During the COVID-19 period, one of the common issues was respiratory allergies in children. Not only children but also many adults also had to struggle with respiratory allergies problem. This article shares on respiratoryaAllergies in children.
Respiratory Allergies In Children
As you know respiratory allergies are quite common in children. And we have basically two commonest types of allergies which are Allergic Nectars and asthma. So there can be comorbid with any of these conditions such as Allergic Rhinitis can be associated with Asthma. It may be associated with Sinusitis or Adenoid Hypertrophy and Asthma also may be associated with allergic rhinitis as a comorbid condition.
What do we mean by Allergic Rhinitis?
So, when there are symptoms of a runny nose or nose block or itchy nose, rubbing the nose frequently, itchiness or pricking sensation in the eyes, rubbing eyes frequently or if there is sneezing in the mornings. These are all the symptoms of allergic rhinitis.
And at any time one or the other symptom may be more prominent. Some children may have morning sneezing and nose block. Some children may have evening itching or a nose block during the night and they may be fine during the day. Some children just have this symptom of rubbing the nose or doing this or rubbing eyes, which is called, this is called actually an allergic salute. And some children may have dark circles around the eyes because of frequent rubbing which is called allergic shyness or a line on the nose which is called dariose line which is again due to allergy.
So, this is a frequent complaint that we see in, that we find and parents come and tell us that doctor my child is just not sleeping well at night as seems to be having some discomfort or in the mornings for an hour or so a child is sneezing has some discomfort continuous sneezes 10/20 times, but the rest of the day the child is fine. So depending on the severity of the symptoms, we decide whether the child needs medication and what medication.
So if the symptoms are more than four days a week, generally lasting for more than an hour, then we do take it as significant. If it is less than four days a week and less than say half an hour or just less than an hour in a day, then it may be taken as mild intermittent. And the child may or may not need medication.
Triggers for allergic rhinitis and asthma
Along with medication, the first step would be to prevent the triggers. So triggers are similar for both allergic rhinitis and asthma. Asthma will discuss in a few minutes. But the triggers are usually the same. Commonest being dust in the house, dust due to the dust mite, and smoke exposure, strong smells, talcum powder, moulds on the walls due to dampness or fungus. These and of course pollution, air pollution, a season change can also trigger that is you know beyond our control. But things which we can control are typically within the home environment and are easily preventable. For example, dusting frequently when the child is not at home is helpful, and wet mopping of the floors is helpful. Something that can be considered is using dust-proof covers on pillows, carpets, on mattresses because these cannot be cleaned very frequently. And, where blankets, and sheets have to be washed and air-dried in the hot sun. That was also helpful. Smoke exposure – preventing exposure to cigarette smoke, cooking smoke, incense, you know sprays from perfumes, air fresheners, room fresheners, the mosquito repellents. All these will definitely help.
The same thing goes for strong smells, perfumes, deodorants and also talcum powder, the dust inhaled from talcum powder application can again trigger both allergic rhinitis and asthma. Air pollution outside we can’t really do much but better to keep the windows closed. If they are staying in a dusty area during peak hours then better to keep the windows shut.
The other trigger is exposure to cold air. So again better to avoid going out when it is very cold and preventing keeping the windows shut at night to prevent the draft of cold air. Wall-to-wall carpeting helps if the floor is very cold but at the same time, it increases dust white. So we usually avoid wall to wall, carpeting. Things like curtains, and fans which are not clean on a daily basis we have to take extra effort to get these also cleaned and keep the house dust-free. Pest control is again very important as broaches, cockroaches and other pests can trigger an attack. So, it’s better to use effective non-smelly, pest control measures and keep the house pest-free.
Intrinsic factors and the extrinsic factors
So, there are both, you know, the intrinsic factors and the extrinsic factors which trigger allergies. Intrinsic is something which may be inherited. If the parents or grandparents have allergies, then again child may be at an increased risk for allergies. So, for any child who comes with these symptoms, we do ask for detailed family history. Sometimes parents forget or they don’t feel that that is significant. But even if the mother or father has allergic rhinitis, then that can be one of the risk factors for children with asthma, if grandparents have asthma.
