Spring is here! Allergy therapy update

The Pediatric Insider

© 2019 Roy Benaroch, MD

Ah, the sounds of spring. Birds tweeting, bees buzzing, and noses sniffling and sneezing. Fortunately, there are some great medicines out there to help reduce the symptoms of spring allergies, and most of them are inexpensive and over-the-counter. Here’s an updated guide to help you pick the medicines that are best to relieve your family’s suffering.

But first: before medications, remember non-medical approaches. People with allergies should shower and wash hair after being outside (though it’s not practical or good to just stay inside all spring!) You can also use nasal saline washes to help reduce pollen exposures.

For my medicine guide this year, I’ve included some photos to make these easier to find. A new trend seems to be color coding, with generics matching the brands in color and “look and feel”. That’s good if it makes the cheaper generics easy to find — they work just as well, and really should be your first choice for any of the options below.

Antihistamines are very effective for sneezing, drippy noses, and itchy noses and eyes. The old standard is Benadryl (diphenhydramine), which works well—but it’s sedating and only lasts six hours. There are better choices. Benadryl products are usually packaged in a pink, hidden sad and lonely in the bottom row.

Pink Benadryl makes people sleepy. There are better options.

It’s better to use a more-modern, less-sedating antihistamine like Zyrtec (cetirizine), Claritin (loratidine), or Allergra (fexofenidine.) All of these are OTC and have cheap generics. They work taken as-needed, or can be taken every day. Antihistamines don’t relieve congested or stuffy noses—for those symptoms, a nasal steroid spray is far superior.

Zyrtec and cetirizine come boxed in springtime green.

 

If Claritin’s for you, it comes in friendly blue.

 

Very few words rhyme with purple. This is Allegra.

There are a just a few differences between the modern OTC antihistamines. All are FDA approved down to age 2, though we sometimes use them in younger children. They all come in syrups, pills, or melty-tabs. Zyrtec is the most sedating of the three (though far less than Benadryl). Zyrtec and Claritin are once a day, while Allegra, for children, has to be taken twice a day. A 2017 study showed that Zyrtec is marginally more effective than Claritin, so I’ve been recommending that one first.

This year, there is one new player among the OTC antihistamines, called “Xyzal.” OK, I admit the name is cool — but it is therapuetically identical to Zyrtec. I don’t think it’s worth its typically-higher price.

Arresting orange says “XYZAL!”

Decongestants work, too, but only for a few days—they will lose their punch quickly if taken regularly. Still, for use here and there on the worst days, they can help. The best of the bunch is old-fashioned pseudoephedrine (often sold as generics or brand-name Sudafed), available OTC but hidden behind the counter. Don’t buy the OTC stuff on the shelf (phenylephrine), which isn’t absorbed well. Ask the pharmacist to give you the good stuff hidden in back.

Nasal Steroid Sprays include many choices, all of which are essentially equivalent in effectiveness: OTC Nasacort, Flonase, Rhinocort, Sensimist, and many generics are available. All of these products are essentially the same. They all work really well, especially for congestion or stuffiness (which antihistamines do not treat.) They can be used as needed, but work even better if used regularly every single day for allergy season.

Lots of steroid nasal sprays. They’re all essentially the same.

Some minor distinctions: Nasacort is approved down to age 2, Flonase to 4, and Rhinocort to 6, though there’s no reason to think any are more or less safe for children. Flonase is scented (kind of an odd, flowery scent, which seems weird in an allergy medicine), and seems to be a little more burny to some people than the others. My personal favorite is Nasacort or its generic version. Here’s a quirk: Nasacort comes in 2 differently-packaged versions, for adults and for children. But the product itself is the same. The pediatric version sells for less, but it’s a smaller bottle. I guess because children are smaller. Weird.

Children’s and regular Nasacort (and generic triamcinolone) are the same product in a different-sized bottle.

Nasal oxymetazolone (brands like Afrin) are best avoided. Sure, they work, but after just a few days your nose will become addicted, and you’ll need more frequent squirts to get through the day. Just say no. Steroid nasal sprays are much safer than OTC Afrin.

Eye allergy medications include the oral antihistamines, above; and the topical nasal spray steroids can help with eye symptoms, too. But if you really want to help allergic eyes, go with an eye drop. The best of the OTCs is Zaditor. There’s a generic version, though some people have told me the generic stings a bit.

Zaditor? Who names these things?

Bottom line: for mild eye or nose symptoms, a simple oral antihistamine is probably the best first line. For more severe symptoms OR symptoms dominated by clogging and stuffiness, use a steroid nasal spray. You can also use both, in combination, an antihistamine PLUS a steroid spray, for really problematic symptoms. Anything not improving on that combo needs to see a doctor.

This is an updated version of previous posts.

