Joey Wahler (Host): They're very common in the United States, so we're discussing children's allergies. Our guests, Dr. Ankit Patel and Dr. Scott DiVenere. Both are otolaryngology specialists and ENT surgeons with Silver Cross Hospital.

This is Silver Cross Hospital's IMatter Health podcast, where medical experts bring you the latest information on health topics that matter most to you and your family. Thanks so much for joining us. I'm Joey Wahler. Hi, doctors. Welcome.

Ankit Patel, MD: Hello, Joey.

Scott DiVenere, MD: Thank you.

Host: Great to have you with us. So first for you, Dr. Patel, we alluded to it there at the top, just how common are children's allergies in this country and what are they exactly?

Ankit Patel, MD: Yeah, great question. So, children's allergies are actually quite common, ranging anywhere from about 20% to up to 40% of kids may experience some level of allergies or allergic rhinitis. And in terms of what are allergies, essentially, what it comes down to is it's the body's kind of dysregulated immune response to things that are normally harmless from the environment, like a dust or a tree pollen, and kids are reacting and they may experience symptoms such as congestion, sneezing, watery eyes, itchy eyes, et cetera.

Host: So, more environmental allergy than to anything in particular then, yes?

Ankit Patel, MD: Environmental allergies are quite common, yes.

Host: And I've heard it said that in recent years, perhaps because of global warming or what have you, that more people are picking up allergies that they didn't have before, yes?

Ankit Patel, MD: The incidence of allergies is on the rise and the exact reason is a bit up for debate. Some of it, for a while, was thought to be related to kind of the over-cleanliness hypothesis, meaning we were sanitizing everything and kids weren't exposed to germs. And so then, their immune systems were almost looking for something to react to. And so, we have seen an increase in incidence, you know, across the board and across the world.

Host: So for you, Dr. DiVenere, what are the typical symptoms of children's allergies, and at what age does it typically start or can it start?

Scott DiVenere, MD: Yeah. It actually can start from the earliest. It can start even in the first months of life. But it's usually more in terms of, as Dr. Patel alluded to, sneezing, runny nose, possibly itching, nasal drainage. Sometimes kids have skin conditions, rash or oversensitivity. And in our field, we see a lot of kids with sinus issues and you don't know is it sinus infection, is it allergy sometimes? And then, chronic ear problems as well. So, the inflammation can actually be so bad in the nose that it can actually sort of back up and cause problems with the sinuses and then subsequently problems with the ears.

Host: Gotcha. And so, Dr. Patel, what children are typically at risk for allergies and how do you go about diagnosing them in the first place?

Ankit Patel, MD: Yeah, great question. So, first off, any child can potentially be at risk for allergies, but certainly it's much more common if there's a positive family history. So, if either mom or dad has allergies, then the child certainly will be at increased likelihood. And if both parents have allergies, then really the child is at much higher risk for allergies. The other area where allergies are quite common is in kids who have asthma. In fact, the majority of children who have asthma have concomitant allergies as well.

Host: Dr. DiVenere, what about the difference between an allergy and what's known as a sensitivity?

Scott DiVenere, MD: Yeah, it's really sort of a degree. You know, some people are sensitive to something, but doesn't objectively get too severe. And on some of the testing that we do, it doesn't always show up, and yet you know that if you're linked to a certain environment or exposed to a certain condition, you might actually not feel as good as you should or have nasal drainage or symptoms or sneezing. But usually, those cases, sometimes the testing doesn't show it. And it's really a degree of how the immune response, how strong of a reaction it is. Usually, a classic allergy is antibodies going a little wild and things that are really more of a true of what we think of a more severe reaction.

Ankit Patel, MD: I would just add sensitivity is different than a true allergic reaction in that body isn't forming an immune response to the substance. So for example, people could be sensitive to cigarette smoke, but technically it may not be a true allergy or sensitive to the smell of perfume or, in children or adults, lactose intolerance, for example, an example of a sensitivity, but they're not really forming a true allergic response per se.

Host: Understood. And Dr. Patel, maybe we can address kind of a misconception or a myth, if you will, here. Do children outgrow allergies?

