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The word “rhinitis” comes from Latin. “Rhin” means nasal and “itis” means inflammation. Therefore, a patient with rhinitis has nasal inflammation due to certain substances that are being inhaled through the respiratory filter system – the nose. Symptoms may include any or all of the following: frequent or chronic runny nose, nasal congestion, post nasal drainage, overproduction of mucous and phlegm, sinus headaches, sore throat & cough. All of these symptoms can create an environment in the upper respiratory tract that makes the patient more prone to getting secondary bacterial sinus or ear infections.

There are two distinct types of rhinitis. The first is “allergic rhinitis.” In this type of rhinitis the nasal lining is overreacting to harmless substances called “allergens.” The most common allergens are animal dander (skin flakes), dust mite particles, mold spores, and various pollen granules from trees, grasses, ragweed and weeds. Patients with allergic rhinitis show many positive skin tests due to an allergic reaction of their immune system to the harmless substances (allergens).

The second type of rhinitis is “nonallergic,” also known as “irritant rhinitis.” The symptoms can look exactly like “allergic rhinitis”, but there are often no positive skin tests detected. This type of rhinitis is due to extremely sensitive nasal lining that overreacts to many types of irritants. Examples of irritants which often set off nasal symptoms include smoke, dust, smells and odors, perfumes, aerosol sprays, and changes in outdoor weather conditions (temperature and barometric pressure). A patient’s nasal symptoms may be exactly like those of a patient with allergic rhinitis. Only by doing skin testing and proving that allergies are not present can one be sure of this diagnosis.

Treatment for many years for nonallergic rhinitis has utilized the same medications used for the allergic type of rhinitis with mixed results. Sometimes antihistamines or decongestants have helped and other times they have not improved patients’ symptoms. Nasal sprays with steroids have proven beneficial in some patients as well. Often, these medications have to be used on a daily preventative basis to control mucous production in order to decrease the frequency of sinus and ear infections. More recently, a nasal spray that contains an antihistamine (Astelin) was studied and found to be the first medication that actually was proven to be effective for nonallergic rhinitis. By spraying the antihistamine directly on the nasal tissue, high nasal tissue levels of antihistamine can block the chemical histamine directly, with less medication circulating through whole body.

There are relatively few side effects, with the exception of sleepiness in some patients and nasal bleeding in others (likely due to the drying effects). Astelin works within 1 hour to improve symptoms and lasts for about 12 hours. It may be used along with other medications as there are no drug interactions to be concerned about. The major complaint with Astelin is that it tastes bad to some people when it drains down the back of the throat. By leaning the head forward when spraying it, massaging it in with tissue, and several minutes later gently blowing out the excess, a lot less will drain down the throat. Also, chewing sugarless cinnamon gum seems to numb the taste buds in order to allow the patient to comply with taking it. It is not addictive and can be taken for long periods of time or can just be used in some patients on an as-needed basis.

Asthma is a chronic, inflammatory lung disease characterized by recurrent breathing problems. Patients who have asthma may experience one or more of the following symptoms: wheezing, coughing, chest tightness or shortness of breath. Symptoms and severity can differ greatly from one person to another. Some people experience occasional symptoms while others may have daily symptoms, which can vary from mild to severe. Patients with more severe asthma may have a sudden onset of symptoms that require emergency care.

Everyone has a series of air passages (bronchial tubes or airways) in the lungs resembling an upside down tree. The windpipe (trachea) divides into large branches to the left and right lungs, and these large branches form progressively smaller branches all the way out to the edges of the lungs. Each branch has a thin blanket of mucous lining the inside of the bronchial tube to help trap inhaled pollutants, germs and allergy particles (allergens). The bronchial tubes are also surrounded by a layer of muscle. It is these bronchial tubes that are affected by asthma.

Asthma affects the breathing tubes (airways) of the lungs in three important ways:

1. Inflammation: This is characterized by swelling of the wall of the airway and increased mucous production. The inflammation of the airways makes them narrower for air to flow through, which may cause a wheezing or whistling sound.
2. Muscle constriction: The muscles surrounding the airway contract, further narrowing the airway.
3. Triggers: The airways become overly sensitive to a variety of triggers that worsen the inflammation and muscle contraction.

