Seasonal Allergies – PediaCast 264
Join Dr David Stukus and Dr Mike Patrick in the PediaCast Studio as they discuss seasonal allergies. With ragweed season in full swing, you’ll want to know the cause, symptoms, diagnosis, treatment, complications, and prevention of this common disorder. All this… plus the hottest topics in the world of allergy research!
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Announcer: This is PediaCast.
Announcer: Welcome to PediaCast, a Pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio and this is Episode 264 for September 11, 2013
We're calling this one Seasonal Allergies; seems like a good time of the year to do that. We're in a ragweed season full swing here in the Midwest and I know there's a lot of — not just kids but moms and dads suffering from allergy symptom as well. So, we'll get into that.
I want to welcome all of you to the program; I do want to take a moment right at the beginning of the show to acknowledge the date. It is September 11th and 12 years ago today a terrorist hijacked four large aircraft and crashed them into the twin towers of the World Trade Center, the Pentagon and a field in Rural Pennsylvania.
And when time has continued its journey, we do well to remember the past and the lives at nearly 3000 Americans that were lost that day. Many of whom raise toward danger in an effort to save others, we called them heroes. So it take sometime today please, to remember their sacrifice — to remember what you were doing — what you were feeling, the fear, the anger, the hope on that day when America came to a crashing halt and stood as one.
Share your stories at that day with your children including your fear and anger, and hope, and the answer to your questions is on as slow as you can because someday your grand kids and your great grand kids will be asking your children the same questions, so I give them a verbal tradition to pass along "don't cross just stay over,… remember.
All right let's move on to the reason you tuned in to pediacast today to learn more about seasonal allergies also known as allergic rhinitis and hay fever. As I mentioned ragweed season is in full swing here in the Midwest and many people are suffering from the symptoms.
We're going to explore those symptoms in detail today along with the cause, diagnosis, treatment, prevention, long-term outlook and the latest research topics in the world of allergies. And to help me cover the basis I have a great returning guest lined up for you today, Dr. David Stukus, he is a Pediatric Allergist here at Nationwide Children's and will be joining me in the moment.
Before we get to him I do want to remind you that PediaCast and our new short format single topic shows also known as PediaBytes are available on iHeartRadio talk just head over to iheart.com or download the iheart.com app for iPhone, iPad or android devices and search for PediaCast and PediaBytes.
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Also, I remind you the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So, if you do have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.
So, let's a quick break and I will be back with Dr. Stukus, we'll talk seasonal allergies, right after this.
Dr. Mike Patrick: All right we are back. Dr. David Stukus is an attending physician with the section of Allergy and Immunology here at Nationwide Children's Hospital and an Assistant Professor of Pediatrics at the Ohio State University College of Medicine.
He joined me back in episode 242 to talk about asthma technology and mobile apps and he's back in the studio today with a new topic of discussion one that affects millions of Americans seasonal allergies. So welcome back to the program Dr. Stukus.
Dr. David Stukus: Thank you so much, it's a pleasure to be here.
Dr. Mike Patrick: Really appreciate you taking time to stop by and just back from vacation too, so nothing like jumping right back in.
Dr. David Stukus: Better now or never?
Dr. Mike Patrick: Yes. Before we get started I didn't want to put in a quick plug for Dr. Stukus on twitter, he's handle is AllergyKidsDoc and I'll put a link to it in the show notes for this episode 264 over at pediacast.org. So, you're pretty active with your tweets, what can parents find there?
Dr. David Stukus: I like to tweet about all kinds of information regarding asthma, seasonal allergies, eczema, food allergies; really anything that you know covers what I do on a day to day basis.
Dr. Mike Patrick: Sure. And I think it's a great resource cause if it's one person is asking you about it in the office then you know that there are thousands of parents out there who have the same question in dealing with the same stuff at home, so great resource for moms and dads.
Dr. David Stukus: Oh, thank you, if you spend any time on the internet looking up anything you'll see all the information and this information is out there, so that's part of why I'm involved with this with twitter.
Dr. Mike Patrick: Yeah, absolutely, so a source you can trust AllergyKidsDoc and that's over at twitter and again I'll put a link in the show notes for you, for episode 264 at pediacast.org. All right so let's talk about seasonal allergies, I guess a good place to start which is be a definition what is meant by a term seasonal allergies?
Dr. David Stukus: Well, these are symptoms that are brought on by exposure to environmental pollen and mold spores. This is typically occurs in the spring, summer and fall and pollen can be release by various plants including trees, grasses, weeds, ragweed which is currently an issue right now and mold as well. And then whenever a susceptible person is exposed to it they develop pretty characteristic symptoms.
Dr. Mike Patrick: Now, I've mentioned a couple of the other names in the intro to the program, so allergic rhinitis is another thing that parents may hear although sometimes that's more indoor allergies when you have may be allergies all year long.
Dr. David Stukus: Well, you can lump everything under allergic rhinitis then you have perennial all year round when you can be allergic to things such pet dander, cockroach, and also dust mites then it's seasonal and a lot of patient actually have a mixture of both seasonal and perennial allergic rhinitis.
Dr. Mike Patrick: Sure, and I supposed that the indoor stuff could have a seasonal been to just because certain season are closing up the house and all the stuffs getting recirculated so it may seem like it's seasonal.
Dr. David Stukus: Absolutely.
Dr. Mike Patrick: And then another term is hay fever which is not really triggered by hay and doesn't cause a fever.
Dr. David Stukus: Right, it's a biggest misnomer idea with.