Case Study – Respiratory Allergies In Children
For example, we had a baby admitted to our intensive care unit who came with a history of fever and cough and breathing difficulty. And the elder sister had a similar history of cold cough and was treated at a clinic with the paediatrician at an outside clinic and she had improved fairly quickly. So this looks more like viral flu or a lower respiratory infection and it was just last month when COVID was at its peak. So we did rule out COVID and we admitted the child and started treatment for a lower respiratory infection. Parents initially denied any other history, family history of allergies or asthma and this was a nine-month-old or a 10-month-old infant who had not had any breathing difficulty episodes earlier. This was the first episode. So, we treated for infection but soon it became apparent that there was no significant bacterial infection.
There was no pneumonia on the X-ray and it appeared to be a mild viral which had triggered quite a bit8 of breathing difficulty in this babe. And as the way we continue to have a reason, it we began, we treated with all the measures for both infection and wheezing. But on repeated questioning, the father did come back to tell us that there was a significant family history. The grandmother had asthma. And the older sibling had an episode of hospitalisation similar to what this baby had a few years back requiring nebulisation and medications.
So, sometimes these episodes may be severe, needing admission to ICU and needing more treatment apart from just the regular treatment for allergies or asthma. Hence a family history becomes very important. As preventive measures are advised by us to prevent these episodes from recurring.
How do we treat allergic rhinitis?
Avoidance of triggers is the first thing and the second step would be what we call antihistamines. So, these are available as syrups or tablets, and anti-allergy medicines. The older generation or the first-generation antihistamines are they cause quite a bit of sedation. So, they are not much recommended. Second-generation antihistamines like Cetirizine, Levocetirizine, Ebastine, and Veratridine. These are water-preferred children and can be given to infants older than six months of age and children above the age of infants and children above the age of six months. So these help to control the symptoms of allergy effectively. It can be used on a need basis if the symptoms are only intermittent or if it is more frequent symptoms, then it can be given as a preventer for a short period of time on a daily basis.
There is something called antagonists that is which can be given in combination with Cetirizine or depending on the symptoms. But what we prefer for treatment for allergic rhinitis is a nasal spray called Intranasal steroids. These are locally acting nasal sprays. They contain a very low dose of the steroid medication which is typically zone or fluoroid or which will act to decrease the inflammation at in the nose, at the nasal mucosa level itself and prevent the allergy from increasing, from going down to the air passage and causing further problems. Over a period of time, they help to reduce the inflammation in the nasal mucosa and decrease the symptoms significantly. The side effects that we see with anti-histamines are not seen with internasal steroids. So children who go to school can develop sleepiness because of antihistamines. Some children develop constipation and these cannot be used for very long. So, instead, we prefer if the symptoms are more frequent, then internal steroids would be the first line of treatment, the preferred line of treatment.
It is important for parents to understand that these have to be given for a period of anywhere between four to eight weeks, sometimes up to 12 weeks. And this acts as a preventive measure and reduces symptoms significantly even after stopping the children generally remain symptom-free for a period of two months. They are not curative, no allergies can be cured completely with just one course but they can be controlled. So this would be the preferred line of treatment for allergic rhinitis along with avoidance of triggers. And these have to be given on prescription bases by your paediatrician. So if your child has symptoms of this allergic rhinitis, what I described earlier do take your child to your paediatrician and discuss the treatment options.
Asthma in children
Asthma is basically a constriction of the air passage. Many parents or many people are under the impression that asthma is a lung problem. Basically, it’s not inflammation or infection in the lungs. It is a bronchospasm or a constriction of the air passage that leads to a feeling of tightness, chest tightness, difficulty in breathing, coughing or wheezing. Wheezing is a whizzing sound that is heard because of the air passage and difficulty in obstruction during exhalation or during the expiratory phase. So, if it is mild, there may be only a nighttime cough or there may be a cough only after play or exercise.