Common triggers include:

• Exercise
• Allergies
• Irritants such as cold air, smoke, perfumes, or weather changes.
• Infections such as viral respiratory infections or sinus infections. Patients often report that “colds always settle in my chest.”

Asthma is Treated in Two General Ways:

1. Environmental control: Eliminating triggers of your asthma is important! Cigarette smoking (and passive smoke exposure) should be avoided. Measures to reduce allergic exposures are helpful. Avoiding pets, pollens, dust mites, and molds may reduce asthma symptoms and lessen the requirement for long term medication.
   1. Click here for more information about managing asthma through environmental control.
2. Medications are the mainstay of treatment. Patients who experience symptoms more than three days a week usually require a preventative, or controller, maintenance medication. People who experience occasional symptoms may require only a rescue inhaler to be used as needed. Patients with severe asthma may require two or more daily medications to adequately control symptoms. Each patient should have a plan tailored to the frequency and severity of symptoms, and know what to do if symptoms worsen.

Commonly Prescribed Medications Include:

1. Inhaled Corticosteroids: These act directly by blocking the inflammatory response of the airways. These inhaled medications have far fewer side effects than oral corticosteroids such as Orapred or Prednisone. Inhaled steroids are the most powerful and effective medications to reduce inflammation and are recommended by the National Heart, Lung, and Blood Institute for patients who need daily anti-asthma medication (e.g. Pulmicort, Flovent, Asmanex, Advair, Symbicort).
   1. Click here for more information about inhaled steroids
   2. Click here to learn more about Pulmicort Respules & Nebulizers.
2. Leukotriene Antagonists: These are non-steroid oral medications that also prevent inflammation of the airways (e.g. Singulair). They may relieve nasal symptoms in some patients.
3. Bronchodilators: These help to relax the muscles of the airways and open them. There are short-acting, quick reliever or “rescue” forms (e.g. Albuterol, Maxair, Xopenex) and long-acting (e.g. Serevent, Foradil) forms of them. Bronchodilators provide temporary relief of symptoms but do not control the underlying inflammation.
   1. Click here for more information about Bronchodilators.
4. Combination Inhaler Medications: Some products combine an inhaled steroid with a long-acting bronchodilator, which is useful if anti-inflammatory therapy alone is not effective at controlling symptoms or preventing flares or attacks (e.g. Advair, Symbicort). There is some evidence in the medical literature that the addition of a long-acting bronchodilator in a small percentage of children may be associated with an increase in asthma exacerbations. We trust that you would contact us immediately if you suspect that your asthma symptoms worsen.
   1. Click here to read more about Combination Inhalers.
5. Immunotherapy (allergy shots) may reduce an allergic person’s sensitivity to pollens, dust mites or cat allergens when avoidance and medications do not successfully control the symptoms.

Asthma control:

There is no cure for asthma, but it can be controlled. When asthma is well-controlled, a person should be able to sleep all night without awakening, exercise without symptoms, have good work/school attendance and avoid the need for emergency or urgent treatment. During each office visit there are certain questions we ask that help us to decide if your asthma is optimally controlled.

• Doses of rescue medicine—ideally fewer than two doses per week for symptoms.
• Ability to sleep all night without using a rescue medicine.
• Ability to participate fully in exercise or activities that you choose (whether or not you require a preventative dose of an inhaler).
• Work/school attendance—not having to miss school or work because of asthma.
• Need for oral steroid medication to control an attack.
• Need for emergency or acute care.
• Infections or other illnesses that may impact asthma symptoms.
• Compliance with medications—ideally taking all doses of preventative medicines every day.

Cough variant asthma is often unrecognized as asthma, because wheezing may not be present. “Recurrent croup” and “recurrent bronchitis” are often treated from episode to episode only to realize later that the underlying problem was actually cough variant asthma. The symptoms may first begin after an upper respiratory tract infection and then seem to “settle in the chest.” A cough can be present day and night and can be forceful enough to provoke vomiting. This cough may have a “barking” or “honking” sound and can persist for months or even years. The person may cough as frequently as every few seconds. Wheezing or other symptoms of asthma are not usually present. Other conditions which can give similar symptoms to cough variant asthma include a chronic sinus infection, allergies with post nasal drainage, gastric acid reflux, pertussis (whooping cough) and rarely, aspiration (choking) of a foreign body (for example a piece of a peanut).

