Dust, Pollen & Pets - Kids and Environmental Allergies

Podcast Transcript

Speaker 3: Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Jackie Bjelac, MD: Welcome back to Little Health. I'm your host, Dr. Jackie Bjelac, and I'm a pediatric allergist immunologist at Cleveland Clinic Children's. Chances are your child has experienced sniffles, itchy eyes, and an endless cycle of what might be a cold. But what if it's more than just a passing bug?

Today as part of our season on pediatric allergy and immunology, we're gonna be talking about environmental allergies in children. We'll be discussing common triggers, and I think really importantly, what are some ways that we can bring our little ones, some relief?

So our guest today is Dr. Kara McNamara, my colleague, friend, and a pediatric allergist immunologist at Cleveland Clinic Children's. So welcome to Little Health, Dr. McNamara, and would love if you could tell people a little bit about you.

Kara McNamara, MD: Great. Thanks so much. I'm happy to be back. Um, I am, as Dr. Bjelac mentioned, one of the allergists here at the Cleveland Clinic. I have bounced around Ohio, but am originally from Columbus and have been in Cleveland for quite a while here at the Cleveland Clinic. I live with my husband and then my two children, and also interesting to this conversation, have two dogs and two cats at home as well.

Jackie Bjelac, MD: So lots of good tips about environmental allergens to pets that we'll be sure to talk about later.

Kara McNamara, MD: Absolutely.

Jackie Bjelac, MD: So I am a pediatric allergist and mother of four, and I really struggle sometimes with teasing out if my kids' stuffy drippy noses are colds or could it be allergies. So can you comment on some things to look for that as an allergist helps you feel more confident that we need to be going down that allergy pathway.

Kara McNamara, MD: Honestly, I agree that we won't always know. There are some times it can be very difficult to figure out because some of the common viral seasons such as that fall back to school season as well as the spring season, can be big for both viruses and certain kinds of pollens.

There are definitely some symptoms such as itching, itchy eyes, itchy mouth that point us a little bit more towards allergies versus the common cold, but we also sometimes have to look at the big picture. Does this happen multiple years in a row? Is it happening all the time, even in between times that they seem sick? And sometimes time helps us figure and sort that out.

But it can be very tricky when you first notice some of those symptoms.

Jackie Bjelac, MD: That's helpful. And you know, you mentioned symptoms happening in between apparent illnesses. In kids can allergy symptoms be present year round or do we only see them seasonally?

Kara McNamara, MD: It really depends on what kids are allergic to. There are some allergens such as animal dander from cats or dogs, dust mites, certain types of molds that can be present indoors. And if kids are allergic to these, then they may have symptoms all year round because they're always exposed.

However, there are some allergens such as pollens, tree pollens, grass pollens, weed pollens that are only out at certain times of year. And then the kids may have particular seasons where they have these symptoms and then they may be better the remaining part of the year. So it's really all about what the kids are allergic to.

Jackie Bjelac, MD: Can you comment a little bit on some symptoms that we should be looking for in kids that might tell us that they have allergies?

Kara McNamara, MD: So some of those things you mentioned right off the bat, stuffy nose, drippy nose, kids may have a lot of sneezing or itchy and watery eyes.

Many of our allergic kids have a sensation of something in their throat, like mucus or just an itching in their throat, and they may clear their throat frequently. And you may see these kids rub at their nose at their eyes. Some kids will rub their nose in a way that we term it the allergic salute. And if they're doing that all the time, they might even get a crease across the middle of their nose and that can all be suggestive of allergies.

There are some kids that may have a cough, um, associated with their allergies as well, but it really just depends on the individual child.

Jackie Bjelac, MD: When you have a kid who's coughing with allergies, um, should we be worried about more than just nose and eye symptoms?

Kara McNamara, MD: That's a great question. One good thing about, if you can call it that, a good thing about environmental allergies is they don't tend to cause severe reactions. They don't cause anaphylaxis, which is that whole body reaction that can sometimes happen with things like a food allergy or a medicine allergy.