Dr. Mike Patrick: And you know me I always like to look up these little historical things, so I did discover that the term was coined by a British doctor in 1819, in the late summer in Great Britain they harvest alfalfa and other grasses and this hay was not the cause of periodical infection of the eyes and chest, however I guess when hay is harvested we now know it's not even — that's not when it's pollenating and so it was probably the symptoms were cause by other allergens that the workers were exposed to what they were in the fields for long hours with the hay. So, I had to throw that in because ,
Dr. David Stukus: I appreciate history as much anybody.
Dr. Mike Patrick: So, how common is allergic rhinitis or seasonal allergies?
Dr. David Stukus: It's actually very common about 1 in 10 children and adults in the United States of America suffer from some form of allergic rhinitis.
Dr. Mike Patrick: And do you see a difference at various ages was more common in preschoolers for instance, or school age kids or teenagers, there's a pre-match across the board.
Dr. David Stukus: When it comes to seasonal allergies we really don't see the onset until kids are at least two or three years of age you have to be exposed for a couple of seasons before you can actually become allergic, so we really see the onset once they're in preschool kindergarten and school age.
Dr. Mike Patrick: Sure. Do you see any difference between males and females, ethnic groups, that sort of thing was a pretty much across the board there.
Dr. David Stukus: It seems like boys more than girls in early childhood and that trend reverses during adolescence.
Dr. Mike Patrick: Interesting, and what about with different cultures and ethnicities?
Dr. David Stukus: There's a slight increase in prevalence in a Caucasian compared with African-American but not much.
Dr. Mike Patrick: Sure and what about this is something that you sometimes hear industrialize nations versus developing nations, do you have any sense of differences there?
Dr. David Stukus: Certainly, and there's a concept that's refer to us the hygiene hypothesis and that as we have a cleaner environment more urban living exposed less and less to farm animals and dirty environments where our immune system really are challenge at an early age to find out different microbes and infections and things like that. When you're not challenge at an early age then your body may be more up to develop an abnormal immune response to things like pollen or ragweed.
Dr. Mike Patrick: Sure.
Dr. David Stukus: Absolutely.
Dr. Mike Patrick: So you'd see it more in industrialized societies and also more urban areas than rural maybe.
Dr. David Stukus: That's great.
Dr. Mike Patrick: Although certainly if you live in the country you may very well suffer from these allergies.
Dr. David Stukus: Those people have allergies in the country where are you different.
Dr. Mike Patrick: Yes. What about family history? Is there a genetic component to allergies as one of the strongest risk factors either or both parents have a history of any type of allergies, asthma or eczema that significantly increase the risk in children as well. And then are there other risk factors that I've missed or suffer most?
Dr. David Stukus: Those are the biggest ones, really it's in the DNA, people are programmed to be allergic at that early age.
Dr. Mike Patrick: Do you see an association between seasonal allergies and food allergies, so as if you have one or you more likely to have the other?
Dr. David Stukus: It goes in reverse so there's something called the atopic march. Atopic really means allergic and a lot of allergic children will start off with eczema early in infancy, usually around three to six months of age and then they may or may not develop food allergies and then they'll develop more respiratory allergy as they get older as you mentioned before concerning school age.
Dr. Mike Patrick: So and here's the million dollar question, what causes seasonal allergies? And we do have a number of folks in the show who are science sophisticated and so don't be afraid to go down at the cellular level.
Dr. David Stukus: All right, I love it. A person forms an allergy antibody which is called IgE. IgE is the abbreviation for immunoglobulin and this is what all antibodies refer to. When you form specific IgE towards allergens in the air called aeroallergens, this IgE lives on allergy cells throughout the body called mast cell.
We have billions of mast cells throughout our body living inside every single organ, nose, eyes, lungs, skin everywhere. These mast cells contain various chemicals; the most problematic for people suffer allergies is called histamine.
If you have specific Ig living on those allergy cells towards a grass pollen and you were to breath in grass pollen, it would then unlock those allergy cells by binding to the IgE immediately you release histamine. Histamine does a couple of important things that people with allergies know very well. It causes itching, it can cause localized swelling or you know it can cause nasal congestion things like that and it can cause hives on the skin, things along those lines.
The other thing that happens in those allergy cells than release other chemicals that basically tell the body that there's an allergy party going on at that site and then 6 to 12 hours later other inflammatory mediators come by and that what leads to sort of a late face allergic response, chronic inflammation ongoing persistent symptoms things like that.
Dr. Mike Patrick: Sure. Now the symptoms then — so when you look at the fact that they have the allergen you've been sensitize so the antibodies are there, they activate the mast cell then releases histamine and we talked about the symptoms that you see like runny nose, nasal congestion, watery-itchy eyes, sneezing, cough. That sounds like viral upper respiratory infections. So there are some other things that can causes — how do you tell the difference between which really allergies and what's a viral infection?
Dr. David Stukus: That's a great question, that's something I hear all the time. So part of it is going to be what time of the year you affected by and so you know viral illnesses are much more prevalent during the school time, so to starting right, right now cause you're going to start to get that runny nose and tickle on the throat.
How long symptoms last for is a big indicator as well? If you have seasonal allergies most of the seasons are going to last for 2 to 3 months, so you really should have symptoms during that time whereas if it's a viral infection you're only going to be sick for 7 to 14 days. The other distinguishing factor be itch, so there's no there's no allergy except if it doesn't itch then aren't allergic. So as I mentioned before histamine is the main mediator involved in allergic rhinitis, so you'll have a lot of itching and sneezing associated with your symptoms as well.
