Kids and Allergy Season: A Q&A with Dr. Matthew Bell

Q:  Tell us a little bit about what you do and your medical background.

Dr. Bell: I grew up in Arkansas, went to med school at UAMS, and did a combined residency in internal medicine and pediatrics at UAMS and Arkansas Children’s in Little Rock. I then went on to complete a fellowship in Allergy and Immunology at the University of Wisconsin at Madison. After I completed the fellowship, I came back as full-time faculty at Children’s in Little Rock for another two years. Then I moved to northwest Arkansas, where I’m part-time faculty at Arkansas Children’s Northwest, in addition to having a private practice here. I’ve practiced allergy and immunology for kids and adults for the last nine years and I love it.

Q: How common are seasonal allergies in kids?

Dr. Bell:  Some studies in the pediatric population suggest that up to 40% of kids have seasonal allergy symptoms. More conservative studies suggest that number is probably closer to 15–20%, when you look at folks who actually have documented evidence of seasonal allergies.

Q: Does seasonal pollen only affect people who have allergies?

Dr. Bell: Every year, we’ll see people in clinic who thought for years that they’ve been allergic to pollen, and then we test them and they’re not. That’s often a big shock to folks. Pollen affects people who are allergic because it triggers an immunologic reaction, whereby you have binding of pollen proteins to antibodies called IgE, that then trigger the release of histamine and other substances that cause the symptoms we classically think of as hay fever: sneezing, itchy, watery eyes, etc.

But pollen is a solid particle so it definitely can affect people without them being allergic to it. We don't want to get it in our lungs, so the nose filters out a lot of those solid particles. It does so in a couple of ways: by swelling to limit airflow and by producing more mucus, which can trap some of the pollen. So even folks that don't have allergies can still have some symptoms that mimic allergies this time of year.

Q: What are the symptoms that can help differentiate between allergies and a normal reaction to pollen irritation?

Dr. Bell:  Repetitive sneezing is the symptom most linked to having nasal allergies. Everyone sneezes, but it’s those people who sneeze over and over again who are almost all allergic. Itchy, watery eyes and a clear, drippy, runny nose are strong signs of allergic rhinitis, which is what we call nasal disease caused by allergies.

Q: Are there any symptoms specific to children that may not be present in adults?

Dr. Bell:  I don’t tend to see a large percentage of kids with allergies that have terrible eye symptoms. Symptoms tend to be more prominent in the adult population than in the pediatric population. In terms of the other symptoms, kids do tend to get more of the physical manifestations that we associated with allergies. For instance, dark circles under the eyes, which are called allergic shiners. They also tend to get what’s called the transverse nasal crease, which is caused by repetitively doing what we call the allergic salute, where they push the tip of their nose up, and they actually will get a crease right across the tip of their nose. By and large, the symptoms are similar between people of all age groups.

Q: Can infants have allergies?

Dr. Bell: We have parents who bring in their babies with concerns about allergies. While it’s possible for a child less than two years old to have allergies to year-round triggers such as dust mites or dog and cat dander, the likelihood of a two-year-old having pollen allergy or seasonal allergy is very, very, very low. Typically, what we see in those kiddos is just their immune systems still maturing. A two-year-old is going to have symptoms of a viral respiratory illness about 200 days a year, which is really crazy! I can count on one hand the number of two-year-olds I’ve seen with six significant seasonal allergic rhinitis.

Seasonal allergies tend to develop between age two and five because it takes repetitive exposure to an allergen to develop allergies. For instance, maple trees pollinate for about seven to 10 days every spring. So your typical two-year-old has only had about two weeks total of maple pollen exposure, which may not be enough time for an allergy to develop.

Q: As a parent, is there anything that that we can do to keep allergies at bay?

