Seasonal to Serious _ Everything Allergy & Asthma
May 14, 2013
Did you know that nearly 1 in 5 children suffer from some type of allergy or asthma? Did you know that a majority of kids with asthma also have allergies?
Spring is a peak season for asthma and allergy sufferers. According to the Asthma and Allergy Foundation of America, nearly 60 million people are affected by allergies and asthma. Each year, allergies account for more than 17 million outpatient office visits with seasonal allergies account for more than half of these visits.
Asthma is the most common chronic disease among children under 18 years old. Similarly, allergies are also one of the most common diseases, which limit the activities for more than 40 percent of affected children during the spring and fall. There are no cures for allergies or asthma. However, both can be managed with proper prevention and treatment.
About the Speaker
Dr. Schroer is an associate staff pediatrician for Cleveland Clinic Children’s Center for Pediatric Allergy. He is board-certified in pediatrics, internal medicine, and allergy and immunology. His specialty interests include asthma, food allergies, eczema, allergic rhinitis, drug allergy and allergy immunotherapy.
Dr. Schroer completed an allergy and immunology fellowship at Cleveland Clinic, following his residency in internal medicine/pediatrics at The Ohio State University Hospitals, Columbus, OH. He graduated from medical school at the University of South Florida College of Medicine, in Tampa, FL.
Let’s Chat About Seasonal to Serious – Everything Allergy and Asthma
clv323: My son has been having big problems with unknown allergies and asthma for some time. He is seven years old, and has needed ear tubes many times. He has constant sinus and ear infections due to allergy symptoms, and this has an effect on his asthma. We thought about silicone allergies. I have read that it is used in processed foods and medicines. Could his diet be making him sick? I could really use some answers.
Brian_Schroer,_MD: It sounds like he needs to see a board-certified allergist as most of the symptoms you describe are due to things in the air, such as animal dander, pollen or dust mites, that are causing nose and lung allergy symptoms. An allergist can very easily identify if these are a problem with skin prick testing or blood allergy testing. Are there animals in the home? This is much more likely the cause. Foods do not contribute to daily nose or asthma symptoms. Most food additives are very safe and very rarely cause reactions. Silicone in particular is not particularly allergenic.
Bee Sting Allergy
Samson: If you're allergic to the sting from a bee does that mean you are also allergic to the sting from a wasp or hornet?
Brian_Schroer,_MD: No. While they do contain some similar allergens the venoms from the different hymenoptera species do not always cross react. The issue is often that people are not certain of what stung them and causes a reaction. Allergy testing can help determine which insect caused the reaction. If a severe reaction occurs, then allergy shots with the venom is the gold standard treatment as it takes the risk for a subsequent severe reaction from 50 percent down to around three percent. It is truly a life-saving therapy.
MOMO: Are there any non-allergic (hypoallergenic) varieties of dogs or cats? What other animals trigger allergic reactions?
Brian_Schroer,_MD: Three major studies have tried to address whether there is any breed of dog that is ‘hypoallergenic.’ None have shown any difference in the amount of allergen between hypoallergenic and other dog breeds. The most recent actually showed slightly higher levels. All cats including wild cats are allergenic, meaning no tigers in the home for cat allergic patients. In terms of which animals are allergenic, any land-based animal can be allergenic including horses, cows, pigs, hamsters and birds. Reptiles may be okay. Fish are always fine, as long as you do not eat them.
Food Introduction to Prevent Allergies
who knows: What are the latest recommended guidelines in feeding children to help prevent food allergies?
Brian_Schroer,_MD: Currently, there are no evidence-based guidelines recommending when to introduce certain foods because there really is not much evidence at this time. The old guidelines recommending delayed introduction of highly allergenic foods, such as eggs, peanuts and fish were rescinded a few years ago because despite those practices, the incidence and severity of food allergies was getting worse. Delayed introduction of certain foods may bypass the normal suppression of the immune system preventing an allergic response. However, what foods should be given when is not clear at this time. Hopefully further studies will give us more answers in years to come.
Pollen Food Syndrome
Momof2: My daughter tells me she gets an itchy throat and that her chest feels tight when she eats fresh fruit, like apples and peaches. Could she be allergic to fresh fruit? If so, are there other foods we should be concerned about?