That being said, while most of the symptoms that environmental allergies cause are simply annoying, like that stuffy runny nose, itchy, watery eyes, the one thing that might be a little more dangerous is if your child has underlying asthma. Environmental allergies can trigger asthma, and if your child has exposures that lead to a severe asthma attack, that would be the thing I worry about most. Um, but because these types of allergies don't cause anaphylaxis, we don't typically have to do things like prescribing epinephrine devices like we might in kids with other types of allergies.

Jackie Bjelac, MD: That's reassuring to hear and certainly though to your point, this is a really significant quality of life issue. You know, these kids can be miserable. They often have trouble sleeping or paying attention in school. So what do you do when a child comes to your office? Like what could a family expect in an evaluation for environmental allergies?

Kara McNamara, MD: Just like we had talked about in the recent food allergy podcast, the most important thing about environmental allergies is the story or the history. So we'll talk a little bit more about what symptoms your child is experiencing and what's been going on, and that will help guide us in terms of next steps, whether that includes testing, treatments, or a little bit of both.

Typically with environmental allergies, the first test we would think about doing is a skin prick test where there are little drops of allergens placed on the skin, usually either the back or the forearm and some type of little scratch. It's not a pleasant test always, mostly because kids can get pretty itchy, but it can give us some pretty quick results about what kids are um, allergic to and give us more guidance on what kind of things we should be avoiding.

The other option if we aren't able to do a skin test for various reasons, maybe your child has really bad rashes on their back, or maybe they aren't able to stop their allergy medications. We might do a blood test which looks for an allergy antibody called IgE to each of the individual allergens and either of those tests can give us results about what a child is allergic to and help guide their treatment.

Jackie Bjelac, MD: That's helpful to understand. So it's important to do the test to make sure that you have environmental allergies to help you with what we call avoidance measures, what are things we can control to reduce exposures. And then I always think it's really helpful to understand if there's only seasonal symptoms, what are the times of year that we need to focus on for medication use?

So would love to hear, um, your perspective on some of the medicines that are available. What works best? I think we should acknowledge that a lot of allergy medicines are available over the counter and you know, I'm a board certified allergist and I walk into these aisles and it's just overwhelm. It is an abyss in there of different allergy medication options.

So let's talk about some of the things that you would recommend once you meet somebody in your office with environmental allergies.

Kara McNamara, MD: Absolutely. There are a lot of options out there and, and to your point, many of them are available over the counter now, so I think on occasion parents may be able to try some initial treatments on their own, but if the symptoms really aren't improving or your child's quality of life is impacted, then absolutely getting to an allergist to help look and confirm some allergies, see what you can avoid or perhaps just find the best plan and what medications to use together can be very helpful.

Some of the initial medications that we think about for treating environmental allergies include some of the intranasal steroid sprays, meaning a spray you use in the nose, typically on a daily basis to help control some inflammation. Many of them are available over the counter, but again, an allergist can help give you a little bit more guidance about when to use it or how to use it.

Other medications include the oral antihistamines, so these are medications such as cetirizine or loratadine, fexofenadine, and these are taken orally, either in a tablet or a liquid, and again, can be utilized over the counter or with some guidance from your allergist, um, to help control certain symptoms.

And I think it's important to know that not all of these medications treat the same thing. So, for example, many parents of young children who might not love the idea of a nose spray, may reach for the oral medications first, and they're great at helping itchy and sneezing and runny noses, but not as good at taking care of congestion.

So again, I think while there are a lot of medications out there and available to reach for. Putting a plan together to know which ones to use and in what combination can be really helpful from a board certified allergist.

Jackie Bjelac, MD: That's great to know. So certain medicines treat certain symptoms and when dosed appropriately, a lot of these can be used together.

Now you and I were allergist, immunologists and I think perhaps more than many we're sensitive to putting things in our kids' bodies or into our patient's bodies. And I heard you mention nasal steroid sprays. I have a lot of families express hesitation to use topically applied steroids, either in the nose or on the skin for eczema.