Common triggering factors for cough variant asthma include exercise, respiratory tract infections and allergies, but many times, the triggering factors are unknown. Most diagnostic tests including a chest x-ray will usually be normal. A measurable decrease in a lung function test may be noted, but can also be normal in many cases. Occasionally, a special breathing test called a Methacholine Challenge Test must be set up at a hospital. During this test, the patient does repeated breathing tests after inhaling gradually increasing concentrations of a substance called methacholine. This can conclusively prove the diagnosis of asthma. However, since it is time consuming and somewhat expensive, it is not done regularly. It is usually more realistic to give the patient a trial on asthma medication instead.

Cough variant asthma responds to the same medications and treatments used to manage the more classic forms of asthma. It is important to understand the goals and objectives of the treatment plan and discuss any problems with your physician.

Although food allergy reactions can be very scary, proper education, precautions and advanced planning will empower you to better protect your child and help prevent future serious allergic reactions. We will review your child’s tests, but by reading the following information, you will better understand about food allergies and anaphylaxis (a potential life threatening allergic reaction). You will be provided with a written FOOD ALLERGY ACTION PLAN and an explanation which will tell you specifically when and how to use injectable epinephrine, also known as EpiPen, EpiPen Jr, or Auvi-Q. You should review this PLAN with relatives, babysitters, teachers and school nurses as well as the proper technique for using EpiPen or Auvi-Q. REMEMBER: PAST REACTIONS DO NOT PREDICT HOW SEVERE THE NEXT REACTION MIGHT BE!! Just because a child seemed to get better quickly with a dose of Benadryl, this CANNOT be counted on to occur next time. There are several KEY POINTS that need to be fully understood and have changed the way experts now approach food allergy patients since new Food Allergy Guidelines were published in the fall of 2010. Not all Emergency physicians or ambulance EMTs, doctors or nurses are yet aware of these changes in the updated Guidelines.

1. If there has been a suspected INGESTION of a food to which your child is allergic and any body-wide (systemic) symptoms occur, EpiPen or Auvi-Q should be given immediately without hesitation and then you should call 9-1-1!
2. Benadryl is no longer recommended for allergic reactions due to food allergy INGESTION as it does NOT stop anaphylaxis (a potentially life threatening and rapidly progressive body-wide reaction).
3. Benadryl may help a rash from a skin contact to a food allergen, but it takes 30 to 60 minutes to begin working. Always wash off any area on the skin where a food allergen has contacted.
4. There is NO HARM in giving an EpiPen or Auvi-Q for a suspected food allergy reaction. Fast heart beat and shakiness are major side effects for about 15 to 20 minutes, but failure to administer epinephrine injections or a delay has resulted in fatalities.
5. You must have your child firmly in your grip or pinned down carefully when administering EpiPen or Auvi-Q in order to keep the injection in place in the side of his/her leg for 3 seconds in order to absorb the best dose. Your child will naturally try to get away from the pain of the injection. The EpiPen or Auvi-Q will have some medicine still in the vial even after administration.
6. When EMTs arrive, always insist on being transported to the E.R. Stay at the E.R. a minimum of 4 hours for observation even if they attempt to reassure you he/she is fine and you can go home. Some patients just stay in the waiting room for the remainder of the 4 hours from the time of the reaction. The reason for waiting is that some patients improve at first and then have a relapse of the reaction called a “biphasic” reaction. Most experts agree that 4 hours of observation is reasonable, although occasionally a “biphasic” reaction can occur later than 4 hours after the initial reaction.
7. The Expert Panel for the New Guidelines now suggests that ALL patients have TWO EpiPens or Auvi-Qs everywhere the child is at all times, since 20% of reactions can require a second dose, if the patient is getting worse again (biphasic reaction). So, you will be provided with a prescription for TWO EpiPen or Auvi-Q “two packs” which contains two injectable pens each and a demonstration device to practice on yourself and others. There are two reasons why two EpiPens or Auvi-Qs are necessary: 1) because if the child is getting worse despite the first injection while waiting for the EMTs to arrive, a second dose should be administered within 5 to 15 minutes and 2) any mechanical device could malfunction, so a second dose should always be available.
8. The organization Food Allergy Research and Education (www.fare.org) is one of the best organizations for further education and support. Their information sheet on “How to read food labels” will be given to you today.  Another excellent organization to check out is the Allergy and Asthma Network (www.allergyasthmanetwork.org). Also, the best local area patient/parent support group is the “Gateway Feast” on Facebook.
9. In general, it is safest for homes where a child has a food allergy NOT to have that food in the home at all due to the potential for accidental ingestion.
10. For young children in preschool and elementary school, sitting at a peanut, nut, milk or egg free table for lunch is the safest way to prevent accidental ingestion.

