Allergic Rhinitis - Pediatric Conditions - Children's Health

Allergic rhinitis is a reaction of the nose (and the throat and eyes sometimes) in people who are allergic to things in the air such as pollens, molds and dust ("triggers"). Each person has his or her own trigger and some people have more than one. The allergic reaction may occur during one season of the year (seasonal allergic rhinitis) or all the time (perennial allergic rhinitis), depending on when a person's triggers are in the air. Allergic rhinitis is most often seen in children who have a history of another allergy-related condition such as eczema or asthma, or who have family members with allergies.

Seasonal allergic rhinitis, commonly called hay fever, typically is caused by sensitivity to the pollens of certain trees, grasses and other plants. This rarely develops before age 3 years. Each person’s hay fever "season" tends to happen at the same time every year, depending on when their specific allergy-triggering plant is in bloom. For example, people who are allergic to grasses tend to have their worst symptoms during the late spring and summer months (year-round in some regions) while people with ragweed allergy tend to have their worst symptoms during the fall. Seasonal allergic rhinitis also can be caused by certain molds (for example, molds found during the fall in compost or leaf piles).

Perennial allergic rhinitis happens throughout the year because it is caused by sensitivity to triggers that are always around, such as animal dander, the waste of house dust mites and cockroaches, and molds. It is more common in children than seasonal allergic rhinitis and occurs at any age.

Stuffy (congested) nose
Runny nose
Sneezing
Itchy nose
Watery eyes
Scratchy throat
Mucus in the back of the throat (postnasal drip)
Nagging, irritating cough
Mouth breathing
Snoring

Itchy eyes, ears and roof of the mouth (palate)
Nose bleeds (epistaxis)
Blocked or plugged ears
Headaches or facial pain
Difficulty sleeping
Poor appetite
Loss of smell and/or taste.

Ask about your child's symptoms, especially about when and where they occur (what times of the year, indoors or outdoors).
Review your child’s medical history. The doctor will ask about any allergy-related conditions, including eczema, hives or asthma; a family history of these conditions is also important.
Look at your child’s:

Nose, for clear nasal discharge; a pale, swollen lining inside; or a wrinkle across the top caused by frequently wiping and pushing upward on it (known as the allergic salute).
Throat, for mucus; or pale bumps on the back of it (caused by chronic irritation from dripping mucous).
Ears, for fluid behind the eardrums from chronic congestion.
Face, for dark circles (allergic shiners) under the eyes; or wrinkles under the eyes.

Discuss whether any further testing is necessary. In most cases the timing of allergy symptoms is all that is needed to figure out which allergen is triggering the allergy. Occasionally, skin testing or blood samples may be helpful.

Skin testing involves a small amount of a specific allergen that is scratched, pricked or injected into the skin and then the doctor watches for signs of an allergic reaction on that area of the skin.
Blood samples can be taken to measure levels of allergen-specific IgE antibodies (things in the blood that attach to the triggers). Checking the blood like this generally is more expensive and less accurate than skin tests; it also usually takes several days to get results. This typically is used when someone cannot have skin testing done, such as with severe eczema (allergic reaction of the skin).

Recommend ways to avoid the allergen (trigger).
Discuss whether any medications may help your child. Although it always is best to limit exposure to particular allergens, often it is not possible to avoid them completely. Therefore, many children need to take some type of medication to try to control their allergies. Several choices are available, depending on your child’s age, symptoms and needs.

Cromolyn sodium (Nasalcrom) is a nonprescription nasal (nose) spray that prevents allergy symptoms. It blocks the release of histamine and other irritating chemicals from mast cells (special cells in the body’s immune system) when a child is exposed to an allergen. This medicine doesn’t work right away; it usually needs to be used regularly for several weeks before the allergy season starts.
Antihistamines reduce swelling, redness and irritation of the nose and other parts of the body (such as eyes and throat) by blocking the effects of any histamine released by mast cells. These medications are available as prescription and nonprescription pills or liquids (taken by mouth) and as a prescription nasal spray. Some antihistamines (for example, diphenhydramine or chlorpheniramine) can make you drowsy; newer antihistamines (such as cetirizine, fexofenadine or loratadine) usually are less sedating.
Nasal steroids act to reduce nasal swelling and redness (inflammation) caused by histamine and other chemicals released from mast cells. Sprayed directly into the nose, these medications are thought to be the most effective treatment for allergic rhinitis.
Allergy shots (immunotherapy) require regular injections of small, but slowly increasing amounts of allergen (for example, dust or pollens) that fools the immune system, so the nose and other parts of the body become less sensitive. Allergy shots can be uncomfortable, can take as long as 12 months to work, may need to be continued for several years, and only work for some allergens. Therefore, they typically are used only for those children who cannot control their allergies by avoiding triggers and taking other medications.
Leukotriene receptor antagonists block the allergic response through a different pathway than antihistamines. Montelukast is approved for use in children 2 years and older. Zafirlukast can be used in children starting at age 5.