Can you comment on the relative safety of like a nasal steroid spray?

Kara McNamara, MD: Absolutely the nasal steroid sprays, since they are delivered to the nose, the vast majority of the steroid is staying and working right where you need it. So very little gets absorbed by the body. Similar to, as you were mentioning, some of the ointments or creams that we use with steroids for eczema or other skin conditions.

So at the end of the day, anytime you're putting steroids right where you need it, you have a lot fewer side effects than if you were to take a steroid pill or liquid by mouth. So even though it is a steroid the nasal steroid sprays tend to be very safe and effective even in young children. There are some side effects, for example, nosebleeds, especially if you're not using the proper technique. Uh, but a lot of times they are very well tolerated and can be very helpful for our patients with environmental allergies.

Jackie Bjelac, MD: Yeah, and I think something I always try and point out to our families is the goal here is like a risk benefit kind of balance. If you can use this nasal steroid spray and then your kid can sleep better and play outside, clear choice to use it. Um, and I think that's part of the benefit of seeing an allergist, frankly, you know, to help kind of work through the pros and cons of these different, different choices.

Kara McNamara, MD: Absolutely. I like to tell my families that my goal in treating your child's allergies is to make your child comfortable and able to live a normal social, happy life with the least amount of medication possible.

And quite honestly, that amount that it takes to keep them happy and, and living their best life may change over time. So we'll work together to adjust the plan as needed. We don't want these kids to live in a bubble. We do want them to be able to go outside. So we will use the medication when we need it. And we are always weighing those risks and benefits like you talked about.

Jackie Bjelac, MD: I think that's great. And you know, thinking about, some kids come in to see us and we start them on a nose spray and an oral antihistamine and even an eye drop or maybe even a nasal antihistamine and they're still having symptoms or that their parent or caregiver looks at us and says, you know, my kid needs four or five medicines for these three to four months of the year to feel well. What other options do we have as allergists to help these patients?

Kara McNamara, MD: I think that's where we get into what I like to call our third level of treating allergies. I think of the first level as avoiding what you can, like we talked about, but obviously you can only get so far to avoid things like a tree pollen that are just gonna be in the air at certain times of year.

Then we use the medications as our second line, but if both of those are not quite enough or if we're looking for a little bit more long-term solution, that's really where we think about something called allergen immunotherapy, or many people will hear this referred to as allergy shots. Allergy shots are something where we actually desensitize the body to the allergens. So we literally take all those things on your list of allergies, cats, dust mites, tree pollens, et cetera. We mix it up in a little vial and we give kids shots of that starting in tiny doses and gradually increasing over time.

It is a very involved treatment and not without risk, so it's not something we take lightly, but it can be a real game changer for kids with severe allergies. And after several years of this treatment, some kids will have even long lasting benefit. So it's a really great treatment option for those that aren't getting enough relief with those other steps.

Jackie Bjelac, MD: So you mentioned allergy shots, and I wanna be really clear because sometimes people come in and they say to me, you know, when I was a kid or I know someone who went and just got a shot once a year and it made all their allergy symptoms go away. Can you do that for me? What is that shot? Why aren't we doing it, and what can we do instead?

Kara McNamara, MD: I wish that was a better option, but unfortunately when people are thinking of this single one time or once a year allergy shot, they're probably referring to a steroid injection. While people did sometimes use this for treating environmental allergies in the past, the data really showed us that this has a lot of risk associated with it, and there is a whole page of side effects that comes along with steroids given to the whole body, including an injection in a muscle.

So when you think about treating environmental allergies, it's really not an acceptable level of risk. So this is not something that is standard of care anymore in the allergy field, and our national allergy organizations really recommend against it.

So unfortunately, this is not something that we offer, and allergy shots are great, but when we talk about allergy shots, we're talking about the desensitization and the long kind of several year process.