Classification Of Asthma
Again, in asthma also, we have the classification or grading of the severity based on whether it’s mild or moderate or severe and based on whether the symptoms are intermittent or persistent. So, the Indian Academy of Pediatrics has given guidelines for treatment for degrading, severity and treatment. We also follow what is called the Gina guidelines, the Global initiative for asthma, which describes how asthma should be graded and treated based on the severity of symptoms. Gina also has a lot of patient education. So I would recommend any of you who have these symptoms to look up the Gina website and this thing also the look of the patient education information on that which is very useful.
So when a child comes to us with these symptoms, sometimes it may be very clear child’s parents have noticed recurrent or repeated episodes of cough, wheezing, or this thing nighttime cough, breathing difficulty, chest tightness, waking up in the middle of the night with difficulty in breathing. Then it is clear. Sometimes it may not be so clear like how I said the young infant who was admitted with wheezing following the first episode of viral infection or sometimes they may just come with an effort intolerance. They may just say that my child gets tired after playing for a short while and does not want to run or play as other children do. So is there any issue and what could be? Is there a problem with the lungs or the heart of my child? And sometimes there may not be continuous symptoms but there may be one or two severe episodes in a year which happen typically with the season change. So the child may be fine most of the year and may not need any medication or may have had mild symptoms which have gone unnoticed and when season change happens during the onset of the monsoon or the winter the child may experience an episode which can become severe very quickly.
Asthma can be life-threatening
So it is important for parents to know that asthma can be life-threatening. These children may need hospitalization, they may need ICU admission or they may need very intensive treatment if it is not being controlled. So it’s very important to control asthma symptoms and to follow up with a paediatrician regularly to continue the medications as advised. So for asthma again depending on the severity and the frequency of symptoms the treatment is decided. And the preferred evidence-based recommended treatment is inhalers. So the inhalers or the puffs that are called are available as both controller medication and reliever medication. And these have to be given just as an inhaled way using what is called a spacer or a spacer and mask depending on the child’s age. So the inhalers are the safest, very low doses. They are preferred because they are targeted therapy. They go directly to the air passage where the action is needed, unlike oral medications which need to be absorbed from the blood and are not as effective as inhalers.
So our most common misconception amongst parents or the doubts that we face from parents when we advise inhalers are, the doctor isn’t these addictive? You are prescribing inhalers to my child. I have heard that these are harmful. I have heard that this contains steroids, and we don’t want to give inhalers to our children. He just had a coughing episode. He doesn’t have asthma. So, you know and these kinds of questions are very common which we can understand come from the parents’ understanding of asthma or the misconceptions.
Inhalers are safe
So, inhalers are very safe. They can be given for years. They don’t make the child dependent and they don’t make the child resistant to treatment either. It is not that if we give it for months or years, the child will stop responding to the treatment. No. And it is not the inhaler which makes the child get these repeated episodes. It doesn’t mean if you give it to someone and you stop it and the child gets the episode, we have made the child dependent. No.
Asthma is a condition that can recur
It’s important to understand that asthma is a condition which can recur. It is reversible airway obstruction. So, it is the reversibility may be mild initially, it may be quick and the child may symptoms may get reversed even without medication. But if these episodes keep happening on a regular basis and then the severity also may increase. The reversibility is not so easy and the child may come with a severe episode at any point in time. Hence the need for treatment.
If it’s a reversible condition, why should we treat parents ask? This is the reason. Because as airway inflammation happens again and again it leads to airway remodelling. The airway diameter becomes narrow because of swelling in the air passages due to the secretion, due to inflammation and that leads to a decrease in the reversibility of the whole thing.
