Allergies and Asthma in Children with Dr. Jaclyn Bjelac

Podcast Transcript

Intro:
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Molly Shrodes:
Hi, and thank you for joining us for this episode of the Health Essentials podcast. My name is Molly Shrodes and I'll be your host. Today we're talking about two very common conditions, allergy and asthma. Now these conditions can cause you to make changes to your everyday life. They can happen to anyone, but specifically we'll be focusing on kids today. To help tell us about this topic, we are being joined by Dr. Jackie Bjelac. Thank you so much for joining us.

Dr. Bjelac:
Thank you, Molly. It's my pleasure.

Molly Shrodes:
So just starting off, can you tell us a little bit about the types of patients you see and what brings them through your door?

Dr. Bjelac:
Yeah, happy to. So allergy immunology is a really unique subspecialty where you're able to see, we say, womb to tomb. We can see brand new babies to the oldest patients. I primarily focus on pediatric patients in my practice, but do see a number of adults as well, and we see at the Cleveland Clinic, a patient with a range of allergic and immunologic concerns, patients with allergies, asthma, eczema, and also concern for immune deficiency and problems fighting infections.

Molly Shrodes:
Great. I think a lot of people are very familiar with having an allergy or kind of a base level of what an allergy is, but can you give us a definition, an explanation if you will, of what an allergy actually is and what it does to your body?

Dr. Bjelac:
Yeah, absolutely. So basically allergy is an inappropriate immune response to something in the environment or something that you ingest. Where, what I explain to patients, is it's basically a gross overreaction where your immune system flags something that's not dangerous with a danger signal, and the way that your immune system responds to this danger signal creates symptoms, depending on what you're reacting to. For things in the environment like tree pollen, for example, that unfortunately many of us are familiar with, it can create symptoms that can make you very uncomfortable, stuffy nose, itchy, watery eyes, and then sometimes coughing, and in patients who have asthma, sometimes environmental allergies can trigger your asthma as well. This is of course different than reactions perhaps to foods, but the mechanism is very similar. It's just an inappropriate immune response to something in the environment or that you're eating where your immune system flags that is dangerous and it's really not.

Molly Shrodes:
Now, is this something that happens from birth or can this develop over a child's life? How early do you typically see allergies in children?

Dr. Bjelac:
That's a really good question. So we do see food allergies in infants. Food allergy is a really broad blanket statement. You can have immediate hypersensitivity reactions to foods, which is sort of what we stereotypically think of when we talk about allergy. When little Johnny eats a peanut, breaks out in hives immediately, maybe has some vomiting and trouble breathing, but you can also have other adverse reactions to foods. Many infants have something called milk soy protein intolerance, where they can't break down the proteins and it leads to pretty significant gas and sometimes bloody stool and a fussy baby, which is no fun for anyone, but doesn't tend to be dangerous unless very severe. So adverse reactions to foods is a really broad topic, but we do see them in infants.

Environmental allergy doesn't typically develop until the child's a bit older. When a child is very young, they can be allergic to things present year round in the environment like cats, dogs, or little tiny microscopic creatures called dust mites. Those kids, when you're very young, tend to have more skin symptoms. So exposure to those environmental allergens might result in really difficult to control eczema. Whereas as a child gets older, we might see them develop stuffy drippy nose, itchy watery eyes. Typically the earliest you would see a child react to things on a seasonal basis like trees, grasses, weeds, ragweed, would be two or three years old because your immune system needs to see something a couple of times to decide that it needs to be flagged with a danger signal in an allergic way.

Molly Shrodes:
Awesome. Now are there any additional types of allergies? I know you just mentioned environmental and food. Are there anything else? Any other types?