Jackie Bjelac, MD: But what I love about the desensitization is it's actually teaching your immune system that these things are safe, right? It's not a bandaid like a medication or like the steroid shot, so even a much more powerful tool.

Kara McNamara, MD: Absolutely, I, I talk about it that same way that everything else we do, the medicines are all band-aids. It helps the symptoms, but it doesn't change the actual allergy where, as you mentioned, the allergy shots or immunotherapy really changes the body's response. So it's a lot more meaningful long-term benefit.

Jackie Bjelac, MD: Honestly, one of the more gratifying things I do as an allergist is definitely put, put a kid on shots and see how well they do the next season. Um, but you know, to your point, not without significant logistical considerations for the family, which is, you know, an important consideration. Can you do allergen immunotherapy without doing shots?

Kara McNamara, MD: There are other ways. It depends a little bit where you live and what kind of allergies you have. There is in particular another kind of therapy called sublingual immunotherapy or slit. In the US we have several of these that are FDA approved, where it's actually a tablet you place under the tongue and you can be doing that treatment at home, which is a bit different than the allergy shots where you have to come into the office every time. So, as you said, is logistically complicated.

The slit treatment option is available for certain individual allergens here, such as there's a tablet for dust mites or a different tablet for ragweed, but we don't have a lot of options for kids that have multiple environmental allergies right now. It's done more in other countries in Europe, for example, but we are a little bit limited at this time in the US.

Jackie Bjelac, MD: But hopefully sometime in the near future it'd be nice to have that as an option for, for some patients.

Kara McNamara, MD: Hopefully.

Jackie Bjelac, MD: That'd be great. So you mentioned a couple of times a cat and dogs, and I wanna take a couple of valuable minutes to talk about animal allergies.

So one question that I hear a lot when families come in is, will, my kid lives with a cat or dog, so they can't be allergic to our pet? Right.

Kara McNamara, MD: That is not correct.

Jackie Bjelac, MD: Oh, no.

Kara McNamara, MD: Uh, it is possible to develop allergies at any time. Some kids will start off with not many and have an increasing number of allergies over time. Some kids may actually go the other way and outgrow certain allergies, but new ones can absolutely develop. And unfortunately with animals, the allergen comes not only from the skin, but saliva and other places.

So despite popular conception, there actually is no hypoallergenic dog or cat out there. This myth gets perpetuated a bit, but there's no dog breed, for example, that reliably does not release allergen.

And because animals are in the house and your kid's exposed to them all year round, sometimes the symptoms can be a little bit more subtle. You may not notice a slightly stuffy nose, that's always there. Versus the kids that have tree pollen allergy, one day tree pollen's not there, the next day it is, they walk out the door and boom they experience all these very dramatic symptoms. It can be a lot more subtle with something that you're exposed to all year round and you maybe have some symptoms, but it's not as sudden or dramatic.

Jackie Bjelac, MD: That's interesting. So one question that I ask families is, does your kids seem different when you guys go on vacation or when you leave the house, right? When you remove kind of that exposure. And I'm very transparent with my patients and their families. I say, I am not a very good allergist because it is very rare that I actually recommend a family rehome a pet. Even when a kid is allergic.

So what are some things that we can tell families to hopefully help a child with symptoms related to their pet allergy? Understanding of course, that if they're very severe or impacting breathing, re-homing is probably safest and best for everyone.

Kara McNamara, MD: Absolutely. So if your child is experiencing maybe eye symptoms or no symptoms because of a pet in the home, while you will never completely eliminate that allergen, there are things you can do to help decrease the amount. Things such as washing the pet dog or cat, if you can manage it.

Jackie Bjelac, MD: Do you even have cats, Kara? They don't like to be washed.

Kara McNamara, MD: I do. They don't go in the bath. But if you can manage it, um, that's great. Um, washing cats or dogs once a week, even with just water can reduce how much allergen is let off. Things like Hepa, H-E-P, H-E-P-A air filters can help pull some of that allergen out of the air.