And then really the runny nose associated with allergies is going to be clear. If it starts to change color that's going to signal other type of immune cells fighting off an infection most of the time viral, so if you start to have a snotty nose that's more yellow or green and you start thinking more infection. And certainly the presence of fever as you indicated before doesn't go along with allergies but may go on with infection.
Dr. Mike Patrick: Sure and then what about sinus infection? That's something but then can be a complication of allergies or it can happen after a virus to what kind of occlusion does a sinus infection might be going on.
Dr. David Stukus: So actually, there were new guidelines released this summer that state that after the 13 days is really the prime point. So you really just start to get better if not completely resolve from a typical infection in the first two weeks.
If things are persistent, especially if you have new onset fever, worsening congestion or runny nose, after that 13-day period time that may indicate that you may have a secondary bacterial infection. And we don't want to rush up and treat folks who have a viral illness or allergies with antibiotic cause it's not going to help for one, there's risk that are involved such as allergic reaction and then can we worry about the resistant organisms by overuse of antibiotics.
Dr. Mike Patrick: Absolutely, Let's say you do have a kid who has this chronic congestion and watery eyes and there's the itching the component to it, no fever and it's been going on for quite a while and you really do think that allergies could be involved here. How do you go about making that definitive diagnosis?
Dr. David Stukus: Well there's really two different ways, I was preferred actually have an accurate diagnosis through testing but we'll get to that in a second, if you just want to try an over-the-counter antihistamine to start with, that's a very reasonable option, if that makes your symptoms go away within the first day or two that's a pretty good but let's do the allergies.
Dr. Mike Patrick: Yeah.
Dr. David Stukus: Whereas over-the-counter antihistamines really won't make you feel any better if you have a viral or upper respiratory infection. And then if you want to get an accurate diagnosis there's really two main ways that we can perform that testing, most test is going to be done by a specialist such as myself or my allergy colleagues.
The most common way we do that in the office is by doing something called skin prick testing or scratch testing. We take a drop of whatever allergen we choose and if we're doing seasonal allergy we can choose different types of tree, pollen grass, pollen weed, ragweed whatever you like, place a drop of that liquid which looks like you know tinted water on the back from the forearm and you just scratch through with the plastic device.
There are no needles involve contrary to popular belief. As you scratch to the top layer of the skin you introduced that allergens to those mast cells that we thought to have before that live on the skin. You wait 15 minutes, if your body have form an IgE antibodies towards that allergen then within 50 minutes you're going to develop basically hive.
You're going to have a big red, itchy bump, and you get some redness around the area, and the size of that hive that develops can determine whether or not you actually have sensitization to whatever you're tested for. Now there's a lot of people out there that may have a positive skin prick or scratch test to multiple different allergens that may not or she have allergies.
So it's not a full prove test, it's not 100% sensitive but it's a pretty good test it always match up your positive results with the history and we will only do a shot gun testing to test for a bunch of different things unless it'll be really relevant for the diagnosis or treatment.
And then the other way that you can test for allergies is actually by doing a simple blood test and what this can do is measure the amount of specific IgE in the blood stream towards whatever allergen you would like to detect. Now the problem with the blood test is that it's really not a good screening tool, you can't just do the test just to find out which you're allergic too?
We tend to believe negative results more than we believe positive results and the reason why it's because you get range reported back to you and that range is pretty large it goes to point 1 up to 100. And there is no definitive value that says if you have x number towards ragweed that clearly means that you are allergic. So we often get what I like to call wishy-washy results for you may get levels of 1.2, 2.1 and we don't really know what to do with those, but blood testing is a nice option if you can't perform skin testing for whatever reason.
Dr. Mike Patrick: Now, just from a kind of a practical standpoint, there are a lot of kids out there who have those symptoms in a seasonal pattern and they do try an oral over-the-counter antihistamine medicine so just some simple treatment and it does improve their symptoms and then you know they might be on it for two or three months and then they go on to the season to — the next year to have the same symptoms during that same season and I would suspect that there aren't enough allergies out there to actually do the test that you're recommending for all of those kids, so would you say for a parent who — just their kid has the simple symptoms, they don't have any side effects from the medicine, their kids seems to tolerate it pretty well.
Is that reasonable just to treat them empirically with the fact that they're allergic to something, we don't know what it is or do you really feel like that all kids who are on an allergy medicine on a seasonal basis really do need to have this test and I'm not trying to lead you in one way or the other, what's your feeling on that, cause there are a lot of kids who are on those medicines?
Dr. David Stukus: Absolutely, my approach to testing is really is the test result is going to alter diagnosis to your treatment. So if you have mild symptoms that are very well controlled with the regimen hereon, you probably don't need to be seen by a specialist.
However, if you are not getting the relief that you ought to be or if you know symptoms are lasting longer than you feel they're sure of the diagnosis and question without a doubt that's where the testing can be extremely helpful.
Dr. Mike Patrick: Sure. And if you have a kid who you try the simple antihistamines then you've also added in a steroid nose spray and you know maybe Singulair and they're still not getting better absolutely they ought to see an allergist.
Dr. David Stukus: Once you start reaching two, three, four medications it's probably in her best interest, yes.
Dr. Mike Patrick: Sure. So that kind of lead us into in the treatment, what sort of treatment options are you looking to us, we mentioned the couple here if we just kind of go through the list of the different tools that are in your tool box and how they work, that'll be great.
Dr. David Stukus: So we have multiple options to choose from and they all work very differently, so that's one of the biggest misconceptions that I see from even pediatricians is thinking that the medications all treat the same symptoms whereas they don't.