Dr. Bell: I divide allergens as being either an avoidable allergen or an unavoidable allergen. Avoidable allergens would be like dogs, cats, horses, dusts mites. I consider pollens and mold spores to be kind of unavoidable, but that’s not entirely true. We can’t live in a bubble all spring. But we can do things to decrease how much we’re exposed to pollens during times of year when there’s a lot of it out.

• I recommend washing the clothes frequently, nightly baths and washing the hair for any kid that has seasonal allergies.
• Upgrade the filters on your HVAC unit. They all have a minimum efficiency reporting value (MERV) rating, which tells you how big the pores are and what they will allow through. The old school blue fiberglass ones that you can see through will allow almost anything to pass through. What you're looking for is a MERV rating of nine or higher.
• Keep the windows closed. I know it's that time of year when it's finally warm, and everyone wants to just pop those windows up and really enjoy that fresh air. But again, with that fresh air, anything that's in that air is also coming inside the house.
• Fans can also be an issue because they’re constantly circulating that pollen and keeping it from settling.
• Pollen loves early morning hours, and it loves dry, windy days. Minimize outdoor activities, especially between the hours of about six to eight in the morning especially on days that are dry or windy.

Q: Are there any medications that we should have on hand at home to help with allergy symptoms?

Dr. Bell: The three classes of medication that I typically use are oral antihistamines, antihistamine eyedrops, and nasal steroid sprays. Oral antihistamines tend to get billed as a multipurpose “allergy pill.” We’re talking Cetirizine, which is Zyrtec; loratadine, which is Claritin; and fexofenadine, which is Allegra. In all actuality, these are very narrow spectrum drugs which people expect more out of than they can actually provide. They are really only going to help with sneezing, itchy nose, and to a lesser degree, a clear runny nose and itchy, watery eyes. They’re not going to work for congestion because histamine has nothing to do with congestion.

Kids tend to metabolize antihistamines like Zyrtec, Claritin, and Allegra faster than adults do. When we give them the prescribed dose on the packaging in the morning, they're just miserable when they get home from school. So, with those drugs, it's fine to give a second dose 12 hours later.

Topical antihistamines, like eyedrops, are great for breakthrough eye symptoms. If your child is fine Monday and Tuesday, spends a lot of time outside Wednesday, and comes home with itchy eyes, you can use eyedrops for breakthrough relief. Keep those in the fridge because they feel a lot better if they're cold going in the eye.

The third medicine that we recommend using are nasal steroid sprays, which are all over the counter. These are some of the most misunderstood and misused medicines. They have to be used consistently, and they're going to take about five days to really start working. If you stop using them after a few days and start using them again in a couple of weeks, you start that clock over again. I tell folks you don't necessarily have to use nasal sprays 365 days a year but if you know that spring and fall are problematic, use them in March, April, May, and then again, August, September, October. It doesn't hurt to do them every day, but if you're not doing them consistently for several weeks at a time, you're really missing out on their benefit.

The majority of my allergy patients are on loratadine or Claritin. But Zyrtec or cetirizine has the best cost benefit ratio. So, I have folks on cetirizine one to two times a day, one to two sprays of a nasal steroid spray daily, and then antihistamine eyedrops available to use for breakthrough symptoms. And for most folks, that's enough to at least make things manageable.

Q:  If your child sneezes right after they get the nasal spray, do you have to do it again? Or does it get in there quick enough?

Dr. Bell: It’s a frequent response for kids to sneeze right afterwards, but the medicine generally gets in there quick enough to work. In nasal sprays, the steroid molecule is suspended in either a water-based vehicle or in the case of Flonase, an alcohol-based vehicle. Flonase is the one that kind of has that funny smell and taste. If that’s a problem, switch to one of the water based ones, and they’ll typically tolerate it. But as soon as that water-based solution hits the mucus in the nose, the steroid is going to stick pretty well.

