Nolan Alexander (Host): This is Children's Health Checkup where we answer parents' most common questions about raising healthy and happy kids. Today, we're talking with Dr. Erin Wallace, a pediatrician at Children's Health. And as a parent, I know it's so difficult. Here we are getting close to springtime on the back end of cold and flu season—and then, bam, here come allergies. And it's tough as a parent to distinguish exactly what's going on. So today, we'll be exploring why medicine might not be easing your child's allergy symptoms and what steps you can take next. So with that, let's get to know our guest today. Dr. Wallace, how are you?

Erin Wallace, MD: I am doing well. How about yourself?

Host: I'm doing great. And first, I'm just curious, what are the most common reasons you see for allergy medications not relieving symptoms?

Erin Wallace, MD: So, the most common reason is that parents, if you've ever gone into the allergy aisle, it's overwhelming. And the vast majority of allergy treatments are over-the-counter treatments. And so, as a parent, you're standing in the aisle trying to figure out what am I supposed to give my kid. And then, you also are looking at: Is this medication safe for my child in their age? And then, how much do I give my kid? So, the most common reason is that they're not giving them the correct medication. They're not giving it to them consistently enough or correctly dosing it, or that what they're treating just isn't allergies. So, that's really hard as a parent.

Host: That's extremely hard, and maybe that's a whole separate podcast of how you go through exactly what to pick out and how much to give. It's not easy. Do you ever encounter anything, any environmental triggers that medicine alone won't fix?

Erin Wallace, MD: The vast majority of medications have their limitations. And what I tell my patients is that treatment with allergies is additive. So generally, we do start with antihistamines. And then, we start to add in nose sprays and eye drops and prescription medicines. Generally with that, it depends on what their symptoms are for what medication that they should be using. A lot of times the medications are, like, it really is symptom control. So generally, with that, it kind of goes back to are they on the right medicine and are they treating the right illness?

Host: So, it's probably tough to draw a line in the sand, but how long should parents try medication before deciding that it's not effective?

Erin Wallace, MD: Generally, for antihistamines—and I'll just use the name brands, Zyrtec, Allegra, Claritin—those types of oral medications, you really should see improvement even the first day that you give it. But really giving it to them at least three to five days before you really can kind of say, "No, this one's not working, or we're not seeing any relief with it." The nasal steroids, so like Flonase, Nasonex, those usually do take about that also three to five days. And then, if your child were to go on prescription medicine like Singulair or Montelukast, usually about a week where you should see improvement. As far as kind of maximized improvement, generally, that is going to be a couple of weeks.

Host: So, you're saying improvements potentially as soon as one day, but really give it about a week, three to five days. If you start on a Monday, hopefully, you start to see something there towards the end of the week.

Erin Wallace, MD: Yes. Exactly.

Host: So, how can parents tell the difference between allergies and then something else, and this overlap right now of a child dealing with a cold, a sinus infection, asthma, anything else?

Erin Wallace, MD: So again, that gets tricky. What I tell parents is, if all of the sudden parents' allergies are way worse since your child started daycare or school, it's not your allergies. It is most likely your child bringing home viruses on top of your allergies. But sometimes parents will come in and say, "Every time my allergies flare, I see my kid's allergies flare. And what can I do to help that?" And generally, it is a little bit of trial and error, especially for the really young kids. So, kids under the age of five or six, it is saying, "Okay, let's try them on some antihistamines. But if after a week there's really no improvement, most likely this is a cold." And then, I would say stop giving the medicines.

With allergies, it's your body's immune system being triggered by something your body is perceiving as an intruder. When in fact, I mean it's a pollen, it's nothing bad, but for whatever reason, your immune system's just responding to it. From allergies, we call it kind of the triad. Very commonly, we will see seasonal allergies, where you'll have the runny nose, itchy eyes, sneezing, that goes right along with asthma or wheezing, where you get the difficulty breathing, repetitive cough, tight chest, and even eczema or that like dry, itchy skin.

Asthma can very much be triggered by allergies. So if your allergies are poorly controlled and you have asthma, you can have both going on at the same time. But they are actually two different illnesses. So basically, allergies really do affect the nose, the throat, the eyes, even digestive symptoms. Asthma is really what's going on in your lungs and inflammation in your lungs. So, that's the wheezing and the cough. But then, you do get cough from your allergies. But generally, that's going to be more like the postnasal drainage, mucus, cough. So, it is learning that and that changes just as your child's growing and changing, that changes as well.

Sinus infections for children aren't like adult sinus infections. So, adult sinus infections are like infection actually in the bone of your skull, your sinus. Kids, as they're growing, their sinuses are developing. But a lot of times, when they get sinus infections, it's really actually more because of just all this soft tissue stuff in the back of their nose, in the back of their throat, and their little airways are so tiny. But generally, from a sinus infection standpoint, they may or may not run fever with it. But it's chronic, thick, runny stuffy nose. Generally, they kind of just feel bad, even if they don't run a fever. And most kids aren't going to complain of like a headache or face pain, because that's not where their sinus infection is. But sometimes they will, or especially as you get more into the teen years, you can get more of that kind of facial tenderness or even like toothaches, because of where your sinuses are.

