Environmental allergies: treatment for kids

Allergies can be so uncomfortable and disruptive to day to day life - for an entire family. But the good news is that we have a slew of medication options to treat generalized and specific symptoms to help your child.

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Why do allergies happen?

For more information on why allergies occur, who its at highest risk, and answers to FAQs (eg: can babies have seasonal allergies) read my prior post.

Treatment:

First off, most importantly: you know I’m a big believer in minimizing the amount of medications we give our children. Children (and humans, really) may need medications when they have symptoms that are disruptive to their day to day lives, uncomfortable, or have potential consequences. But there are actually many environmental and behavioral modifications you can make to decrease exposure to allergens (check out my free download that goes over 10 ideas that can really help - available in the guides section).

Remember, I always recommend discussing with your doc to make sure any medication you give your child is the right choice based on age, symptoms, & other meds/health problems. If and when you do start a medication, you want to have a clear sense of the risks and benefits of the medications, and also a sense of what criteria you will use to determine that your child no longer needs the medication (or a timeline for when you’re planning to reassess).

The Pediatrician Mom Tip: If your child has a history of seasonal symptoms, or a known trigger for their symptoms, you ideally want to begin treatment 1-2 weeks BEFORE they are exposed.

General symptoms:

For generalized symptoms, or those that cross multiple systems (eyes, cough, congestion, etc), oral antihistamines are probably your best bet, because they are effective and safe.

Newer (second-generation) antihistamines are a better choice than Benadryl, which we have moved away from recommending (the prior post details why). These newer medications are longer-acting and non-sedating, with a more positive side effective profile. Most also come in child-friendly preparations, eg solutabs and liquid, although not every preparation is appropriate for every age, so make sure you read the label.

• Oral antihistamines peak in the blood between 1-3 hours after the dose is taken, so for the maximum effect, they should be given in the morning. I’ve also seen over time that the response to one seems to fade and sometimes after a few years, patients need to switch to a different medication of the same group (eg. switching from Zyrtec to Allegra).

• Dosing may be adjusted in specific situations (eg kidney/liver disease), which is why talking to your pediatrician is best.

• For answers to whether infants can have allergies, check out the prior post.

The Pediatrician Mom Tip: Generic medications are cheaper & just as effective, so pick these over brand names! And remember that many of the medications discussed in this post are FSA/HSA eligible.

FDA-approved oral antihistamines (not a comprehensive list)

• Fexofenadine (Brand: Allegra)

  • 6mo - 2y: 15mg twice per day

    • Note: technically off-label for allergies, but approved for hives

  • 2y - 11y: 30mg twice per day

  • 12y and up: 60mg twice per day

• Loradatine (Brand: Claritin)

  • 2y - 5y: 5mg

  • 6y and up: 10mg

• Levocetirizine (Brand: Xyzal)

  • 6mo - 5y: 1.25mg (= 2.5ml)

  • 6y - 11y: 2.5mg

  • 12y and up: 2.5 - 5mg

• Cetirizine (Brand: Zyrtec)

  • 6mo - 2y: 2.5mg

  • 2y - 5y: 5mg

  • 6y and up: 10mg

Specific symptoms:

If your child’s allergies manifest primarily in one system (eg eyes, or congestion) then they may only need a medication that targets that specific area of the body.

Pink itchy eyes, swelling of the eyelids (allergic conjunctivitis)

• Sometimes associated with eyelid swelling

• Usually *but not always* seen in both eyes

• Can have some mild eye discharge as well, which is usually thin and worse first thing in the morning (does not usually re-accumulate throughout the day)

• Not really associated with pain

• Randomized controlled trials have found that allergic conjunctivitis is usually more effectively treated with eye drops than with oral antihistamines.

• More general pinkeye info here.

Things to try:

• When studied, allergic conjunctivitis is usually more effectively treated with antihistamine eye drops than with oral antihistamines. Here are a few over-the-counter options (follow dosing instructions on the product you choose).

  • Over 2y:

    • Olapatadine / Pataday (0.1%, 0.2%, 0.7%)

    • Cetirizine / Zerviate (0.24%)

  • Over 3y:

    • Ketotifen / Alaway or Zaditor (0.025%)

• For children who cannot do eye drops, try cool compresses for the swelling and discomfort.

Sneezing, congestion, sinus pressure, sore throat

In the nose/sinus area, the histamine surges cause localized release of mucus, increased permeability of veins (leading to swelling of the nasal tissues around the veins) and sneezing as a protective sensory reflex to try to clear allergen triggers from nasal passages.

The resulting nasal congestion and mucus causes a cascade of symptoms. Sore throat is often worse first thing in the morning because of post-nasal drip (more throat irritation when you’re laying down), ongoing inflammation can lead to sinus fluid build up and pressure as well as eustachian tube dysfunction (fluid behind the middle ear). Treating the nose, therefore, can actually help with an array of symptoms.

Things to try:

• Nasal saline: This removes allergens from the nasal passages (and therefore decreases ongoing irritation). It is helpful for those who are too young or cannot tolerate nasal steroid spray, but also great before using steroid nasal sprays to clear out mucus & deliver the medication more effectively. Saline comes in an array of different formulations: saline spray, saline drops, and saline irrigation. Here is an overview of some of the options (plus safety info).

• Steroid nasal sprays: In trials, these have been proven more effective than oral antihistamines for managing these symptoms.

  • The biggest concern from parents is related to systemic absorption and long-term exposure to steroids, based on a few trials that showed a minor reduction in growth velocity with long-term use (although at doses higher than what we typically recommend).

  • To minimize this, once-daily dosing nasal sprays are better for young kids (PMID 25017530, 15746880). And again, you only want to use them as long as the pros outweigh the cons.