Medication for asthma
So, if your doctor has diagnosed your child as having asthma and prescribed inhalers, kindly take it seriously, give the medications as advised and follow up with your doctor on a regular basis even when your child is not showing any symptoms.
So, the controller medication or preventive medication is typically an inhaled corticosteroid. Again, at a very low dose. The live medication is like salbutamol which is a bronchodilator. It helps to dilate the air passage. But does not prevent anything to prevent the inflammation. Does not do anything to prevent air-wearing water. So if your child is needing too much of a bronchodilator or too frequent bronchodilators that is not a good thing. More than two times a week or three times a week, then it means your child definitely needs to be on control or medication.
A combination inhaler is also available. The combination of steroids with long-acting helps to control the symptoms better than just the bronchodilator or just the steroid. So the doctor will take a detailed history, check the child and then prescribe which inhaler is best suited.
Dry powder inhalers are also available and after discussing with parents based on the child’s age, the ideal medication is prescribed.
Along with the inhalers sometimes ….. can also be given to prevent the severity of asthma. So again the prevention of triggers that I discussed about allergic rhinitis the same thing holds good for asthma also.
Allergies and COVID-19 – Respiratory Allergies In Children
Last word about allergies and COVID-19. So you know parents were very anxious that COVID can worsen asthma or what to do if my child who has asthma contracts covid-19. Fortunately, we have not seen really any increase in the severity of covid-19 in a child who has asthma or an adult unless it was a very poorly controlled asthma. If someone had severe symptoms but was not really showing their doctor regularly, we are not taking the prescribed medicines regularly. Obviously, like any other viral infection, covid-19 can aggravate asthma and these people can end up in the hospital. But as such COVID-19 really did not aggravate any underlying asthma.
Also, we saw that in the last two years because the majority were indoors, wearing masks, and following good hygiene, and respiratory hygiene also, the incidence of asthma attacks and allergies had come down just like how influenza infections had come down. Children were not going to school. So, the incidence of viral infections was less. And viral infections are a frequent trigger for allergies and asthma. So, that was also less in the last two years. But the those who did not have good control, those who needed oral steroids for control of their asthma, if they got COVID-19, they needed hospitalisation was an increase in the severity of illness and also deaths in such cases.
Are COVID-19 Vaccines safe for children with allergies?
Then coming to the immunization against COVID Vaccines, are they safe for children with allergies and acne? So generally vaccines are safe for most people even with allergies. Reaction to the vaccine is very rare. But if your child has had a reaction to any vaccine like say measles or MMR which contains the egg protein, then you should inform your doctor and take the COVID-19 vaccine in a protected setting or in a like hospital setting where any allergic reaction, if it happens, can be dealt with immediately. We do advise the parents to wait for 15 minutes to 30 minutes after the vaccination in the hospital to check if any allergic reaction happens. But generally, even children with food allergies or insect bite allergies, do not really have an allergy to the vaccine. So it is safe. Of course, has to be given after one to one discussion with your doctor. And it is a good idea to give the vaccine just like the influenza vaccine to children with allergies and asthma in order to prevent a severe attack due to a viral infection such as covid-19 or the influenza virus.
So, I guess that would be the discussion and for today I have covered allergy rhinitis, asthma, triggers, prevention and management. And also recently highlighted what we have seen recently in the last two years with COVID and just a note on vaccination of children with allergies and asthma. So thank you for a patient hearing.
Hope that this post was helpful for you to understand better respiratory allergies in children, symptoms and medications. Many children are suffering from this problem because respiratory allergies in children are very common in the current world. Do not do any self-medication. Always consult an expert Doctor and follow his advice.
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References & Credits: Dr Jyothi Raghuram (Senior Consultant – General Pediatrics & Pediatric Rheumatology), Aster Hospitals, Bengaluru. You can watch the video here.
Mathukutty P. V. is the founder of Simply Life Tips. He is a Blogger, Content Writer, Influencer, and YouTuber. He is passionate about learning new skills. He is the Director of PokketCFO.
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