Host: So at home, I've got a toddler, and then I've got an infant as well. And I'm starting to think from what you're saying here, what are some distinguishable things to look at—is this an allergic reaction going on here? Or is this, as you talked about, a cold or a sinus infection? So, this isn't a hundred percent of the time, but it seems like a fever could be a distinguishable factor. Would you say that's correct?

Erin Wallace, MD: So generally, if there is a fever involved, I tell my parents, if your child has a fever up over 101, this is no longer allergies. Now, could the allergies, all that inflammation, mucus, snot—could your toddler have developed an ear infection, or a sinus infection that It's a complication from their allergies? Yes. But a lot of times, especially if you're like, "My child was doing absolutely fine yesterday. And then, today, they woke up, they have 102 fever, they have runny nose and cough," that's not allergies. Your child's most likely picked up some sort of fever, viral infection or older kids like strep throat or things like that?

Host: What about allergy shots? Do you feel that they or other treatments are appropriate for kids?

Erin Wallace, MD: Absolutely. Now, they're definitely not first-line treatment. Most pediatricians and certainly allergists really want to maximize medication treatment, and also certainly avoidance if you really start to figure out that, "Okay, every time I'm around the dog or the cat, that all of a sudden I have itchy eyes, runny nose"—not that we like to get rid of our pets—but trying to have avoidance of those triggers, or as we get older, "If we start to notice that every time Cedar's high here in Texas, my allergies flare"—not that you need to move, but knowing that, "Okay. I really need to stay on top of my allergy medication." But if you've gone to your pediatrician and we've kind of figured out, "Okay, these are some of the triggers." We've really maximized the medications, both over-the-counter and also the prescription medications, and you're getting recurrent sinus infections, ear infections, having to go to the emergency room because, you know, it's triggering your asthma. Things like that, definitely, allergy shots can be very helpful.

But I do tell parents there are limitations. So for younger kids, where you said you have a toddler, a lot of times, we can't do allergy shots with toddlers, simply because they haven't been around enough allergy to actually have reliable testing to confirm that this is in fact what they're reacting to.

Host: So, they got to go through it some more.

Erin Wallace, MD: Yeah. The caveat to that is generally that, if your child, let's say I have an allergic reaction, anaphylaxis because I was bit by fire ants, that is something that even at a young age that the allergists will talk about doing allergy shots, for just because that is very much a life-threatening and your toddler goes outside and plays. And you try, but you know, fire ants are everywhere. But speaking kind of more specifically about kind of like seasonal allergies and those types for allergy shots, generally, you do have to realize that getting allergy shots, you have to go through testing. So, that's going to be a blood draw for your child. And then, a lot of times skin allergy testing, which is a little bit traumatic, even teenagers are not fans of all of that.

And then, once the allergist is able to kind of determine from those tests what exactly it is your body's responding to, then they'll come up with a very specific allergy shot regimen, which is a big time commitment. Initially, for most kids it's going to be about once a week that you're going to the allergist. And it's usually about a three to five-year plan, where you're continuing to expose your body to those allergens so you're becoming less and less sensitive to them. And you can get very good long-term results with that, where you may not even need to be on any allergy medications anymore. But with the allergy shots, it can be very effective, but there's a lot more to it. It's not just a simple answer of, "Oh, I tried Zyrtec, and it didn't work for me."

Host: So, backtracking a little bit before we get to the shots, what are some signs that it's time for a referral to an allergist?

Erin Wallace, MD: Generally, it is where we've tried multiple medications and combinations of medications. And generally, we're just seeing quality of life. So, they're missing a lot of school. More so because of complications, ear infection, sinus infections, asthma or wheezing exacerbations, those are really kind of the big reasons where we'd say, "Okay, we've kind of tried all of the usual things that generally are going to help your child and really diminish those complications and improve your quality of life. But if it's not working, it's at least worth the conversation with the allergist to see what other things can be done.

Host: And as we wrap up, let's leave our listeners with something to take away. What's the most important piece of advice that you want parents to take away from managing their child's allergies?

Erin Wallace, MD: So, it's overwhelming. If you feel that your child does have allergies, really sit down and have a conversation with your pediatrician, because then we can really hammer out a very individualized plan of the right medications, the name brand of the medications and the generic names. Because again, the pharmacy's confusing, what medications are safe and what dose is safe for your child, so that they can really maximize their treatment and feel like they have ownership in caring for their child's allergies. So then, if it's not working, then we can kind of take those next steps. And then, they're also just not really frustrated.

Host: This has been so helpful. Thank you, Dr. Erin Wallace, for joining us today.

Erin Wallace, MD: You are welcome. Thank you for having me.

Host: Thank you for listening to Children's Health Checkup. For more tips on how to ease allergy symptoms in kids, visit childrens.com/allergies. And if you're in North Texas, Children's Health Pediatric Primary Care offers trusted care close to home, from newborn checkups to care for common illnesses and more. Find a location near you at childrens.com/primarycare.