TREE NUT ALLERGY

1. If your child is allergic to even one of the “tree nuts,” it is safest to avoid ALL tree nuts. This is mostly due to the fact that tree nut packaging plants’ conveyor belts cross-contaminate, making other tree nuts unsafe, too.
2. Although there has been some controversy for patients with tree nut allergy as to whether or not to avoid coconut, in the last few years it has been reclassified the “fruit of the palm tree.” Coconut is not frequently cross-contaminated since they do not go along tree nut conveyor belts.
3. Tree nut allergy is not commonly “outgrown,” but could be retested in our office in a few years to check on this. About 20% of those with tree nut allergy can become allergic to peanuts and vice versa.

PEANUT ALLERGY

1. Peanut allergy is probably the most serious of the food allergies in children in general. Any home in which the patient spends time should ideally be “PEANUT FREE,” so that the child cannot climb up and get to it accidentally.
2. Sunbutter (made from sunflower seeds, now available in many groceries) can be a substitute for other siblings or for peanut allergic children if you are careful to make sure they understand the difference between the Sunbutter YOU give them vs. the look-alike, true peanut butter.
3. There is an epidemic of peanut allergy in the U.S. in the last decade and NO ONE knows the reason(s) for this. Although peanut allergy does not commonly run in families, a family history of allergies or asthma in parents is common.
4. Peanut allergies are not commonly outgrown (only approximately 15 to 20% of patients). Retesting in our office in a year or two may be done.
5. Although the peanut is in the “legume family,” it is uncommon for children in the U.S. to be allergic to other legumes such as peas, soy, or beans.
6. For those children with peanut allergy, the FARE organization has stated that their experts feel that it would be very rare for a peanut allergic child to have a reaction to commercially available peanut oil, since it is 99.99% fat with no significant protein. Protein is what causes allergic reactions, not fat. However, some parents are more comfortable just avoiding peanut oil.
7. Although about 80% of patients with tree nut and peanut allergies never outgrow them, retesting may be considered a few years from now.

MILK AND EGG ALLERGY

1. For those children who are allergic to milk or eggs, about 70% of them can ingest foods “baked” with one or more of these ingredients without any reaction. However, they cannot drink cow’s milk directly or eat scrambled eggs. Diluting out the allergic protein in a baked goods recipe and heating at 400° for an extended time may alter the allergenic protein and make it safe for some, but not all patients. Research has shown that children who CAN tolerate baked goods and eat them regularly are more likely to outgrow their food allergy completely, and sooner. However, no skin test or blood test can prove which children are likely to tolerate baked egg or baked milk. One must still be cautious when ingesting foods to which the patient is allergic. Discuss your individual case with your doctor.
2. Lactose free milk (Lactaid) is NOT safe for patients with milk allergy as it contains casein (cow’s milk protein).
3. Egg beaters or “egg substitutes” usually contain egg white protein (most commonly ovalbumin, the most allergic protein in eggs), but just not egg yolk for those with cholesterol problems. Avoid these substitutes.
4. Flu vaccines contain such a minimal amount of egg protein these days that it is no longer a reason to avoid getting the flu shot. Ask your doctor if there is any question first.