  • Newer steroid sprays, however, have minimal systemic bioavailability so they are a safer option. My two favorites:

    • Mometasone (Nasonex): 2y and up

    • Fluticasone (Flonase)

      • Sensimist approved for 2y and up (and doesn’t cause the burning sensation so many people hate)

      • Regular nasal spray approved for 4y and up

• Nasal spray overuse can lead to nose bleeds or irritation of the nasal septum. If you notice this, talk to your pediatrician. I have seen bacterial superinfection (impetigo) of the skin around the nose from overuse.

Headache, fatigue, poor sleep

Often, headaches from allergies are related to sinus pressure and congestion build-up. But headaches can be caused by fatigue. Here are some ways that allergies can interfere with sleep:

• Postnasal drip is worse at night, which can result in more cough and sore throat

• Adenoid and tonsil swelling from allergic triggers can lead to snoring and worsen sleep apnea

• Congestion on its own makes it hard to sleep!

• Because headaches can have other causes, always talk to your pediatrician if symptoms are persistent, even if you think allergies are the cause.

Things to try:

Long term use of pain meds is not ideal. Steroid nasal sprays and oral antihistamines can help, as can ensuring that you are showering and cleaning out nasal passages before bed. Steam inhalation can also be helpful here.

• Afrin can be very tempting here but do not use for more than 3 days - can lead to rebound congestion & worse symptoms!

Cough, wheezing

Much of the time, allergic cough is due to post-nasal drip from nasal congestion. But not always. Up to 50% of patients with asthma may have allergic rhinitis as well, and exposure to allergens can trigger wheezing, chest tightness or an allergic cough.

Things to try

If your child has asthma, talk to your pediatrician to make sure their asthma treatment plan is optimized. It may need some seasonal modification (such as using preventive medications). For these patients, consider starting oral medications 1-2 weeks before they are exposed to triggers to try to prevent bronchospasm before it occurs.

Skin concerns

More than 2/3 of kids with atopic dermatitis develop asthma or allergic rhinitis as they get older (this is called the “allergic march”). During allergy season, it’s not uncommon to see eczema worsen. Some kids also get hives with exposure to triggers.

Make sure you are on top of your eczema regimen - especially moisturizing frequently.

For flares, use topical steroids and talk to your pediatrician about other eczema options (I have several posts / a free guide as well). Consider colloidal oatmeal to soothe irritated skin.

The Pediatrician Mom Tip: Generic medications are cheaper & just as effective, so pick these over brand names! And remember that many of these medications are FSA/HSA eligible.

What about Singulair?

This medication is a leukotriene receptor antagonist and requires a prescription. It is sometimes used for treatment of allergies in patients with asthma, and for some it can be extremely effective.

But most healthcare providers lean away from using it unless absolutely needed because it carries a black box warning: it can cause nightmares, headaches and serious neuropsychiatric issues. It should be used with caution in patients with pre-existing mood disorders. Your doctor will discuss these side effects with you if they are considering it.

What about local honey?

The internet is full of claims that local, raw, bee pollen or honey will work for allergies. The claim? To desensitize your body to the pollen in your local environment by exposing you in small quantities (similar to allergy shots). BUT does it actually work?

There aren’t many studies. In one RCT (PMID: 11868925) people who had scratch-test confirmed allergies received either placebo, local raw unfiltered honey, or national pasteurized honey. There was NO significant difference in symptoms. In another (PMID: 21196761), patients with birch pollen allergies were given either NO honey, REGULAR honey, or BIRCH POLLEN honey. ONLY the group taking birch pollen honey showed an improvement in symptoms. Which makes sense because those patients were actually allergic to the birch pollen.

Remember: bees make honey from flower nectar - not pollen. The pollen that causes seasonal allergies primarily comes from trees, grasses & weeds — not flowers. Yes, some of their pollen may end up in the honey due to wind transfer, but this amount is inconsistent & small. In allergy shots, exposure happens carefully, consistently & with gradually increasing amounts.

There is only one study (PMID: 24188941) which found that a honey dose of “1g/kg weight” daily for 8wks may be helpful for symptoms compared to placebo. That is a LOT of honey!

Think about it: 1 tbsp honey (~21g) = 17g of sugar. So my 8yo (~45lb) would need about 1tbsp of honey A DAY for EIGHT weeks. The AAP recommends kids/teens consume a MAX 25g sugar per day.  Less is better. This amount of honey would equal 75% of her daily sugar allowance.

My bottom line here: Honey has its uses (see my post on cough!) But taking it for 3-5 days during an acute cough is different from taking it daily for 8wks. Remember to be careful that a cure isn’t worse than the disease! If you want to give your child over 12mo locally grown honey, thats fine — but DON’T expect miracles, be limited about sugar intake the rest of the day & brush their teeth!

Other homeopathic interventions

Your pediatrician is not gatekeeping information.

There are big claims about therapies like propolis, herbal remedies, and more, but if the data was anything but equivocal, we would be sharing it. These types of interventions have not usually been researched well in pediatric patients, so any dosing recommendations are blind guesswork or extrapolation. I’ve spoken before about my concerns with the lack of regulation for over-the-counter supplements and other products and the lack of safety oversight. That social media influencer or homeopath on instagram who is making claims that she has the magical supplements to cure your child’s allergies? She’s trying to sell you something!

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What about if all of this fails and your child is still suffering?

There are, thankfully, new and evolving options to help, such as allergy shots, and oral/sublingual immunotherapy.

There is no need to be miserable during allergy season. I encourage you to advocate for your child and ask for a referral to your local pediatric allergist if you want to explore these options!