 

 

What causes dark circles under the eyes in children?

The Pediatric Insider

© 2017 Roy Benaroch, MD

Rachel wrote in a topic suggestion:

My 8 year old daughter has for years had dark circles under her eyes. What causes this? She is very healthy and hardly ever gets sick. I have ‘heard’ this can be caused by food allergies or liver problems, but I’ve been very skeptical about that.

Rachel, I see these in kids all the time. Most commonly, I think it’s just normal – especially in children with a fair complexion. It’s easier to notice these in kids with thin, light, milky sort of skin (often with light eyes and light or red hair, too.)

One medical issue that can contribute to darkness under the eyes is congestion in the veins lining the nose. This makes the blood vessels dilate and become more noticeable. You’ll see this in children with nasal allergies or “hay fever” to airborne allergens like pollen or dust or molds. That’s why these dark areas are sometimes called “allergic shiners.” If the nasal allergy symptoms are bothering the child, this can be treated by avoiding the triggers (not always easy), or nasal spray OTC allergy sprays like Nasacort or Flonase. Oral antihistamines like Zyrtec or Claritin will be less effective for nasal congestion.

I’ve also often heard that lack of sleep can cause dark circles – Google it, and there are plenty of people who say this. I couldn’t find any evidence that this is true in children, but it might be. And more sleep couldn’t hurt.

As for food allergies – you know, I wouldn’t have thought so, at least not in my experience. But this report showed that about 50% of kids who had classic GI symptoms of food allergy also had allergic shiners. So, yes, in a child who has GI symptoms of food allergies, they might get shiners too. But in a child with no GI symptoms, I don’t think allergic shiners would be a likely isolated finding of food allergy. And liver disease? No, I don’t think so. I couldn’t find any evidence for that at all, at least not in children.

So: pretty much benign, maybe related to allergies, and probably best ignored unless the allergic symptoms themselves are bothering the child. You can add “dark circles under eyes” to our ever-growing list of things parents really don’t need to worry about!

Spring is here! Allergy therapy update, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Ah, spring. The birds are tweeting, the flowers are blooming… and there’s a layer of yellow dust all over my car. And a whole lot of sneezing and stuffy noses! Fortunately, there are some great medicines out there to help reduce the symptoms of spring allergies, and most of them are inexpensive and over-the-counter. So many choices! Here’s an updated guide to help you pick the medicines that are best to relieve your family’s suffering.

But first: before medications, remember non-medical approaches. People with allergies should shower and wash hair after being outside (though it’s not practical or good to just stay inside all spring!) You can also use nasal saline washes to help reduce pollen exposures.

Antihistamines are still very effective for sneezing, drippy noses, and itchy noses and eyes. The old standard is Benadryl (diphenhydramine), which works well—but it’s sedating and only lasts six hours. It’s better to use a more-modern, less-sedating antihistamine like Zyrtec (cetirizine), Claritin (loratidine), or Allergra (fexofenidine.) All of these are OTC and have cheapo generics. They work taken as-needed, or can be taken every day. Antihistamines don’t relieve congested or stuffy noses—for those symptoms, a nasal steroid spray (see below) is far superior.

There are a just a few differences between the modern, OTC antihistamines. All are FDA approved down to age 2, though we sometimes use them in younger children. They all come in syrups, pills, or melty-tabs. Zyrtec is the most sedating of the three (though far less than Benadryl). Zyrtec and Claritin are once a day, while Allegra, for children, has to be taken twice a day.

Decongestants work, too, but only for a few days—they will lose their punch quickly if taken regularly. Still, for use here and there on the worst days, they can help. The best of the bunch is old-fashioned pseudoephedrine (often sold as generics or brand-name Sudafed), available OTC but hidden behind the counter. Don’t buy the OTC stuff on the shelf (phenylephrine), which isn’t absorbed well. Ask the pharmacist to give you the good stuff hidden in back.

Nasal Steroid Sprays include OTCs Nasacort, Flonase, Rhinocort, and generic fluticasone (essentially identical to Flonase.) There are also many prescription versions of these, like Nasonex and Veramyst. All of these are essentially the same. They all work really well, especially for congestion or stuffiness (which antihistamines do not treat.) They can be used as needed, but work even better if used regularly every single day for allergy season.

Some minor distinctions: Nasacort is approved down to age 2, Flonase to 4, and Rhinocort to 6, though there’s no reason to think any are more or less safe for children. Flonase is scented (kind of an odd, flowery scent, which seems weird in an allergy medicine), and seems to be a little more burny to some people than the others.

Nasal oxymetazolone (brands like Afrin) are best avoided. Sure, they work—they actually work great—but after just a few days your nose will become addicted, and you’ll need more frequent squirts to get through the day. Just say no. Steroid nasal sprays, ironically, are much safer than OTC Afrin.