The one thing I would also caution with nasal sprays is when we use them, point the tip of the bottle to the corner of your eye on the same side, not straight up. It doesn't need to point towards the middle or the septum, which can cause nosebleeds. The other thing I would caution is don't tilt the head way back, because that's going to induce us to swallow more of the medicine. The larger percentage of the spray we swallow the less there is available to help with the nose. I recommend patients tilt the head a little bit forward, put the spray in at that angle we described and spray, and then just a gentle sniff like you're sniffing a flower. The harder we sniff the more medicine that goes down the back of our throat. So just a gentle sniff.

Q: What’s your opinion on Benadryl as an allergy medicine?

Dr. Bell: In my Fayetteville clinic, I’ve got a framed picture on the wall of a box of Benadryl with a circle and a line through it. It’s worthless as an allergy medicine, which is a big shock to a lot of folks, even in the medical community. It’s still ingrained in people’s heads that allergy equals Benadryl, but unfortunately, that thought is way behind the times.

Benadryl was discovered in 1946 and approved by the FDA in the 50s. It was grandfathered in without being studied a lot. I'm not sure it would pass muster if we were trying to resubmit it through the FDA as an over-the-counter medication today.

My problems with Benadryl are multi-fold. Number one is the obvious side effects. People tend to use Benadryl more for the side effects than as an antihistamine: Can't sleep at night? Take a little bit of Benadryl and it'll help you sleep… which is not true. It doesn't help you sleep, it puts you to sleep. So, drowsiness is a big side effect. In little kids, we sometimes see the opposite, and it's more of an activating type medicine. The bottom line is there are some neuropsychiatric side effects with Benadryl that are not great.

Number two, its length of action is very short. If you look at a bottle or box of Benadryl, it's going to recommend dosing every four or six hours. So, you need to take it throughout the day. And while the antihistamine effect wears off after a couple of hours, that drowsiness may last for eight or 10 hours. So, you're sandwiching together these long periods of drowsiness to get these short durations of antihistamine activity. It can also cause dry mouth, which can cause urinary retention.

One of my favorite studies that I like to show people about Benadryl is one that was done about 20 years ago. They took a group of adults who were known allergy sufferers and compared the effects of fexofenadine, which is Allegra, Benadryl, and 80 proof vodka. Allegra does not cross the blood brain barrier so it cannot cause any neuropsychiatric symptoms. They put the test subjects behind a driving simulator to see the comparative effects of each of these substances on driving.

They found that the Allegra didn't have any effect because it's not affecting the brain in any way. Alcohol had the expected effect: it reduced reaction time, and it impaired coordination. But by far, the worst of the three tested was Benadryl. A single 25 milligram dose of Benadryl performed worse than the alcohol, which always hit home. So, the side effects are bad, it doesn't last very long, and it causes cognitive impairment that may increase the risk for things like Alzheimer's later in life.

Canada finally got wise and made it a scheduled medication. It still doesn't require a prescription, but its dispensation is regulated by the pharmacist who may suggest better options like we've mentioned earlier.

Benadryl is a worthless drug. It's a drug that we don't need to use anymore. Does it work faster than other antihistamines? No. Cetirizine, Zyrtec works the fastest of all. For long-term treatment, pick one of those three that I mentioned previously. If you need something in an acute event, let's say hives or something like that, and you would normally reach for Benadryl, reach for Zyrtec, instead. It's going to work faster, it's going to last longer, it's not going to knock you out.

Q: At what point should you take your child in to see an allergist during allergy season?

Dr. Bell:  There are a lot of nuances to that question. Sometimes parents just want to know what their kids are allergic to and that’s something we can answer pretty quickly in the allergist’s office. The three times I really think an allergist needs to be involved is when symptoms are there year ‘round. They may be worse in spring and fall but the symptoms are always there. The second time is when they’re on good allergy medicines and the symptoms are not resolving. The third: When there’s an underlying disease like asthma, which is made worse by allergies. That’s where it’s more important for us to get involved because sometimes getting allergy symptoms under control can make asthma easier to control.