Ankit Patel, MD: So, predisposition is always there. But when kids notice symptoms, the most tend to be at younger ages because their immune systems are younger, they're still developing, their bodies are smaller. So if they're breathing in something that's causing nasal congestion, just physically there's not as much space to deal with these things, and so then they can lead into problems such as tonsil issues, adenoid issues, obstruction later on sinus infections just like Dr. DiVenere had mentioned.

And as kids get older, in some kids, some of the symptoms may start to reduce, but that predisposition is still there. And many times, because we see children and adults, we'll see people coming back later where they felt that they had allergies as a kid, they thought they outgrew them, but really they were always there, it's just that their bodies became bigger and their ability to tolerate some things increased, but eventually those symptoms returned later.

Host: And when you mention tonsils and one or two other things there, in a moment we'll delve more into that. But first, back to you, Dr. DiVenere, how are children's allergies typically treated these days?

Scott DiVenere, MD: Yeah. The classic is usually, you go to the drug store and you go to the over-the-counter section. And oftentimes, the two mainstay medications would be an antihistamine, something as classic as Benadryl that's been around forever still works, but a lot of people are sensitive to that, making them drowsy or feeling foggy or sleepy. So, sometimes that's good at bedtime, but not really a good option during the day. And then, other options like Claritin, Allegra can work well. But all those just sort of take the edge off of it. And the worry is that they could cause some dryness and they can cause a little drowsiness or alertness issue that may not be quite your hundred percent. And then, sometimes the kids can combine that with a nasal steroid, such as like a Flonase spray or something along those lines for the nasal decongestion. But in many cases, those just aren't enough. And those are really more treating the symptoms.

And what we've started doing for over 20 years is doing allergy testing. And basically, kids tolerate it better than one might expect. For younger kids, we actually write for numbing creams. They come in, they have these little prick tests generally on the arms. In the old days, it was more on the back, the way allergist did it. Now, it's on the arms with the numbed arms where they don't feel anything, and the staff sort of just eases them into it and they get the results. And based on how reactive those little pricks get, that's how strong of a reaction you have to those things. And so, that can test anywhere from dogs and cats and dust mites and ragweeds and pollens and molds, and really all the common Midwest allergies that we all sort of live within. And then, based on that, if it is significant, then the way we love to treat those is allergy drops called sublingual immunotherapy, which sort of desensitizes. It's almost like a long-term vaccination against the allergies. It makes the body less allergic over time. And it is a process. It's usually about a three to four-year process on average. And it's a drop that you do under your tongue three times a day. And by doing that, you're not just making the symptoms better, but it gives you many years, sometimes a lifetime of benefit afterwards. So, it's really more of a way of getting to the root of the problem. So, it's closer to a cure in many cases.

Host: Gotcha, great to hear there. So, switching gears, and Dr. Patel has mentioned, what role do tonsils actually play in a child's health?

Ankit Patel, MD: Yeah. So, tonsils, we call them kind of lymphatic processing sites. So, they are structures or organs within the body that essentially they're almost like they're filtering in everything that's exposed to that person from the environment. And just like the tonsils, there are structures called the adenoids, which sit a little bit higher up, but behind the nose and do a similar function, essentially. And throughout the head and neck, including lymph nodes, lymphoid follicles behind the throat, there are many of these similar structures that all kind of participate in that filtering and processing, you know, process.

Host: And speaking of which, Dr. DiVenere, I'm wondering how often are tonsils removed today, and is it in fact less than in years past? Because it seems like I don't hear about tonsils in kids now the way I did back when I was a kid. True?

Scott DiVenere, MD: It depends on one's age. But it depends, because it has evolved over time. There was a time that probably the peak, as far as I know, the peak was 1959. And at that point, 1.4 million people or kids under 18 in this country actually had their tonsils removed. And things were quite different than the anesthesia and everything was just a little riskier. And yet 1.4 million people went through that. And then, it went through sort of a rebound where people thought, "Boy, maybe we're overdoing this." And in 1987, it was at a low point of about 240,000 kids actually had their tonsils out. So, it was a dramatically different number. And now, it's changed where it's somewhere in the 500,000 to 600,000 range. So, it's still quite a common procedure and our practice with our group, we still do it on a regular basis. Probably, the thing that shifted the most is that it used to just be for infection. And so, back then, 90% of the kids who had their tonsils out, it was for frequency or severity of infection. And now, probably 90% of the cases that we do with the tonsils and adenoid is more obstructive issues, things that affect the sleep and things that affect mouth breathing and future orthodontic issues.