Eye allergy medications include the oral antihistamines, above; and the topical steroids can help with eye symptoms, too. But if you really want to help allergic eyes, go with an eye drop. The best of the OTCs is Zaditor.

Bottom line: for mild eye or nose symptoms, a simple oral antihistamine is probably the best first line. For more severe symptoms OR symptoms dominated by clogging and stuffiness, use a steroid nasal spray. You can also use both, in combination, an antihistamine PLUS a steroid spray, for really problematic symptoms. Anything not improving on that combo needs to see a doctor.

Food allergy “testing” is usually a bad idea

The Pediatric Insider

© 2015 Roy Benaroch, MD

People like tests. You get numbers, and maybe a printout, and there’s science and blood and things just feels more… serious, when testing is done. You can picture Marcus Welby  (or perhaps a more modern physician), looking solemn, declaring “We’d better run some tests.”

Are medical tests magical and mysterious, and can they unlock the secrets of life? Usually, no. And among the worst and most misunderstood tests we do are food allergy tests.

A few recent studies illustrate this well. A review of about 800 patients referred to an allergy clinic found that almost 90% of children who had been told to avoid foods based on allergy testing could in fact eat them safely. The study, bluntly titled “Food allergen panel testing often results in misdiagnosis of food allergy” also found that the positive predictive value of food allergy blood tests—the chance that a positive test accurately predicted real allergy—was 2.2%. That much, much worse than the odds if you flipped a coin, and much, much worse than your odds of winning at a casino. If someone told you that a positive test was only correct 2% of the time, would you even do the test?

What about the other way of food allergy testing, with skin scratch or prick tests? A recent study about peanut allergy made big news when it turned out to show that early peanut exposure can prevent allergy. (This isn’t new news, by the way—I’ve written about that before. But I get fewer readers than the New England Journal of Medicine.) But hidden in the methods and statistics of that paper was another gem. The authors tested all of the enrolled babies for peanut allergy, at the beginning of the study. And most of the babies who “tested positive”, whether or not they then ate peanuts, did not turn out to be allergic. A true statement from the data from that study would be: If your baby tests positive for peanut allergy, your child is probably not allergic to peanuts.

Read that sentence again. Kind of makes your brain hurt, doesn’t it?

It is true that positive-tested kids were more likely than negative tested kids to be allergic—among the group with more allergies later (those who avoided peanuts), 35% of those who had positive tests developed allergy, versus 14% who had tested negative. But still, in either case, most of the kids who tested positive did not turn out to be allergic, whatever they ate or did.

The fundamental problem, I think, is that doctors either don’t understand or can’t seem to explain the difference between sensitization and allergy. None of these tests can actually test for allergy—they test for sensitization, which is different. We gloss over that distinction, and end up giving out bad advice. People should not be told to avoid food based on the results of allergy testing alone.

Bottom line: if you child eats a food without having a reaction, he or she is not allergic, and you should not do any testing for that food as a potential allergen. You should never do broad panels of “allergy tests”—they’re much more likely to mislead and confuse than to give useful information. Any food allergy testing that is done should only look at foods that seem to have caused reactions in the past, and even then any positive testing should be confirmed by what’s called an “open challenge.” Under safe conditions, usually under an allergists’ care, give the child some of the food to eat to see what happens. That’s the only real way to “test” for allergy.

What should a seven-month-old baby eat?

The Pediatric Insider

© 2014 Roy Benaroch, MD

Naomi wrote, “I’d like to start letting my 7 month old try some of the foods we’re eating during dinner. He always sits at the table with us and seems fascinated by what we’re putting in our mouths. It seems like most baby books say not to give babies anything with added salt, however, and cooking for adults without salt would ruin dinner. My question: if we’re only talking about home made food, is a little salt really so bad for a baby that’s eating solids? And if it is, at what age can he start eating table foods? I get that the salt levels in processed foods might be too high, but I’ve always thought home made food had much less.”

Listen to your baby—he’s fascinated by what you’re eating, and wants to try it. As long as the food isn’t a choking hazard, let him enjoy!

We think of “traditional” baby food as the stuff in boxes and little jars and little plastic tubs. Cereal, pureed veggies, pureed fruits—single-ingredient, bland, with minimal salt and other stuff. Of course, this is hardly “traditional” at all. It’s just what the baby food companies have been selling in the developed world for the last 100 years or so. “Traditionally,” once babies started weaning, they ate whatever everyone else ate.

There are a few different reasons why some have recommended sticking with “baby food” for toddler-aged kids. None of them are really very good reasons—and in fact, moving towards “real food” as soon as practical is better for everyone involved.