And the options that we have as far as over-the-counter options we're really dealing with oral antihistamines. We have other antihistamines such as Benadryl which click in very quickly but only last 4 to 6 hours and they have significant side effect such as sedation, drowsiness and then we have newer second generation antihistamines that are over-the-counter including these are the trade names such as Claritin, Zyrtec, and Allegra.
This generally last 18 to 24 hours have much less risk of sedation or any side effects and things like that and those were all why they're available over-the-counter now. You also have topical antihistamines in the form of eye drops and you have combination agents that can actually stabilize those allergy mast cells in the eye as well.
Multiple different eye drops available over-the-counter and those are the biggest over-the-counter allergy treatments. Now I would like to spend a second talking a word of caution about other available therapies that are target us being effective for allergy such as decongestants.
So we can have a real problem when you use topical decongestant such as for the nose most commonly called Afrin, also for the eye called Visine, because what people can experiences our rebound phenomenon, the fancy medical term is rhinitis medicamentosa. We actually become physically addicted to these nasal decongestants.
It provides short term relief after about a week of using it regularly, you need to use it more and more and more to achieve the same desired result and eventually you're actually addicted to it. So it's something we always try to prevent and then oral decongestants, so any medication has a big capital "D… associated with it and a lot of times it is combined by antihistamines that's an oral decongestant they just don't work very well, now we have better options that I'll talk about in a second and they actually have more side effects such as insomnia, behavior changes in children and things like that.
Now when it comes to prescription medications topical nasal steroids are most effective treatment option for allergic rhinitis, they are the most effective medicine that we have to treat nasal congestion and runny nose, antihistamines are much better at treating itching and sneezing and they are not very effective for stuffy nose so often times we have to use an antihistamine combined with nasal steroid but nasal steroids are very effective the one downside with nasal steroid is that you really have to use them every day and we have to achieve the desired result is they don't work very well just when they get to sniff was on the high pollen count days or using for a day here and there.
If you're going to use them they really should be started a least a couple of weeks before your pollen season and you continue them throughout the entire season on a daily basis. Other medications would include Singulair, which actually blocks that late phase allergy response I talked throughout before. I see ton of patient who are placed on Singulair as their only medication and that provides no relief whatsoever.
It doesn't do really good job at treating the itching with sneezing or really a stuffy nose but it can be helpful add on therapy if you're not doing well with the nasal steroid and with the antihistamines. And that's really the mainstay of therapy, the FDA is currently reviewing one of the topical nasal steroids spray for use over-the-counter and they're going to make a decision on that sometime in the next 6 to 12 months, I think, so they're may be actually an over-the-counter option available for that as well.
Dr. Mike Patrick: Sure. I want to focus on really quick on the over-the-counter antihistamine medicine, so you had mentioned Zyrtec, Claritin and Allegra as three of the trade names that are out there and you've also mentioned Benadryl and the fact that it causes more sleepiness and mood changes, sometimes we get toddlers who actually have the opposite of sleepiness when they're on those.
Dr. David Stukus: Right.
Dr. Mike Patrick: And that's because Benadryl crosses the blood-brain barrier and so actually has effects on the brain and so that's why we see behavioral changes. Is there a difference in the level of sedation that you see with the over-the-counter ones like Zyrtec, Claritin and Allegra like her son more sedating, some less sedating or really just kind of depend on the individual and which one do you like to start with?
Dr. David Stukus: So, Allegra does not cause sedation. It does not cross into the brain at all. So that one will not cause any sedation or drowsiness which is really a nice feature of that medication. Zyrtec and Claritin are probably about 10 to 13% of people who experienced some level and it's really just individual dependent. You won't know it until you try. But most people do really well with those.
Dr. Mike Patrick: Do you find if it does causes problems if you're going to push through and use that every day for a couple of weeks that those go away or once you have those and your experience is that going to be an issue for that particular medicine, for that particular child all the time.
Dr. David Stukus: They're usually right.
Dr. Mike Patrick: So can you sort of breakthrough with the side effects?
Dr. David Stukus: Yeah. Generally no if it's going to affect you, it's going to affect you. So there are other options that you can try and that's the nice thing if there are so many different options.
Dr. Mike Patrick: Sure. And then — I guess and to be fair you don't really think of this as treatment but I guess if you know what you're allergic too and you can try to avoid those triggers that would be part of the treatment as well.
Dr. David Stukus: It's absolutely mainstay that you — I'm glad you brought that up.
So in addition to medication, so we always talked about avoid on certain known allergen which is not always easy to do especially for some of this outdoor pollens. However there are couples of tips that can really help with it. So, pollen levels are generally highest in the morning between about 5 and 11 am so they can't live an outdoor activity during that time.
We want to make the home a safe zone because you know most children are going to spend anywhere from 8 to 12 hours a day indoors and so if you want to leave all that pollen outside we need to really can make sure that the window stay close 24 hours a day. You can even crack them on nice days cause that's when pollen counts are really highest, no blow inside.
And then after spending time outdoors when they come inside change those clothes that you're wearing, wash you face and wash your hair. Try not to hang the laundry outside because I know just kind of collect pollen and bring it inside with you and then air-conditioning can be a very effective tool both in the home and inside the car to help filter out that pollen as well.
Dr. Mike Patrick: Let's talk also about well something folks can do in the house, cause now I suspect, okay you've got a pollen out of the house and you've closed the windows and you're re-circulating the air and I would suspect that some of these kids who have seasonal allergies also have allergies the things inside of the home, so what do you suggest for inside, so the pet dander and the molds and what can folks do to eliminate the allergens there.