Keeping cats or dogs out of your child's bedroom can limit the amount of exposure they have for those long hours that they spend sleeping in there at night. And more recently, there's even a certain kind of cat food that's able to neutralize some of the main cat allergen. Usually the more things you can do to reduce exposure, the more your child will benefit.

And I agree that I think it's very different if a child is having eye or nose allergies, um, that is maybe uncomfortable, but they choose to have the pet in the home, then we try to make the child as comfortable as possible. However, if a child is experiencing asthma attacks or landing in the emergency room with these severe episodes, that might be a different discussion and time to really think about the option of rehoming uh, animal.

Jackie Bjelac, MD: And for patients with cat or dog allergies, do allergy shots work for those as well?

Kara McNamara, MD: Absolutely. We have better data on cat than dog just because dogs can vary so much animal to animal. Um, but we routinely do use allergy shots to both cat and dog, and we have some kids that experience some amazing benefit.

Jackie Bjelac, MD: So I think something that really goes under recognized when a family is managing environmental allergies in their child. You know, we talk about it being a quality of life issue and it's uncomfortable, but I don't think it gets the attention it deserves for impact on sleep and school and also social emotional health.

You know, I've had, um, kids start to to cry in my office when they learn that they're allergic to their cat or dog. So can you comment on some of the ways that a pediatric allergist can help support your family as you receive these diagnoses and manage these symptoms?

Kara McNamara, MD: It can be incredibly difficult to live with allergies for all those reasons you mentioned. And if you recall, our former program director actually used to joke that if an allergist recommends a family remove a cat or dog from their home, they're more likely to get rid of their allergist than the animal. But I think a lot of this is really about managing risk and benefits as we talked about.

If your child is having bothersome but not dangerous symptoms around a animal in the home, then the right thing for that family may be to use some fairly benign medicines to help the symptoms, but keep that animal in the home. If your child is having more severe symptoms, then that may not be as straightforward of a choice.

But I think our job as an allergist is really to balance all these things and put it in perspective. What's the risk of the allergy? What's the risk of the medicines and treatments? And try to find a plan that's best for everyone. And as we said before, to really let the child, be a kid and enjoy all the normal things in life while managing the symptoms and, and making it as comfortable as possible. But it absolutely can be challenging to live with all those things on a day-to-day basis.

Jackie Bjelac, MD: Yeah, and you mentioned, you know, coming up with a plan and I think that that plan can look different for every child and their family, depending on a variety of factors, and I think really important to acknowledge the plan can change.

That's one of the really important things about, I think, establishing with a peds allergist is we did this intervention, what was the impact? And are we happy here? And then do we maintain excellent control? And you know, I acknowledge it is hard to find time to come in and see the doctor or do a virtual appointment, but I do think it's something that we really have the opportunity to really positively impact our families when we see them regularly and in a longitudinal fashion.

Kara McNamara, MD: Definitely, that's one of the most exciting things about the allergy field for me, is that we can really have a big impact on quality of life. And as you said, the conversation will change from visit to visit, but that's why we're there to work together and make the best plan possible.

Jackie Bjelac, MD: That's awesome to hear. Well, thank you so much. I'm really hoping that we've empowered, you know, patients and families to recognize these symptoms and their kids maybe be able to choose some medicines before they get in to see us and know what to expect when they come to see a pediatric allergist. So thanks so much for joining me today.

Kara McNamara, MD: Thank you.

Jackie Bjelac, MD: So we hope you've learned some hopefully easy ways to help your child with their allergies. Knowing what triggers them and having a consistent plan to manage their symptoms can make a huge difference in their comfort. Next time on Little Health, we'll be discussing ways to strengthen your child's immune system.

And if you'd like to schedule an appointment with one of our pediatric allergist immunologists. Please call 216.444.KIDS. That's 216.444.5437. Thank you.

Speaker 3: Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit Cleveland Clinic Children's.org/little health.