Dr. Bjelac:
Yeah, so you can be allergic to a lot of things. So, in addition to foods and environmental allergens, we do see patients who have anaphylactic reactions to flying insects. In northeast Ohio, those are limited to honeybees, wasps, hornets, and yellowjackets that can cause those types of life-threatening allergic reaction symptoms. But we do see many people who have really big bumps after they get bit by mosquitoes. They're wondering what those are like. That's also an immune reaction to a mosquito, but very different than an immediate allergic reaction response. Then I think most of the people who are going to be watching this podcast can empathize with poison ivy, for example. So you can have late reactions to things that come in contact with the skin. It's a specific allergy called contact dermatitis and it results in an itchy rash that can be very uncomfortable, but typically doesn't have other symptoms and usually it goes away on its own.

Molly Shrodes:
Now these things that cause the reaction, I've heard these called triggers. Can you tell us a little bit about that?

Dr. Bjelac:
Yeah. So when you say something triggers a reaction or triggers a flare of an underlying condition, something like asthma or eczema, basically what we mean is this allergic trigger is setting something off, either a cascade of an allergic reaction for food allergy, for example, or many of my patients have allergic triggers for their asthma. Every time they go over grandma's house where she has a cat, their asthma will flare, for example.

Molly Shrodes:
I imagine keeping track of these triggers and signs are pretty helpful in the diagnosis process, right?

Dr. Bjelac:
Yeah. So seeing a board certified allergist is really important if you think that you are having allergic symptoms that are impacting your quality of life because we're able to determine what those things are to which you're reacting, and we can pinpoint the times of year that it'll be beneficial for you to perhaps take medications and implement avoidance measures that can help reduce your symptoms even without using medicines.

Molly Shrodes:
Great. So if a parent is noticing a few things, what kinds of signs should they be keeping track of and looking for to see if their child maybe has allergies?

Dr. Bjelac:
Especially in young kids, sometimes it can be really hard to recognize environmental allergy in particular because they can mimic cold symptoms, and as I think most of us will appreciate kids get sick a lot. So kids who have stuffy noses, itchy watery eyes, runny noses that last for long periods of time, allergies should definitely be in the back of our minds. Kids who are sick aren't typically itchy, whereas kids who have allergy tend to rub their noses. They do something called an allergic salute where they rub their nose trying to get rid of the snot that's running out. Very often we can see impressive accompanying eye symptoms with those nose symptoms, so itchy red watery eyes that sometimes can even be swollen, which can be very alarming to parents.

So if ever your child's having symptoms that you're not comfortable with, we do recommend that you see your pediatrician and they can help you kind of tease out does this appear to be an illness that we need to address immediately, or does this look like it could be allergy? Then we're happy to see you to confirm or help figure out what's going on if allergy is not the cause of your child's symptoms. Very often in the pediatric age group, kids will also have a cough and it's really important to see someone who can help tease out is that cough because of the drainage down the back of a kid's throat or are they developing asthma? Very often in young children, a cough is the predominant symptom for asthma, as opposed to wheezing or telling you, "Mommy, it's hard to breathe."

Molly Shrodes:
Now diving into asthma, I feel like many people might be confused a little bit about where the line is between allergies and asthma. Can you tell us a little bit about childhood asthma?

Dr. Bjelac:
Yeah. So childhood asthma is unfortunately increasing and is managed either by a pediatrician or a pediatric pulmonologist or a pediatric allergist immunologist, and it is a chronic lung condition where you have inflammation in your lungs. This inflammation makes the tubes that carry the air down to the tippy tips of your lungs too narrow. So we use medicines that treat the inflammation and help widen the airways a little bit to make it easier for children to breathe. Many children who have asthma have allergic triggers of their asthma as do many adults, But the proportion of children who has allergic asthma is quite high. So in addition to managing the symptoms and treating the underlying inflammation, helping families identify any potential allergic triggers that can be remediated to reduce their child's symptoms is really important in managing childhood asthma.

Molly Shrodes:
Now, I think we've all heard the term asthma attack. What happens to the body when you have an asthma attack?