Naomi asked specifically about added salt. The thinking goes: many of us consume too much salt, which has been linked to hypertension in some genetically-predisposed individuals. So why get Junior used to the taste of salt too early? Won’t that cause him to crave salt later? But there’s no evidence whatsoever that more or less salt at seven months is going to make any difference. Later on, he’ll get used to the kind of meals eaten by everyone else, salted or low salt. There’s no critical window for deciding how salty someone likes their food.

There are also concerns that the early introduction of a mix of foods to youngish babies might increase their risk of food allergies. The truth is the opposite. There’s no evidence that waiting until later than four to six months of life increases the risk of allergy to any foods—not peanuts, not eggs, not fish. Those and any other foods can safely be introduced starting within the usual four to six month window. In fact, there’s some evidence that this earlier introduction can make food allergies less common.

The only significant health concern I have about early “real food” is whether it could be a choking hazard. Early foods should be a mashed-up or pureed consistency that can easily be eaten without teeth. Once Junior can pick up a morsel with his hands, start with soft little bits (about the size of the last part of his thumb, past the knuckle.) It’s messy, it’s fun, and it’s the best way for Junior to learn about textures and flavors. Eat as a family, and eat the same things. Yum!

Allergist, nutritionist or dietician?

The Pediatric Insider

© 2012 Roy Benaroch, MD

Anthony wrote in, “My son has a lot of allergies, and I’m not sure what is safe to feed him. Should I see an allergist or a nutritionist?”

Anthony, the first step is to figure out exactly what foods are truly allergic triggers. Many people have the impression they’re allergic to things for a variety of reasons, but they really aren’t. The best way to know for sure is by the history– what reaction occurs when your son eats that food? Though allergy testing is available, it isn’t exact, and doesn’t always show what the true allergies are. Even people who test positive for allergies might not really be allergic.

However, if your son really has food allergies, it is important to avoid those food triggers. You should work with either a pediatrician or allergist to determine what foods need to be avoided. There seem to be many “alternative practitioners” in the world of allergy these days, and they sometimes offer non-standard or genuinely quacky testing. Beware. Work with someone who’s board-certified and knows what they’re doing. Your pediatrician should be able to offer you a referral.

Kids with multiple food allergies can be challenging at mealtimes. If you’re having trouble coming up with a good, well-balanced, and safe diet, working with an expert in nutrition is a very good idea. Again, you need to be careful. A “nutritionist” can be anyone. That word doesn’t have any legal meaning, and there are no educational requirements or certifying authority for nutritionists. Basically, anyone can call themselves a nutritionist, and some of them may have no idea what they’re talking about. A genuine authority on feeding and nutrition is called a “dietician”. Requirements vary by state, but to call yourself a dietician means that you’ve met educational and practice guidelines. Working with a dietician is a very good idea for families with kids who have multiple allergies or other dietary issues. Working with a nutritionist may be a waste of money, or worse.

Allergies without allergy

The Pediatric Insider

© 2011 Roy Benaroch, MD

“My ten year old daughter seems to have allergies—she sneezes a lot, and is always congested. She’s been tested for everything and isn’t allergic. What is going on, and how can I help her?”

No one can be allergy tested for “everything.” With skin testing, there’s only so much skin to use to test; and for blood testing, well, even a vampire can only get so much blood out of a child. Allergy testing uses a panel of common allergens for the area, but can’t possibly cover all possibilities.  It may be that she really is allergic to something, but she wasn’t tested for it.

It’s also possible that the test itself didn’t give an accurate answer. Allergy testing isn’t close to 100% correct, and both false positives (the test is positive, but the child really isn’t allergic) and false negatives (the test is negative in a truly allergic child) do occur. Even though she’s been extensively tested, it could also be that the test is wrong, and she is allergic to something that she tested negative.

There are other things that might be going on, besides allergies. Cold viruses can trigger an itchy or runny nose, so if she’s been getting one cold virus after another it can seem like one long illness. There’s also a non-allergic condition called “vasomotor rhinitis” which causes nasal congestion and sneezing, especially in bright sunlight. Noses can also be bothered by cigarette smoke or other irritants, triggering allergic-like symptoms, without actually causing true allergy. Rarely, an anatomic obstruction like a nasal polyp may cause symptoms similar to chronic allergies.

It can sometimes be tough to tease these situations out. Often, a best next step is to try regular use of an effective allergy medication, even though she tested negative. The most effective allergy medicines are topical prescription nose sprays (do NOT regularly use an over-the-counter medicated nose spray—they’re addictive.) If allergy medications work,  at least she’ll get some relief. You can also try to rinse her nose out with gentle saline solution, which may relieve symptoms caused by irritation (warning: some kids do not like to have their noses rinsed out. Imagine that.) Further discussions and evaluation by an allergist, pediatrician, or ENT (ear-nose-throat) specialist may also be helpful if her symptoms continue to bother her.