Managing Childhood Allergies, Treatment

When avoidance measures fail or are not possible, many children will require medications to treat their allergy symptoms. The choice of medication depends on numerous questions to be answered by the parent or child’s physician: 1. How severe are the child’s allergies?2. What are the child’s allergy symptoms?3. What medication can the family get (over the counter, prescription)?4. What medication will the child take?5. Is the medication needed daily or intermittently?6. What side effects might the child experience from the medications?

Oral anti-histamines. This is probably the most common class of medications used for childhood allergies. The first generation anti-histamines, which include diphenhydramine and chlorpheniramine, are generally considered too sedating for routine use. These medications have been shown to result in decreased school performance and learning in children.

Newer, second-generation anti-histamines have now become first-line therapy for children with allergic rhinitis. These prescription medications, including cetirizine (Zyrtec®), fexofenadine (Allegra®), and desloratadine (Clarinex®), are indicated down to 6 months of age in children. Loratadine (Claritin®/Alavert®), which is available over the counter, is indicated for use in children as young as 2 years of age.

These medications have the advantage of being relatively inexpensive (and over the counter in the case of loratadine), easy for children to take, start working within a few hours and therefore can be given on as “as needed” basis. The medications are particularly good at treating sneezing, runny nose, itchy nose/eyes/ears as a result of allergies. Side effects are rare, and include a low-rate of sedation or sleepiness, but much less than the first-generation anti-histamines.

Topical nasal steroids. This class of allergy medications is probably the most effective at treating nasal allergies, as well as non-allergic rhinitis. There are numerous topical nasal steroids on the market, all available by prescription, without significant differences in efficacy among the group. Some children note that one smells or tastes better than another, but they all work about the same.

This group of medications includes fluticasone (Flonase®), mometasone (Nasonex®), budesonide (Rhinocort Aqua®), flunisolide (Nasarel®), triamcinolone (Nasacort AQ®) and beclomethasone (Beconase AQ®), and are indicated to treat allergic rhinitis in children as young as 2 years old (in the case of mometasone).

Nasal steroids are excellent at controlling sneezing, runny nose, nasal congestion, post-nasal drip and itchy nose symptoms. However, the sprays need to be used daily for best effect and therefore don’t work well as needed. Side effects are mild and limited to nasal irritation and nose bleeds.

Some data suggest that the nasal steroids may reduce vertical growth velocity in some children, as is the case with inhaled steroids used in asthma, but it is not clear that this occurs in all children and with all nasal steroids. Parents should discuss the potential side effects of nasal steroids with their child’s physician.

Other prescription nasal sprays. There are two other prescription nasal sprays available, a nasal anti-histamine and a nasal anti-cholinergic. The anti-histamine, azelastine (Astelin®), is effective at treating allergic and non-allergic rhinitis in children 5 years and older. It treats all nasal symptoms similar to nasal steroids, and should be used routinely for best effect. Side effects are generally mild and include local nasal irritation and some reports of sleepiness, as it is a first-generation anti-histamine.

Nasal ipratropium (Atrovent nasal®) works to dry up nasal secretions, and is indicated at treating allergies and symptoms of the common cold in children as young as 5 years old. It works great at treating a “drippy nose”, but will not treat nasal itching or nasal congestion symptoms. Side effects are mild and typically include local nasal irritation and dryness.

Over-the-counter nasal sprays. This group includes cromolyn nasal spray (NasalCrom®) and topical decongestants such as oxymetazoline (Afrin®) and phenylephrine (Neo-Synephrine®). Cromolyn is indicated in children as young as 2 years of age, and only works to prevent allergy symptoms if used before exposure to allergic triggers. This medication therefore does not work on an as-needed basis.

Topical decongestants are indicated in children to as young as 6 months of age in the case of phenylephrine, and are helpful in treating nasal congestion. It is important to note that these medications should be used for limited periods of 3 days every 2-4 weeks; otherwise there can be a rebound/worsening of nasal congestion called rhinitis medicamentosa.

The side effects of the above are both generally mild and include local nasal irritation and bleeding, but topical decongestants should be used with caution in patients with heart or blood pressure problems.

Oral decongestants. Oral decongestants, with or without oral anti-histamines, are useful medications in the treatment of nasal congestion in children. This class of medications includes pseudoephrine (Sudafed®), phenylephrine, and numerous combination products. Decongestant/anti-histamine combination products are indicated in children as young as 6 months of age in the case of Rondec Drops® (chlorpheniramine/phenylephrine).

This class of medication works well for occasional and as-needed use, but side effects with long-term use includes insomnia, headaches, elevated blood pressure, rapid heart rate and nervousness.