So, the indications have changed. We still treat the infections too, of course, but it's still a common procedure. And in many ways, even though it is common, it's still a little bit underdiagnosed because we see a lot of kids coming in referred by their orthodontists or by their dentist and not necessarily by their general doctor because of these changes and obstructive issues. And, you know, the thought that maybe by addressing the sleep issues when they're young, it's hard to do long-term studies, but no one really knows the impact that that could have on sleep as an adult. And so, we see a lot of people coming in as adults who wish they had had their tonsils out, because they were always big, always a source of problem, and it's quite a bit simpler for kids to go through the procedure than it is for adults.

Host: And for the record, by the way, that peak time you mentioned back in 1959, that is in fact way before my time. I don't go back quite that far.

Scott DiVenere, MD: Of course.

Host: A few other things. Dr. Patel, speaking of this, when should a parent typically consider seeing an ENT such as yourselves about their child's tonsils?

Ankit Patel, MD: Yeah. So, I would say, if ever they have a concern, they should seek out care. And parents are really the primary people that know their children the best. But certainly, some symptoms would warrant further evaluation. And so, from the tonsil and adenoid standpoint, for example, if your child is snoring, mouth breathing, or having restless sleep, those are things that would prompt further evaluation, because normally kids should sleep quietly and restfully. If they are having disturbed sleep, studies have shown that that affects their cognitive development, how they do in school, and their overall health. So, that's on the tonsil and adenoid side.

And in terms of allergies, you know, if they're having problems with sneezing, mouth breathing, congestion, frequent ear infections or frequent tonsil infections, difficulty breathing through the nose, those are all things that would say, "Okay, I think it would be worthwhile to seek out consultation with an ENT."

Host: And Dr. DiVenere, just so we're clear, Dr. Patel has mentioned it a few times when we talk about adenoids, it seems like tonsils get all the attention, right, publicly? What exactly are adenoids? What's their function?

Scott DiVenere, MD: It's really the same type of tissue as tonsil. Couple reasons why you probably think more of tonsil when these topics are being discussed is that it's hard to see the adenoid. So when kids come into the office, if you look in the back of the throat, in the very back between the tonsils and back by that little punching bag, uvula, if you look up, and so we can sometimes take a mirror to look up, or sometimes we'll take a scope and actually go through the nose and numb it up, of course, so the child doesn't feel it much. And in the very back of the nose, that's where the adenoid sits. And so, it often goes hand in hand when the tonsil's causing troubles, often the adenoid causes troubles. Adenoids, specifically, can cause sinus and ear issues, and sometimes we will take just take the adenoid out, do the adenoidectomy, and put in ear tubes or something like that, where it's all sort of at a higher level above the nasal, more sinus-type issues.

But part of the reason we also think more of tonsils is that when we talk to parents about surgery, almost every child with big tonsils who needs their tonsils out also has adenoids that's bigger than it should be, and we'll often remove that at the same time.

But the tough part of the decision about do you do this for your child or not is the recovery. And the tonsil recovery is really the tough part of that. So, a child who just happens to need their adenoid out is sort of lucky because that's about 10% the misery of the tonsil recovery. The tonsil recovery is a bit rougher. So, we tend to emphasize that when we talk to parents.

Host: All right. Another thing that's great to know. Well, folks, we trust you're now more familiar with children's allergies and beyond. Dr. Patel, Dr. DiVenere, valuable information indeed. Keep up the great work and thanks so much again.

Scott DiVenere, MD: Thank you very much. Thanks for having us.

Host: Absolutely. And for more information, please do visit silvercross.org/pediatrics. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler, and thanks again for being part of Silver Cross Hospital's IMatter Health Podcast.