how using um immunotherapy can help prevent asthma so um the original study is shown here on the left and then the follow-up study is on the right And basically their aus ratios are basically saying that their data was in favor of their hypothesis That using immunotherapy does prevent the development of asthma in children with allergies in the short term Which was the first study and then also again in the long term after at least two years after stopping the immunotherapy So once they had completed it, um more people who had used it did not develop asthma So a it can prevent asthma But then also it's been shown that if you treat the allergies in the context of asthma the asthma gets better um So there's a bunch of data about that and those papers are shown or some of them are shown here from that consensus statement So I think for those reasons if you have a kid who's like super allergic nothing's working We know what they're allergic to and or you're worried they may or may not have asthma or they're going to get asthma It's reasonable to have them come to have a discussion about maybe needing to do immunotherapy So ultimately this is Also smaller than I wanted it to be and i'm sorry about that But this is sort of the pathway that our our academy recommends on how to manage this so Ultimately if someone comes in with concern for allergic rhinitis and has all the right symptoms We do our history in our exam look for comorbidities To decide if they need treatment which pretty much always they will need treatment The first thing to try are the medicines You can always recommend environmental factors and avoidance It's never wrong to say that but it probably isn't going to do much And then if and or when those things aren't working well enough you can go on to do allergy testing and then ultimately immunotherapy Um something else that ent's do is we can do to terminate reductions, but that's Irrelevant for right now And that's it So thank you all for having me