Dr. David Stukus: So, this is why it's very helpful to have an accurate diagnosis, so because some of those things will have some cause associated with it, and significant amount of work. So, if you're allergic to dust mites, dust mites tends to hide out inside pillows, in bedding, in mattresses and stuff toys and things like that. There are dusts mites proof encasements that are actually zippered that you can get for every pillow on the bed and also the mattress in box spring.
It's also helpful to wash all the bedding at least weekly in very hot water. The drier actually doesn't hot enough to kill the dust mites off, it's very helpful to remove all stuff toys from the bed completely not even allowing them to kind of go in the bed during the day and take them off at night because what happens is that as you move the stuff toys you actually shake the dust mites out and you'll breath them in all night long and they helps to vacuum, carpeting or remove it completely and the you know some people recommend removing any type of cloth drapes and things like that, I think that's an extreme measure, it can't be helpful.
Dr. Mike Patrick: It depends on how severe your kid's symptoms are.
Dr. David Stukus: Sure, right. For pet dander you know pet dander exists in our entire environment. I don't have any pets in my house but I have pet dander on my clothes right now just from being out and about today interacting with other people, it's everywhere. So inside the home one of the biggest things that you can do is make sure that pet never has access to the bedroom that the person with allergy is going to sleep it.
So sort of like with the pollen came crack the windows at all don't even want to pick that one for 30 seconds because you want to restrict them from that room otherwise that dander levels will go up significantly. There's a lot of misinformation regarding pet allergy. There is no such thing as a truly hypoallergenic cat or dog despite what are wonderful present his family has to say about their Portuguese water dog and other things you'll read on the internet.
Dr. Mike Patrick: It's a customs, it's a dog.
Dr. David Stukus: There are certain breeds that may cause more allergies than certain individuals as suppose to the others but — and other thing is that it's not the hair that you see, it's the dander that actually causes allergy symptoms and it's a microscopic protein that secreted from the sweat glands and the pet skin, also from their saliva and urine, so even if you take care of the coat things like that they're still going to secret dander throughout the home.
So we really want to keep them out of the bedroom at all times, make sure you vacuum any carpeting and you dust on a regular basis and then it can be helpful to wash the pet and I'm sure your family will laugh at me cause it's a recommend that you wash them twice a week. [Laughter]. Let's go laugh with that.
Dr. Mike Patrick: Yeah, right exactly.
Dr. David Stukus: And the mold is only an issue really if you can see it. A lot of people there's a — if you type in you know toxic mold or black mold on Google you're going to get 3.9 million hit or something like that. And you guys can scare to death. We all have molds, it's part of our environment. It happens anywhere they have moisture and any type of organic material for you to grow on such as dry wall or what are things like that.
It's really an issue when you have water leak, it damage inside your home and you see that mold growing. So common that you're going to see it inside the bathroom on the tiles of the grout or in the kitchen you can just fix that water or clean that right up but if you really see it inside the basement or in the bedrooms or on the wall and things like that — that source of water leak are damage needs to be remediated otherwise the molds are going to continue to accumulate.
And you can easily remove the molds that are already visible with the 10% bleach solution.
Dr. Mike Patrick: Great.
Dr. David Stukus: And then furnished filters, air filters should be change regularly, there are different types of filters that can be helpful to somebody's, some of the pollen and dander and thing like that and then half the filters can be extremely helpful and vacuum cleaners.
As far as air purifiers, they can be somewhat helpful but the way I think about it is they kind of sit in one corner of the room and they're really not going to do all that throughout the rest of the house. So it's a significant expense, I don't recommend that it's top line if you have one, certainly not going to hurt, I don't think it would replace some of the other measures.
Dr. Mike Patrick: Sure. I kind of debated where we talked about allergy shots, whether that's really treatment or prevention I guess it's probably both cause you have to have the symptoms first before you go looking for the allergy and then decide you're going to do allergy shot but really they're not treating the symptoms, they are preventing the symptoms from happening in the first place once you know the symptoms are likely to be there.
So in any case a lot to say, let's talk about allergy shots.
Dr. David Stukus: Sure, absolutely. So allergy shots are also called immunotherapy has been around for 100 years, believe me or not and it's a very simple concept which is still kind of fully understood. You basically take what you're allergic too and you break it down and you don't leave it down at a very sort of deadly concentration and you injected in the body.
Overtime what happens is your body stops forming the IgE allergy antibody towards that allergen and it starts forming a blocking antibody called IgG. This generally happens after 12 months of therapy. Now as you mentioned allergy shots can actually prevent the onset of new allergic sensitization but nobody on the right mind is going to put somebody on allergy shots if they actually don't have allergies, if they don't have symptoms from their allergies.
As a general rule allergy shots or immunotherapy is indicated for anybody's who suffers from severe persistent allergic rhinitis despite following appropriate avoidance measures and multiple different types of medications.
So it's really lesser fact to your patients. Or if they just are sick of taking medication having side effect if it's truly a conversant to them. As a general rule in my experienced those children who suffer from severe spring which is really tree pollen allergy, terrible swelling of their eyes itching, sneezing, medication don't provide any relief and they're miserable and they can't participate in sports, they're missing school, they can't go outside.
Those are the patients who truly benefit the most. Allergy shots are also serious side effects so they have to be administered in the physician's office with about a 20- to 30-minute observation period because we're taking something you're allergic too injecting it in to your body and sometimes if it's been a lack from your last allergy shot, if you're currently sick with that viral illness, if your allergies are actually acting up because it's allergy season or if you have poorly controlled asthma, injecting that allergy shot in the body can actually provoke localized side effects such as swelling and irritation at the site of the injection or a systemic response called anaphylaxis.