Brian_Schroer,_MD: This is typical of oral allergy syndrome or pollen food syndrome. When you are allergic to pollens which cause itching in the nose, certain closely related fruits and vegetables may have similar proteins. Then when you eat the uncooked versions, it leads to oral itching, burning and even sometimes swelling of the throat. This is worse when you eat the foods during the pollen season. Cooking the fruit should make it better, so apple pie and apple sauce should be okay. If apples cause symptoms, then it is likely she has birch tree pollen allergy. Most people have symptoms with only a few fruits or vegetables, but in this case peach, apple, pear, cherry, carrot, hazelnut, kiwi, almonds, onions, and potatoes may cause symptoms. It can happen with melons in patients with ragweed allergy, but who likes cooked watermelon?
crazydog: What is the difference between a milk allergy and lactose intolerance? What are the signs and symptoms to look for?
Brian_Schroer,_MD: Allergy to milk is a specific immune response to proteins in all forms of cow milk, including even small amounts of milk, butter, and cheese. The symptoms can include any or all of the following: swelling of the lips, tongue or throat, itching, hives, wheezing, coughing, severe asthma, nausea, vomiting, or lightheadedness as a syndrome called anaphylaxis. This occurs typically within minutes of ingestion. Lactose intolerance is an inability to digest lactose because of a genetic or acquired deficiency of lactase and enzyme in the gut which helps digest lactose in cow milk. This leads to bloating, abdominal pain and diarrhea. It is a volume issue with more symptoms occurring with more ingestion. One of these is highly annoying, the other is life threatening.
The Course of Allergies Through Life
Russell: Can children ever outgrow allergies?
Brian_Schroer,_MD: Some can, but most tend to outgrow allergies after their 40s. Typically, most people gain allergies as they go through their teens and young adult years. However, I have started people in their 60s on allergy shots for symptoms they have had their whole life.
jessica: How does one develop allergies as they grow older?
Brian_Schroer,_MD: The reason allergies occur in the first place is not very clear. Allergies occur in genetically susceptible individuals who grow up in environments conducive to allergy development. Increasingly, this environment has been identified as very clean western type of lifestyles. In patients who already have allergies, it is clear that they tend to become more allergic as people grow older, most likely because they are living through more allergy seasons and, therefore, are being exposed to a wider array of allergens, such as various tree pollen, grass pollen, weed pollen, or animals.
Genetic Basis of Allergies
enjoylife: My three children do not show signs of being allergic to anything. However, my husband is allergic to everything. As our children mature could they acquire allergies like my husband? Can allergies be acquired at any age?
Brian_Schroer,_MD: If the mother has allergies, the chances the children will have allergies is about 60 percent. If the father only has allergies, then the chances are about 40 percent. If both parents have allergies, then the chances are about 80 percent.
Allergy Prevention and Treatment
Sheri: My child's doctor says that the only way my son's allergies will improve is with shots, do you think that shots could be beneficial? Are they typically a last resort, or do you recommend trying other oral medications first?
Brian_Schroer,_MD: The number one treatment of allergies is avoidance. If you have a cat or dog, then you need to remove the animal from the house. Dust mite covers can help decrease exposure and symptoms from dust mites. Using a HEPA filter in your central air system, and keeping the windows closed during the peak pollen seasons can help decrease outdoor pollen levels inside. Then there are very good medications which should help as a second-line treatment. If these two measures fail, then allergy shots are the best way to change the immune system and make the allergies actually go away to some degree.
Treatment for Allergic Rhinitis and Polyps
healthnut: I have a history of sinus polyps (right by my cheeks) that resolved after I returned to live in Chicago. (Prior to this I lived in Washington, D.C. for six years). In my 20s and 30s I had seasonal allergies and would get sinus infections (on the average of two times per year). As my nine-year-old son gets older, he seems to have the same issues. Can you recommend a test that he may need to determine if this is something that will become serious if we cannot get under control? Is Benadryl-D® (phenylephrine, diphenhydramine) and Mucinex® (guaifenesin) for children safe to give him on a regular basis if it seems to help manage this?(When his allergies are not as bad we use children’s Claritin® [loratadine], Zyrtec® [cetirizine] or sometimes Dimetapp-D®.)