Dr. Bjelac:
Yeah. That's a really good question. Sometimes can come on very suddenly or sometimes a patient will tell me, "I could tell that I wasn't feeling good for a few days and then it just becomes very hard to breathe." So mechanistically, those tubes that I was referring to you have become too narrow to transfer the air so that you have adequate oxygen. It makes it very hard to breathe. So you have a tightness and an inability to kind of move air as you want to. Patients will tell me it's hard to breathe out and to breathe in. Asthma is what's called an obstructive process so the air kind of gets trapped. You're able to sort of force the air in, but it's harder to force it out.

Patients will present with breathing fast, working really hard to breathe, like using extra muscles we call them. Kids will often just kind of be very quiet and they'll want to like sit in their parent's lap whereas normally they would be playful and excited to see you. Really, you do not feel well so it's very important that you have what's called an action plan in place for asthma. So if you or your child starts to have symptoms of an asthma attack, or we call it an asthma exacerbation, that you know how to help them feel better. We use rescue medications which include Albuterol, which as I previously mentioned, can kind of help those very narrow tight tubes open so it's easier for the air to move. Then depending on how the patient responds to those treatments, they may need additional intervention either in their doctor's office or the emergency room.

Molly Shrodes:
So you mentioned a few moments ago about how allergic asthma is kind of asthma caused by an allergen. Is it common to have these together? Is that more common than any other type of asthma?

Dr. Bjelac:
Yeah. So asthma is a condition that's present that can be worsened by allergic triggers. The allergy doesn't necessarily cause the asthma, though they are part of something called the Atopic March. So we know that young kids who come to see us with eczema are at increased risk of developing environmental allergies and those kids are then at increased risk of going on to unfortunately develop asthma. So targeting the allergic inflammation early in life is really important. In those kids who have allergic triggers, I've seen numbers that up to 80% of childhood asthma does have an allergic trigger. It's very important to identify what those triggers are so we can remediate, which means decrease the child's exposure to those allergens, which can help improve their asthma symptoms, improve their asthma control.

Molly Shrodes:
Just to clarify on this, are children born with asthma and experience symptoms right away, or do they generally develop over time?

Dr. Bjelac:
So asthma is something that typically doesn't manifest until a child's a bit older. Certainly we believe that genetics play a huge role in allergies, asthma, eczema, so you're born of course, with the predisposition to develop these conditions. Many children early in life will have something called a viral wheeze where they wheeze and have symptoms that mimic asthma when they're exposed to respiratory illnesses, but then they sort of outgrow that. That's very different than asthma, which once it presents, certainly symptoms can improve as we age, but typically we consider true asthma a lifelong condition. Many babies are born with a lot of breathing problems and we're so grateful to our neonatology colleagues who help those very tiny babies breathe better, and then pediatric pulmonologists who manage any kids with a myriad of breathing concerns very early in life, but it would be highly unusual to diagnose such a very young child with asthma, and many of the diagnostic criteria require that a child be at least two years old for you to make that diagnosis.

Molly Shrodes:
Awesome. So I was actually, as you were talking, I was wondering about with allergies, do they also develop over time and do they get better as a child's exposed to more things in the world?

Dr. Bjelac:
Yeah, that's a really good question. So allergies tend to develop as a person ages. There are plenty of adults who develop allergy in adulthood including to foods and environmental allergens. Most people tend to develop environmental allergy between school age and high school years. They'll start to notice their first symptoms. For some people, their allergy symptoms improve over time without much intervention. But unfortunately for many people, even with continued exposure to something like a cat or dog, your symptoms will worsen, so then need to be managed either by removing the allergen from the home or reducing your exposure to it, which very few people do. That's not a conversation we have often where we're like, "It's time to get rid of a dog." We just manage symptoms.

But that being said, what you can do to sort of change the course of the development of worsened allergy symptoms and even potentially for children prevent the development of asthma, is to do immunotherapy or allergy shots. I think most people are familiar with the concept of allergy shots, which is where we retrain the immune system to stop overreacting to those things in the environment that it's inappropriately flagging with a dangerous signal. Allergy shots are not without risk and are certainly a big time commitment for a family, but in a younger child who has really bad nose and eye allergy symptoms, there are studies that show us that if we do allergy shots in that age group, we're able to decrease the rates of asthma development in those children. So it can be a very powerful tool, not only to help you feel better day to day, but perhaps impact your long-term health as well.