We can actually have total body hives, wheezing, loss of blood pressure passing out and things like that. Because we have to proceed slowly with allergy shots we build them up overtime so you receive build up injections over about 30 weeks or so, and that's plus minus if you can make appointments having side effects, things like that and that's once a week and then after you achieve the maintenance dosing that's really when you start to see the most benefit then you can stretch things out every two to four weeks and most experts will recommend that you receive your allergy injections for about three to five years.
And then many people could stop when they have you know the cure of, their allergies, it's a wonderful therapy. We don't really start to see symptomatic improvement to about 6 to 12 months. So they don't work right away they don't take the place to medications you're currently taking but they certainly can provide a very helpful long lasting treatment from many people who suffer from allergies.
Dr. Mike Patrick: I think a couple of take home points for parents out there, you know one of them when you have to travel to the doctor's office so frequently is like why can I just do this at home and you know for instance diabetics use a needle at home, you know why can't I be trained to do this and really the key is that they could have a severe allergic reaction or the anaphylaxis really at any point. Is that's the case.
Dr. David Stukus: That's absolutely right, that's exactly why we recommend doing it at the physician's office and they watch you. Because it's hard to predict who's actually going to suffer from that.
Dr. Mike Patrick: And they may even had that same allergy dose for several weeks and suddenly it happens.
Dr. David Stukus: Right, you might be pushing along just fine and all suddenly on a ragweed season and you're being injected with the ragweed while you're being exposed to on a regular basis not might be enough to set you over.
Dr. Mike Patrick: And then I guess the other take home is just how long — don't expect instantaneous results but if you can be a forward thinker and you know look at where's your kid going to be five years from now, you then it's worth it.
Dr. David Stukus: I think most allergist will agree, you can tell first I mean with somebody who's going to benefit from allergy shots cause they're just really suffering like I said in spring time especially bad eye symptoms and the medications aren't helping and they're going to approach that path very quickly.
Dr. Mike Patrick: Let's talk complication and we talked about this a little bit about the various treatments. What about complications from allergies themselves? So, if you have a kid who has poorly controlled allergies or they've not really have the proper diagnosis of — that they this is what this is. What kind of complications do we see from poorly treated allergies?
Dr. David Stukus: A lot of people don't understand how severe this can affect people this leads to a very poor quality of life, if you're affected by this people don't sleep well at night. If you're unable to breathe through your nose or if you're very itchy or if you're stuffy or if you're having side effects on medications you have a very poor sleep quality and anybody who has a restless night sleep, I tell you that you're very cranky the next day.
Now seasonal allergies can last for months at a time, so if you're not sleeping well at night for that prolonged period of time, you're going to have extreme fatigue, you're going to have sedation, poor concentration, poorly controlled allergies or significant triggering factor from missed to school and work days and significant cause to our society ever at quotes of billions of dollars every year lost to allergies.
Dr. Mike Patrick: And so this is or moms and dads who have allergies too, I mean it interferes as your ability to be a good parent to go to work and be productive in your work life and so I do kind of want to focus this on the parents too cause there's a lot of parents who have allergy issues.
Dr. David Stukus: And absolutely and there's a lot of people who don't realize that you don't have to live like that, it just amazes me unless they all just struggle through and it's just the way it is. We know we have absolute — we've great driven options available.
Dr. Mike Patrick: And it even extends them to other disease processes. So if a kid has ADHD, poor sleep mimic that worse or if you have a mood disorder, depression, anxiety, I mean all those things are affected too by lack of sleep which can be caused from uncontrolled allergies.
Dr. David Stukus: It can permeate your entire life.
Dr. Mike Patrick: And then what about the relationship with asthma?
Dr. David Stukus: It's a very strong relationship. You know various studies will say anywhere for 60 to 80% of asthmatic children who have allergic sensitization or allergies to indoor-outdoor allergens. We think of the airway as being one airway to the nose is connected to the throat is connected to the lungs. So if you have a lot of inflammation-irritation inside the nose that's going to contribute to the inflammation-irritation inside the lungs.
So it can lead to ongoing long-term poor control. And then it's a significant cause of asthma exacerbation, especially this time of the year with ragweed and molds pores. Once we get the full range and the leaves start collecting, you got a lot of mold outside that could be a significant trigger for asthma symptoms.
Dr. Mike Patrick: Sure.
Dr. David Stukus: And the ER visits and in-patient hospital stays for asthma spike in September-October and the next spike again this spring and it definitely correlates both with environmental allergens and also viral infections.
Dr. Mike Patrick: So it's really something to think about if you have a kid at home who has trouble with her asthma when you think about are they on an inhaled steroids and you know using your albuterol but really another part of that is do they suffer from seasonal allergies and do you have that under control because it may be difficult to bring the asthma under control until the allergy part of it is under control.
Dr. David Stukus: Absolutely and then immunotherapy can be extremely effective for patients with poorly controlled asthma who have allergies and it can led to reduction on their daily control on medication usage reduction exacerbation and make a significant impact on our life overtime. And then for some children there's been great studies that have shown that they just have allergies when they get triggered with immunotherapy, you can actually prevent the onset of asthma in some children as well.
Dr. Mike Patrick: Sure. And then from an infection standpoint because we see more sinus infections and more ear infections if your allergy symptoms were not well-controlled.
Dr. David Stukus: Yes. I heard — somebody told me a great allergy reason where there's fluid inside our inner ears and our nose and our pharynx and things like that where it's a slow moving stream. One thing that causes that stream to stop moving it turns it into swamp such that for infection, Isn't that a great analogy?