Brian_Schroer,_MD: Allergic rhinitis (runny nose and congestion) is clearly genetic and nasal polyps can develop in patients with severe allergies. The best medications for allergic rhinitis and nasal polyps are the same, nasal steroids such as Flonase® (fluticasone propionate) or Elocon® (mometasone furoate). An allergist can help determine if your son has allergies and provide the appropriate treatment.
Seasonal Allergy Treatment
robtoby: I've had seasonal allergies since I was a child. They are bad in early spring (from tree pollen) and then again in the fall (from ragweed). I get a stuffy nose and itchy eyes. I used to take medications like Teldrin® (chlorpheniramine maleate), and Ornade® (phenylpropanolamine hydrochloride, chlorpheniramine maleate). As I grew older, I used medications such as Claritin® (loratadine), Allegra® (fexofenadine), and Zyrtec® (cetirizine). Most recently, I use Flonase® (fluticasone propionate) daily, Patanol® (olopatadine), and now Pataday® (olopatadine) eye drops to ease the symptoms fairly well. Would I benefit from a regimen of allergy injections? That is something that was never offered to me as an alternative, possibly because my allergies are so specifically seasonal.
Brian_Schroer,_MD: If you are using the intranasal steroids and eye drops daily, and still having symptoms then allergy shots can be a nice long-term therapy. However, they are time intensive and take at least one year to kick in. They do last for years though after stopping therapy, and can be a nice long-term option.
Eye Allergy Symptom Control
Gladiator: The pollen has really been affecting my daughter and she rubs her eyes constantly until they're swollen. Is there anything I can do for that—like before she rubs and after they're swollen?
Brian_Schroer,_MD: Avoidance of rubbing will help since the more you rub, the worse it gets. Wearing close-fitting sunglasses outside, limiting outdoor time when pollen is high in the tree and grass season, and washing her hair when she comes inside can help. Then the use of oral long-acting, non-sedating antihistamines or antihistamine eye drops are the best and only available medications. These can be found over-the-counter or by prescription.
Urticaria Prevention and Treatment
jyeomans: My daughter has thermal urticaria and is only eight years old. What are the best treatments or precautions for her in the summer heat?
Brian_Schroer,_MD: Avoidance is the best treatment, but this may not be possible with an active child. The best medications are the over-the-counter, long-acting and non-sedating antihistamines, such as loratadine (Claritin®), cetirizine (Zyrtec®), or fexofenadine (Allegra®) at age-appropriate doses once per day. If this does not help, then a doctor can recommend higher doses or other stronger antihistamines.
like it or not: Are allergy shots safe for children of all ages?
Brian_Schroer,_MD: Yes, allergy shots have been studies in kids as young as two years old (outside of America). However, most of the time, the need for weekly shots—which can be a little painful—limits the tolerance of this therapy to older children starting around seven to eight years old. But again, this therapy should be done if avoidance and medications are not adequately controlling symptoms.
LaSalle: I work as a camp nurse. We have children with allergies bring up epinephrine pens—one they must carry with them and one for the health office. This is quite an expense for the family. In 10 years we have not had to use one. Is this practice reasonable given the likelihood for an allergic reaction is limited?
Brian_Schroer,_MD: Having the patient carry one pen with another available in the vicinity is fine. Two pens are recommended because in about 30 percent of severe food allergy reactions where an epinephrine pen is necessary, the patient needs a second dose. This is why they always come in twin packs. Four pens nearby is not really necessary. Hopefully legislation in a number of states will pass allowing schools and organizations to have a generic self-injectable epinephrine available will be come widely adopted. Many food allergy reactions in schools and camps occur in patients with no documented food allergies—meaning they do not have self injectable epinephrine of their own. This way they can be treated appropriately.
Honey and Allergens
Marcie: Is it true that if you eat locally-sourced honey you will be less sensitive to allergens?
Brian_Schroer,_MD: No, the honey may contain pollen, but that pollen is not the one which causes allergies. Flowering plants attract bees because their pollen is too heavy to get from one flower to another. The trees, grasses and weeds that lead to allergies have pollen which is so light, it can use the wind to get from plant to plant. This is how it gets in your nose, eyes and lungs this time of year. Therefore, honey does not help allergies and has been reported to cause anaphylaxis in highly allergic patients.
Becker: My daughter has allergies and only ‘exercise-induced asthma.’ But when her allergies are bad, I noticed she wheezes a lot! Could her asthma be worse than exercise-induced or is wheezing a typical allergic response, too?