Molly Shrodes:
Wonderful. So will children ever outgrow allergies just naturally?

Dr. Bjelac:
Absolutely. So we do see patients, and I'm not sure that they are really good numbers, because there are so many people who live with allergy symptoms who never seek care with an allergist or even mention it to their doctor. They purchase readily available over-the-counter and just manage their symptoms. So I don't know that the percentages are very clear, but we do know that there are people who, as we get older, allergy symptoms decrease pretty much on their own.

Molly Shrodes:
Speaking of treatment, I would love to know a little bit more about the types of medications that are okay for children to use and kind of some different environmental things you can do just to keep your child safe, as well as what age can you start giving your child's and these medications?

Dr. Bjelac:
That's a really good question. So we always want parents to reach out to their pediatrician or their allergist to get specific recommendations based on their child. But when you come to the allergy clinic, what we try and do is first identify your allergic triggers, and then we give you avoidance measures or suggestions to reduce exposures based on your particular allergens.

So for things like pollens, we know that keeping an eye on the pollen counts, avoiding really high pollen count days with a lot of outdoor play is important, washing kids at least face and hands, but possibly even totally showering them off after they come inside on those high pollen count days can be very helpful at reducing symptoms, keeping windows closed, particularly at night in a child's bedroom as well as in the car when you're traveling. I think we've all, especially in Northeast Ohio, seen that sheen of tree pollen that covers your car in the morning when you go out to get ready to go to work. That just blows in the windows and blows in the windows of your house, so we want to keep a child's environment as allergy free as possible.

So that stuff works pretty well for the environmental allergens that are present outdoors. But you know, we also talk about things that could be inside and trigger symptoms. So when children are unfortunately allergic to family pets, we talk about ways to reduce exposure before the family needs to make a decision to completely remove the animal from the home, things like keeping the pet out of the bedroom, considering a HEPA filter, which doesn't have a ton of evidence to support it but probably isn't going to hurt, washing face and hands after playing with the dog or cat are all things that we can do to reduce exposure to those types of allergens.

Then we have dust mites, which I think I previously mentioned a little bit about, are tiny microscopic creatures that live in anything upholstered or fluffy. So talking about ways to maybe minimize the number of stuffed animals on a child's bed and zip around dust mite covers on their pillow and mattress, these types of interventions are at no risk to the child and can help reduce their exposure to things that are causing symptoms. But even with really fabulous avoidance measures, it's very common to continue to have symptoms, and then we do have a number of medications at our disposal to try and improve symptoms and quality of life for these kids in their families.

So the medications with the best evidence to support use are medicines called nasal steroid sprays. These are the Flonase, Nasonex, Nasocort of the world. Sometimes it's hard to get by and to use a nose spray from a three-year-old, but we have some tricks and I'm always amazed at what kids will do when they notice that a medicine helps them feel better. They're usually more willing to take it.

So in addition to the nasal steroid sprays, we have oral antihistamines. We prefer long acting antihistamines like Zyrtec, Claritin, Allegra and their generics. We really try and avoid the use of Benadryl, particularly in young children, because of the possibility for side effects including sedation, and also because it doesn't last very long so it has to be dosed very frequently. We also have eyedrops that are available both over-the-counter and as a prescription which help treat eye allergy symptoms. There's a prescription allergy medicine called Singulair that we don't use terribly often, but might be a good choice for some patients. So there's so many different medicines, many of which are not approved for very young children. So when deciding what medicines to use for your child, reaching out to your pediatrician or your allergist is always appropriate.

Molly Shrodes:
Great. So I know you mentioned a little bit ago about the possible genetic factor to why allergies develop, but is there anything that a parent can do in terms of preventing allergies from ever happening?