Dr. Mike Patrick: Yeah I love that.
Dr. David Stukus: So, allergies cause that to turn into swamp, everything gets swollen and block and doesn't flow it very well. So absolutely you get significant increase in upper respiratory infections and ear infection.
Dr. Mike Patrick: This just occurred to me I think with allergies you may see all these increase mucus production as a result of the histamine release. What is that mucus trying to do?
Dr. David Stukus: Mucus is our friend, everybody takes this so gross but it's sticky for a reason, so it really is our first line of defense it coats our upper and lower airways, also our intestines and stomach as well and it really traps any type of airborne particle or allergen and the best example I think it's people who smoke cigarettes because what happens is they paralyzed the cilia, there's millions of tiny little hairs that try to beat that mucus out of our lungs and they can no longer clear that mucus and that's why they have that smoker's cough and that's also why their mucus turns nice and block and things like that.
Dr. Mike Patrick: Yeah.
Dr. David Stukus: Yes, and people with allergies they make a lot more mucus because your body is ramping up its own protection against the thing that's trying to invade it.
Dr. Mike Patrick: Yeah, so if your asthma treatment is only basic getting rid of the mucus, you're kind of doing yourself at this service because you're going to even have more allergen exposure.
Dr. David Stukus: You know sure in a way, absolutely.
Dr. Mike Patrick: Tell me ways to look at it.
Dr. David Stukus: Yes and all goes hand and hand.
Dr. Mike Patrick: What about a long-term outlook for those with seasonal allergies, do they last their whole life once you have it and then if you do go to route of immunotherapy or allergy shots, is there a chance that 10 years down the road it could come back.
Dr. David Stukus: So most people who benefit from shots and it's really only effective you know what 80% of people, we can't actually predict who was going to cure. So it's not 100% effective but for those that it does help they can be cured, life-long.
Now certainly it can come back later in life but they're may be predisposed to have other conditions that go along with it such as non-allergic rhinitis or chronic sinusitis or other issues along those lines, but the natural history of seasonal allergies, some people have persistent symptoms throughout their life, many people get better especially boys, I mentioned earlier that boys tend to be worst during childhood and that reverse is adolescence.
So sometimes it just magically goes away the one that teenagers. The hormones do lots of crazy things inside the body and then girls tend to get worst as it becomes teenagers.
Dr. Mike Patrick: Can you prevent, is anything you could do to prevent allergies from happening before they ever start?
Dr. David Stukus: Not that I'm aware of. If you spend any time on the internet, you will read all sort of different things that may help prevent this. I'd like to address this to couple of them, so for every study that I read that says if you grow up in a house that has a cat or a dog it will prevent the onset of allergy there's an equal side that says that it actually cause allergies, so I think that the date is very much regarding that.
And then there's lot of information shatter about honey. If you will say or if you just eat honey on a regular basis because the bees pollenate things like that. Well it's interesting for me because bees pollenate flowers for reason. Flowers actually don't cause a lot of pollen allergy because their pollen isn't release into the air, that's why they need the bees to help pollenate.
So all the honey that you're seeing is doesn't really travel out of the pollen from the air-borne allergens that actually causes symptoms for people and there's absolutely no way to standardized or regulate how much pollen exposure you gets.
Dr. Mike Patrick: You can't buy ragweed honey.
Dr. David Stukus: people will sell it to you but I guarantee you it will not be effective.
Dr. Mike Patrick: Sure. And I guess if you could pick your family you know, that may help. If you, I mean if you could pick you mom and dad is going to be you know sense you're such a strong genetic component.
Dr. David Stukus: Allergic people should not marry any allergic people or you know biological next. Yup!
Dr. Mike Patrick: What are the current hot topics in seasonal allergy research right now? What's going on out there in research world?
Dr. David Stukus: Very exciting stuff and what people — they're going to — I've already heard about I'm sure going to start to hear about is sublingual immunotherapy. So as I mentioned before immunotherapy is traditionally given by an injection. In Europe and other parts of the world they've been using drops or tablets under the tongue to treat allergies for decades and it's extremely effective. This is not currently approved by the FDA for use in the United States of America.
There still study in the efficacy and safety and things like that. I will tell you that there are multiple studies that show that it can be extremely effective. It's generally much safer than traditional immunotherapy injections. I love people who experienced localized side effects inside the mouth and stomach such as either itching, tingling, more upset stomach initially that tends to get better over time, it's usually those either several times a week or daily.
There are some issues regarding the appropriate dose to use and also mixing different allergens. So most of the researches have shown if you're just allergic to grass pollen and you get grass drops under your tongue, will be great. Well I don't have many patients who are just allergic to grass, they're also allergic to trees, and ragweed, and dogs and things like that. So I really figuring out the appropriate dose and duration when you mix all the allergens together cause I think what the FDA is probably waiting for.
And the people are going to start to see more and more about this. These drops are being use by multiple different types of practitioners but I want to make clear that it's not approved by the FDA; it's not currently being regulated by anybody. There's a lot of homeopathy going on. So you may not know exactly what you put on under your tongue but I think this is coming.
Dr. Mike Patrick: Yup and the other thing if you look at it, the risk of anaphylaxis with injection in the skin, I mean you're more likely to have just a localized reaction when it's in the skin but when you put in something under the tongue then you're more likely to have more of the central reaction where you really could have difficulty breathing and …
Dr. David Stukus: Believe it it's actually the reverse, the others is much less. I think because the dose is much lower and then you get the rather absorption is little but different to the mucosa as an assurance to being injected in the body. So that's the one thing where anaphylaxis risk actually decreases.