Recommend some over-the-counter medicines that may be helpful.
Discuss whether your child needs to see an allergist, an expert in diagnosing and treating allergies. This may be helpful if:

Your child’s symptoms cannot be controlled with the usual medications.
You or your child’s doctor has concerns about your child’s diagnosis or treatment plan.

Discuss the things you should watch for at home.
Tell you when your child should be seen again. After you decide on a treatment plan, the doctor usually will want to check on your child’s progress.

If the doctor prescribed an antihistamine, be sure your child takes it exactly as directed.

Check with the pharmacist to see whether the antihistamine should be taken on an empty stomach or with food.
Antihistamines can be taken as needed, but often are more effective if used regularly. They do not "stop working" if used regularly.
Some antihistamines may make your child sleepy. Evening doses of these medicines can affect learning and performance during the next day at school, even if your child no longer seems drowsy.

If the doctor prescribed a nasal steroid spray, be sure your child takes it exactly as directed.

Have your child blow his or her nose before using. Tilt his head slightly forward, hold the spray bottle upright, put the nozzle tip inside the nose pointing toward the eye, and then spray while he slowly breathes in.
Nasal steroids must be used regularly to work and may take several weeks to see their best effects; therefore, start them before or very early in the allergy season.
When taken as directed, nasal steroids are felt to be safe for children and generally do not cause growth problems or other side effects that occasionally are seen with steroids taken by mouth.
Steroid sprays do sometimes cause minor irritations and nosebleeds. Putting some petroleum jelly (Vaseline) inside the nose once or twice a day (after using the spray) can prevent these.

Some over-the-counter medicines may be helpful:

Saline (salt water) nose drops or nose spray does not contain any medicine and can be used safely to rinse out allergy-causing pollen from the nose and to help keep nasal passages open and moist.
Decongestants (for example, pseudoephedrine or Sudafed) taken by mouth help to treat nasal stuffiness by shrinking blood vessels and swollen areas in the nose. They sometimes make children "hyper" or fussy. Decongestants should not be used in children under 4 years of age.

These over-the-counter medicines usually are not helpful:

No vitamin or mineral supplements or herbal remedies have been proven effective as a treatment for allergic rhinitis in children.

Certain over-the-counter medicines should not be used (unless directed by your doctor):

Decongestant nasal sprays may give relief for a few days, but if used for more than three days, they can actually worsen the congestion.
Ephedra (ma huang) has been used as a decongestant, but is not recommended for children because of its possible serious side effects.

Things you and your child can do to reduce exposure to allergens and help lessen the symptoms of allergic rhinitis:

Stay indoors as much as possible during times when outdoor triggers are in bloom. If possible, schedule outdoor activities for early afternoon; pollen counts tend to be highest before 10 a.m. and after sunset.
Keep windows closed, especially bedroom windows, and run an air conditioner on hot days. Wipe windowsills daily with a damp cloth to remove pollen that gets in through the cracks.
Use a HEPA filter (High-Efficiency Particulate Air filter) in your home to cut down on airborne allergens.
When traveling in a car, drive with the windows and external vents closed and air conditioning on.
Take a shower (or wash the hair) before going to bed at night to remove any pollen.
Use special covers for mattresses and pillows to control dust mites.
Vacuum carpets, mop floors, and dust with a damp cloth regularly to get rid of dust mites, animal dander and other dust-borne allergens. Special attention should be given to doing this in your child’s bedroom since children usually spend one-third to one-half of each day in their bedrooms.
Limit the number of stuffed animals in the bedroom.
Change air conditioner and furnace filters frequently (at least monthly).

Call the doctor if your child:

Doesn't seem to be getting better despite giving the treatment plan a chance to work.
Is getting worse.
Develops headache, sinus pain or pressure.
Has difficulty breathing.
Has a fever.

Prevent allergic rhinitis from developing by:

Avoiding exposure to allergens, like dust mites and animal danders, as much as possible.
Never smoking around the child.
Breast-feeding.
Waiting until 4 to 6 months to introduce solid foods.
Waiting until at least one year to introduce certain foods that commonly cause allergies, like peanuts, cow's milk, eggs and fish.

Allergic rhinitis is not contagious (spread from person to person). Children with allergic rhinitis usually don’t need to miss school or day care, but if they do, they can go back as soon as they feel well enough. Check with your school or day care regarding specific policies about returning after any type of illness.

If your child needs to take a dose of any medicine during the school day, it can be helpful to ask your pharmacist to put the medicine into two different labeled containers. That way you can send one to school or day care and leave the other at home. Also, be sure to fill out any necessary forms, including a note from your doctor, with specific instructions for giving the medicine.