Dr. Bjelac:
Yeah. That's a really, really good question and there's lots of very smart people doing a lot of studies to try and look into this because we know that preventing would be so much better than trying to treat and cure these patients. So we do know that exposure to dogs early in life has been shown to decrease rates of the development of allergies and asthma in pediatric patients. We know that individuals who are raised in a rural environment, like on a farm with exposure to farm animals, produces a dramatic decrease in the development of allergies and asthma. Number of siblings is inversely correlated to the development of allergies and asthma, which we think might be a surrogate for how often do you get sick, right, because if you have more brothers and sisters bringing home more illness to you and you get sick earlier in life, that could be an explanation for why that's true.

There's a lot of research being done as to what is causing this increase in allergies and asthma, and unfortunately we don't know, and it's probably a number of different factors which is why we haven't been able to tease out only one cause. But knowing that you or your child's mother or father has allergies, one might consider just keeping a very close eye on symptoms, and if you feel like your child's also developing allergies, reaching out to an allergist to talk about ways to hopefully prevent development of more severe symptoms. This is especially true in the food allergy space where we know that early introduction of food allergens like peanut and egg has been shown to decrease risk for the development of food allergy in the future.

Molly Shrodes:
All right. Is there any truth to the idea that you should eat lots of nuts while you're pregnant to help prevent your baby from being born with a peanut allergy?

Dr. Bjelac:
We have tried so many times to give pregnant mothers and nursing mothers tons and tons of food to prevent food allergy in their kids, and we've not been able to show that that's helpful or harmful. So I just recommend that women follow the recommendations of their OB-GYN and the American College of obstetrics and Gynecology and just eat a healthy, balanced diet.

Molly Shrodes:
Great. So for many medical conditions, you have to adapt every day to make sure that you're living a healthy life. What recommendations do you give parents as they send their kids out into the world if they have asthma or allergies?

Dr. Bjelac:
So the most important thing is that we're prepared should symptoms develop. So knowing that you have an asthma action plan in place, if your child should develop symptoms, and their rescue medicine's available to them, is of utmost importance. That way they're empowered to take their medicines if they start having symptoms which can prevent the development of severe asthma attacks. As far as allergies are concerned, when a child's going over to a friend's house where we know that there's relevant allergen exposures, a cat for example, I often recommend that they take medicines proactively so that they can enjoy their play date. But knowing what your child has reacted to in the past as far as environmental triggers for either nose and eye symptoms or asthma is very important, identifying situations where they might be exposed to those things is important, and being prepared with medicines to help manage symptoms is the name of the game.

Molly Shrodes:
Wonderful. So just wrapping up, I want to ask you for a few tips you could give parents that are listening today about how to talk to their kids about allergies and asthma, maybe some that the kids should look out for.

Dr. Bjelac:
Yeah. So I think it's always important that even from a very young age, we counsel kids to listen to their bodies. If you are feeling uncomfortable and you feel like it's impacting your ability to play or sleep or learn, you absolutely should tell one of your grownups right away. Especially in the asthma space where it can be a safety concern, we really want kids who have asthma to learn to recognize their symptoms so they can take their medicines as needed and tell a grownup right away.

For allergies, unfortunately, I feel like sometimes we can be dismissive of nose and eye allergy symptoms, but we know that they're incredibly impactful to quality of life. Allergies are a huge cause of something called presenteeism where we don't keep kids home from school, maybe this year we would have, but in a typical year we wouldn't keep kids home from school just because they have the sniffles, we just give them medicines and send them in. We know that those kids aren't learning as well as their peers who aren't suffering from allergy symptoms. So I think really just teaching kids how to listen to their bodies and letting their parents know if they're uncomfortable and their medicines aren't working for them is important for all medical conditions, but especially for allergies and asthma.

Molly Shrodes:
Thank you so much for taking the time and sharing your insights with us today, Dr. Bjelac.

Dr. Bjelac:
It's really my pleasure.

Molly Shrodes:
To learn more about allergies and asthma, visit Clevelandclinicchildrens.org/specialtycare.

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