Dr. Mike Patrick: That's interesting, yeah. When they do that daily in your in Europe, lets say, is that something that parents are doing at home or they have to travel to the doctor's office.
Dr. David Stukus: It's an add home treatment that being done in children.
Dr. Mike Patrick: Great, great well hopefully that will come soon.
Dr. David Stukus: That depends on the FDA.
Dr. Mike Patrick: Yeah
Dr. David Stukus: so, other decade or so?
Dr. Mike Patrick: You're right. And what about food allergies with the drops?
Dr. David Stukus: There's different types of desensitization protocols that are being investigated regarding food allergy. None of this is approved by the FDA. There are a lot of people who think that this is going to be a very helpful treatment down the road, most of us are saying within the next 5 to 10 years, a lot of issues to sort out because most patients were sort of built up to a daily dose that they can tolerate but many people are having breakthrough reactions.
So you may be desensitized say that you'll get eight peanuts a day. You are not cured of your allergy but if accidentally you eat it you may not have a life threatening reaction and you go months to months down the road and you get cold and then all of a sudden you breakout or you're having anaphylaxis.
Dr. Mike Patrick: Yeah.
Dr. David Stukus: So, there's still some issues regarding appropriate dosing, duration of treatment who's an optimal candidate things like that so I'm not ready for primetime just yet, for sure.
Dr. Mike Patrick: Sure and then finally I just wanted to talk about that at the allergy and asthma clinic at Nationwide Children's Hospital. Tell us little bit about your division and what services do you provide for folks.
Dr. David Stukus: Absolutely, so we just hired our six faculty person here at Nationwide Children's Hospital. Which makes us really one of the largest pediatric allergy and immunology sections in the country or we're hopping. And we treat all kinds of allergic disorders from allergic rhinitis to food allergies, eczema, venom allergy, medication allergy, chronic hives things like that.
We have clinic five days a week at the main campus and we also have a satellite location at Westville where one of my partners goes to. In addition, to being very busy clinically and all of us were involve in multiple pursuit throughout the hospital including various endeavors and asthma such as myself and my partner Amber Patterson is doing exciting research regarding intralymphatic immunotherapy we actually inject the allergens right in the lymph node which is you know cutting edge stuff. Then we also have interest in food allergy and other things like that. So we are a busy thriving group.
Dr. Mike Patrick: And we have several of your colleagues on PediaCast and Dr. Patterson came by and we talked about various food stuff which is actually non allergy related who was just a food talk unlike trans fats and things like that. And we have a couple others to,
Dr. David Stukus: Dr. Scherzer and Mustillo,
Dr. Mike Patrick: Yes, yes we talked food allergies not to undergo. So active division and I do have a link in the show notes for this week on connecting with the allergy clinic. Basically, it's just for referrals and if folks want to know more information or have a question there's a link there on the show notes for this episode which is 264 over pediacast.org. just for people can connect with you r clinic a little bit easier, so, we have that link for you.
Other links again Dr. Stukus on twitter AllergyKidsDoc and we have a link to the actual allergy and asthma clinic at Nationwide Children's has more information on what they do with allergy consultations and allergy shots and comprehensive asthma management plans and skin testing and all that and also have a nice article from the Nationwide Children's Health Library on allergic rhinitis if you'd like some reading materials although I think we went into a much debt and that has — right here on the program. So if you know folks out there who are suffering from seasonal allergies be sure to send them a link to this particular podcast. So, we really appreciate you stopping by.
Dr. David Stukus: Well, thank you so much the invitation was a lot of fun.
Dr. Mike Patrick: Yeah, great having you. We'll have to cook up our next topic and have you back.
Dr. David Stukus: That'll be great.
Dr. Mike Patrick: All right we're going to take a quick break and I will be back with a final word, right after this.
Dr. Mike Patrick: All right my final word this week is a brief reminder. To take some time to remember the events of September 11, 2001, remember the images, remember the victims, the heroes, remember your feelings and share those things with your children of course at an age appropriate level but it is important to remember where we've been and as we determined where we go and I think that — this is really kind of pro harbor in terms of the fact of the fabric of our nation that September 11th had and where we have come from there in terms of policy and you know the things that are out there in the country right now.
And so I do think that we have this ability now to be the people who are giving that history from a verbal standpoint to our kids and our grand kids and so if you think about the folks who live through pro harbor a lot of the things that we, you know you may have a great grandparent who was — was there and their stories about it and so I do think it's important to remember and to talk about those things with our kids. So please take time to it to do that today.
I want to thank all of you for taking time out of your day to spend with us here at PediaCast, really appreciate your support and continued listenership. And of course I want to thank Dr. David Stukus for taking time to stop by the studio today to educate all of us about seasonal allergies.
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If you like to get in touch that's an easy thing to do. If you have a topic, idea where you like to just comment on something that we've talked about here or you have a question, we can get your comments and question in one of our listener episodes, we have another one of those coming up actually I think our next program is going to be a listener episode.
So if you'd like to get in touch just head over to pediacast.org and click on the contact link. Also on the show notes at the end of every episode, there is a link that says contact Dr. Mike, and that's for you to ask questions, provide comments, suggest a topics and then we also have a link that says connect with a pediatric specialist from Nationwide Children's and then again that actually goes to our welcome center which is exclusive for PediaCast listeners that particular link is — takes you to the welcome center, you can get information about referrals and appointments and then they put you in touch with the proper people to help you get referrals and appointments more quickly.
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All right, again thanks for everyone — thanks to everyone for stopping by and making PediaCast a part of your day. And until next time, this is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids. So long everybody.
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