What are the treatment options for a child with allergies?

Treatment of Childhood Allergies

All food-allergic children must be prescribed epinephrine autoinjectors and antihistamines, with comprehensive education on allergen avoidance, emergency action plans, and recognition of anaphylaxis symptoms. 1

Food Allergies: Primary Management Strategy

Core Treatment Principles

• Strict dietary avoidance of identified allergens is the cornerstone of management, as no curative treatments currently exist for food allergy 1
• The most common food allergens requiring avoidance are milk, egg, wheat, soy, peanut, tree nuts, finfish, and shellfish 1

Emergency Medications (Mandatory for All Food-Allergic Children)

• Epinephrine autoinjector: Required for all children with confirmed food allergy, regardless of reaction severity history, as any food allergy can become progressively more severe on subsequent exposures 1, 2
• Oral antihistamines: Prescribed for mild reactions (isolated hives, mild nausea) but never as sole treatment for anaphylaxis 1
• Epinephrine is indicated for severe symptoms including diffuse hives, respiratory symptoms, obstructive swelling of tongue/lips, or circulatory symptoms 1, 2

Comprehensive Counseling Requirements

Every food-allergic child's family must receive education on: 1

1. Food avoidance and nutritional monitoring to prevent deficiencies
2. Label reading skills to identify hidden allergens
3. Recognition of anaphylaxis signs/symptoms (flushing, syncope, tachycardia, hypotension, bronchospasm, urticaria, angioedema)
4. Proper epinephrine autoinjector technique and timing of administration
5. Emergency action plans with documentation for schools (Section 504 plans, IEPs)
6. Annual follow-up for retesting and monitoring for tolerance development

Critical Diagnostic Caveat

• A positive allergy test (food-specific IgE or skin prick test) without clinical symptoms does not establish food allergy diagnosis 1
• Diagnosis requires both sensitization (allergen-specific IgE present) AND reproducible clinical symptoms after allergen exposure 1
• Allergy testing has poor positive predictive value; simply having allergen-specific IgE does not indicate disease 1

Allergic Rhinitis: Stepwise Treatment Algorithm

Mild Intermittent Allergic Rhinitis

First-line approach: 3

• Allergen avoidance measures (HEPA filtration, weekly pet bathing, keeping pets out of bedrooms) 4
• Second-generation oral antihistamines (cetirizine, loratadine) as initial pharmacotherapy 4, 5, 3
• Alternative: Topical nasal saline or cromoglycate 3

Moderate to Severe Allergic Rhinitis

Intranasal corticosteroids are the treatment of choice for moderate-to-severe disease 1, 3

• Intranasal corticosteroids are superior to oral antihistamines alone 1
• Intranasal corticosteroids are equal to or superior to combination therapy with antihistamines plus leukotriene receptor antagonists 1
• These agents lack systemic side effects associated with oral steroids 5

Combination Therapy Options

When intranasal corticosteroids alone are insufficient or contraindicated: 1

• Antihistamine + leukotriene receptor antagonist (LTRA): Superior to either agent alone 1
• Montelukast is FDA-approved for perennial allergic rhinitis in children ≥6 months and seasonal allergic rhinitis in children ≥2 years 1
• Montelukast is particularly useful when treating combined upper and lower airway disease (rhinitis + asthma) 1

Treatment Failure Protocol

If no improvement after 4 weeks of adequate treatment: 3

• Reassess patient compliance with medications
• Reconsider the diagnosis with nasal endoscopy to evaluate for alternative causes of nasal obstruction
• Consider specialist referral to allergist/immunologist 4

Non-Anaphylactic Allergic Reactions (e.g., Pet Allergies)

Mild Skin Reactions (Localized Rash, Few Hives)

Oral antihistamines are first-line treatment combined with topical corticosteroids for symptom relief 4

• Non-sedating options: Cetirizine or loratadine for daytime use 4
• Sedating option: Hydroxyzine (use cautiously in young children, typically at bedtime only) 4
• Topical hydrocortisone 2.5% cream applied to affected areas 4
• Continue monitoring exposure but watch for worsening symptoms 4

Moderate Reactions (More Extensive Rash, Bothersome Symptoms)

• Limit allergen exposure 4
• Continue oral antihistamines 4
• Consider short course of oral corticosteroids if symptoms are particularly bothersome 4

Critical Safety Distinction

• Antihistamines alone are insufficient for anaphylaxis but appropriate for non-anaphylactic reactions 4
• Never delay emergency care if the reaction progresses to involve other organ systems (respiratory, cardiovascular) 4
• True anaphylaxis requires immediate epinephrine administration 4, 2

Long-Term Management Considerations

Allergen Immunotherapy

• Consider referral for allergen immunotherapy (allergy shots) in children with persistent allergies causing significant symptoms despite pharmacotherapy 4
• Typically not initiated in children <5 years unless benefits clearly outweigh risks 4
• Evidence suggests immunotherapy may reduce development of new asthma cases in children with allergic rhinitis 1
• Sublingual immunotherapy shows promise in children with allergic rhinoconjunctivitis 1

Monitoring for Tolerance Development

• Many childhood food allergies (milk, egg, wheat, soy) may resolve over time 1
• Annual follow-up is essential to assess for tolerance development and consider supervised oral food challenges 1
• Peanut, tree nut, fish, and shellfish allergies are less likely to resolve 1

Common Pitfalls to Avoid

• Never use antibiotic creams for allergic rashes unless secondary infection is present 4
• Avoid overinterpreting allergy test results in children with atopic dermatitis; older literature overspecifies the relationship between food-specific IgE and food allergy in this population 1
• Do not prescribe avoidance without treating underlying atopic dermatitis when present 1
• Sedating antihistamines significantly impair learning; prescribe second-generation non-sedating agents whenever possible 5
• Egg allergy does not contraindicate MMR or influenza vaccines; these concerns were disproven in 1995 and 2011 respectively 1
• Primary care clinicians should prescribe epinephrine even when uncertain of food allergy diagnosis, as patients wait an average of 4 months for allergist consultation 1