Brian_Schroer,_MD: This sounds as though she does not have only exercise-induced asthma. Asthma has many triggers, including cold, exercise, allergens such as animals or pollen, irritants such as tobacco smoke, or strong odors. For whatever reason, she is having symptoms. If it is occurring more than two times per week, she needs to see her doctor to discuss preventive therapy.
Asthma and Respiratory Syncytial Virus (RSV)
pwodzisz: My son developed asthma after he had respiratory syncytial virus (RSV) when he was about two years old. I thought it would clear up on its own as his lungs developed. Is this true and if so, at what age does this occur?
Brian_Schroer,_MD: The relationship between asthma development and RSV is complex and not fully understood. It is clear that viral infections predispose patients who are genetically susceptible to developing asthma at a later age, but which patients will get asthma and which will not is not as clear. Eighty percent of kids who wheeze do not develop asthma after the age of five years old.
wave chaser: My son gets asthma attacks with a chest cold or a severe allergy attack. Albuterol does seem to work very well. The only thing that works is steroids. Just one and he is fine. Is it o.k. to use an occasional steroid two to three times per year or should we find something that works better than albuterol?
Brian_Schroer,_MD: By steroid do you mean an oral steroid such as prednisone (oral anti-inflammatory)? If so, then there are many other effective and much safer ways of treating intermittent viral-induced asthma. Albuterol does not treat asthma it only makes you feel better. It does not affect the reason for the symptoms which is inflammation. Albuterol and an anti-inflammatory such as inhaled steroids are the mainstay of asthma treatment. Oral steroids should only be used if these fail.
pwodzisz: Is there a way to control exercise- induced asthma in a child—other than having them take a lot of breaks?
Brian_Schroer,_MD: Warming up for 10 minutes before exercise helps. In most children the underlying asthma—which is causing symptoms during exercise—needs to be treated appropriately for the symptoms to resolve. If the symptoms are frequent, then this may mean a daily preventative asthma medication is needed.
Asthma and Sports
Walnut: My son has moderate asthma. He uses an inhaler when needed and takes medicine daily. I have always been concerned about him playing sports—should I be? Are sports o.k. for kids with moderate-to-severe asthma?
Brian_Schroer,_MD: The goal for all asthma therapy is for the patient to be as normal and active as possible. As far as sports participation, go for it.
jason: My son is 13 years old. He previously would only get asthmatic in the fall and when he got a chest cold. However, this year he has been struggling all year. He is currently only using his albuterol inhaler. Does anyone have any success stories of alternative methods of treatment or medicines that have given true continuous relief?
Brian_Schroer,_MD: Treating persistent asthma, which is occurring more than two times per week, with albuterol alone comes with risks of worsening exacerbations. The gold standard treatment is ant-inflammatory medications that target the reason for the symptoms. These include montelukast (Singulair®) or, more typically, a daily inhaled corticosteroid. The albuterol does not make the reason for the asthma go away, simply makes you feel better when symptoms are present. However, repeated or frequent use can cause the medication to stop working. He needs to see his doctor or an asthma specialist (allergist or pulmonologist) to discuss further therapy soon.
Long-term Steroid Use for Asthma
Petunia: What are the long-term effects of consistent steroid use for asthma? Is there a good option to steroids for children who have asthma?
Brian_Schroer,_MD: I will assume you mean the inhaled forms of corticosteroids which are the gold standard controller therapy for asthma. The main long-term side effects are a decrease in how fast they grow and a very slight decrease in their adult height—typically one to two centimeters, depending on how old they are when they start it and how long they take it. Overall, this type of preventive therapy is very safe and effective. As for oral steroids, there are many long-term side effects and mostly they are used only for brief periods to treat asthma attacks.
Moderator: I'm sorry to say that our time with Cleveland Clinic expert Brian Schroer, MD is now over. Thank you, Dr. Schroer, for taking your time to answer our questions today about allergies and asthma.
Brian_Schroer,_MD: Thank you for allowing me to answer your questions today. All of the questions were excellent. I hope that the information helps you and your families deal with allergies and asthma. Have a great day.
To make an appointment with Brian Schroer, MD or any of the other specialists in Cleveland Clinic Children’s Center for Pediatric Allergy please call 216.444.5437 or call toll-free at 800.223.2273, ext. 45437. You can also visit us online.
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