EPI PEN & AUVI-Q:

1. Parents should set their smart phone alarms to practice using the EpiPen or Auvi-Q demonstration device once per month so that in an emergency, they will react quickly and with confidence. Make certain that teachers, sitters and grandparents practice it too, and review the Food Allergy Action Plan so that everyone will know how and when to use it.
2. EpiPens or Auvi-Qs should be stored at room temperature and NOT in a car, where the temperature can get extremely hot or cold (and freeze the medication).
3. If you find that the medication looks cloudy, show your doctor and do not use it. It can be safely disposed of at your physician’s office along with any expired EpiPens or Auvi-Qs.
4. We are often asked if a patient needs to be given an EpiPen or Auvi-Q, and it is discovered that the EpiPen or Auvi-Q has expired and is the only thing available, will it still work? Although no one has studied potency of expired EpiPens or Auvi-Qs, it would be better to give the injection rather than nothing, and then call 911 immediately.
5. If the child’s symptoms are getting worse despite one EpiPen or Auvi-Q injection and a second EpiPen or Auvi-Q injection is necessary, it makes more sense to use the opposite leg due to localized blood vessel constriction at the site of the first shot, and would likely be less painful as well.
6. Use an expired EpiPen or Auvi-Q on a grapefruit or large orange. There is more of a kickback with the real device compared to the demonstration device. Parents have told us that practicing the actual expired EpiPen into a piece of fruit gave them the confidence to use one when they needed to!
7. Register your EpiPen/Jr at myepipen.com and you will be notified when they are due to expire.

PEANUT IMMUNOTHERAPY (DESENSITIZATION):

1. Although there is no current FDA-approved cure for food allergies, there are many ongoing research studies by different methods attempting to desensitize patients (make them less allergic) to their food allergen.
2. A standardized peanut powder called Palforiza was approved by the FDA in late February 2020 to be used to attempt to reduce the level of allergic sensitivity for patients between the ages of 4 and 17 years of age who are allergic to peanut protein who wish to go through the FDA protocol. This is the first ever FDA approved oral immunotherapy (also called OIT) for food allergies.
3. Palforiza is done initially in the allergist’s office by having the patient ingest gradually-increasing doses of their food allergen until they either reach a predetermined amount of the food successfully without an allergic reaction, or they have an allergic reaction and have to stop ingesting the food, requiring an injection of epinephrine in over 10% of patients. The protocol requires that Palforiza is given and increased gradually over a 2-3-hour office visit to the allergist’s office every two weeks for 11 different visits (approximately 5 months). If they are successful after the 5-month protocol, they are required to continue ingesting Palforiza indefinitely, every day, to reduce the level of allergic sensitivity. If the patient is successful in completing all visits, by the end of the 5-month protocol, an accidental ingestion of one peanut is not likely to cause any serious reaction in approximately 70-80% of patients, but not 100%. If the patient stops ingesting it for any reason (stomach virus, etc.) for too many days, they could have to go through the protocol for OIT again in the allergist’s office.
   1. POSSIBLE SIDE EFFECTS: Studies on OIT have reported up to 20% of patients reporting frequent heartburn, GERD or reflux (esophagitis), or stomach problems from ingesting their food allergen daily and some studies have reported patients needing to start acid reflux medications such as Prilosec or Nexium daily, as well as needing biopsies of the esophagus showing allergic cells throughout the esophagus (Eosinophilic Esophagitis). Although Palforiza has been approved by the FDA, this office has not yet begun using their protocol during the COVID-19 pandemic.
4. The Palforiza protocol will require that the allergist and the patient/parent complete a FDA approved “Risk Evaluation and Mitigation Strategy” training prior to the first dose. Cost will depend upon each insurance plan but estimates by The Medical Letter are over $10,000 per year. If you are interested in this, please discuss this with your allergist.
5. Another promising treatment not yet FDA approved is the so-called “peanut patch.” It is like a small circular Band-Aid with a tiny dose of peanut protein that is absorbed into the skin by changing a new one every night on the patient’s back. Studies so far have shown that after one year of changing the patch nightly, patients who had a reaction to a bite of peanut butter previously, had significantly less after re-challenge to one bite of peanut butter. Whereas Palforiza may protect patients who tolerate it within 5 months, the peanut patch can take up to one year to be protective. The major side effect is a rash at the site of the patch, but typically it gradually becomes less as the patient gets desensitized.

1. Bronchodilator
2. Combination Inhalers
3. Eczema Handout
4. Environmental Control
5. Immunotherapy Info & Consent 2020
6. Inhaled Steroids
7. Pulmicort Respules