Environmental Allergies

Definition

  • Substances that you breathe in or come into contact on an every day basis. These can trigger a release of histamine and other inflammatory chemicals leading to allergy symptoms in nose, sinuses, eyes, skin, and lungs/airways. 

  • Common triggers

    • pollen

    • mold

    • pets

    • dust mites

    • cockroaches

    • mice

    • dust mites

  • Allergic (atopic) March: Describes natural progression of allergic diseases from infancy to adulthood. These may occur at different times in life depending on exposure. 

Group

Common Issues

Infants

 Dry skin, skin irritation such as eczema/ atopic dermatitis 

Infants / Toddlers

Food Allergies 

Top: peanut, tree nut (almonds, walnuts, pecans), cow's milk, egg, wheat, soy, fish, shellfish, sesame

Toddlers / Kids 

Season & environmental allergies, influding allergic rhinitis 

Kids / Teens

Breathing issues due to allergies such as asthma 

Common Conditions 

  • Seasonal Allergic Rhinitis (SAR)

    • Triggered by outdoor aeroallergens (tree, grass, weed pollens).

    • Symptoms are predictable and correspond to local pollen counts.

  • Perennial Allergic Rhinitis (PAR)

    • Year-round symptoms typically driven by indoor allergens (dust mites, mold, animal dander, cockroaches).

Treatment & Management 

  • Identify and avoid the allergen 

    • Skin Prick Testing to evaluate allergen 

    • Blood Serum Testing (May have false positives) 

  • Common Medications 

Medication

Dosing

Information

Cetirizine (Zyrtec)

6 months to 2 years: 2.5 mg daily

2 to 5 years: 2.5 to 5 mg daily

>5 years: 5 to 10 mg daily

Second generation antihistamine used to treat seasonal and perennial allergic rhinitis, and chronic urticaria. Onset of action is 15 - 30 minutes. 

Common Side Effects: Dry mouth, sedation at higher than recommended doses.

Fexofenadine (Allegra) 

<10.5 kg: 15 mg twice per day

>10.5 kg: 30 mg twice per day OR

6 mos to 2 years: 15 mg twice a day (urticaria)

2 to 11 years: 30 mg twice per day 

>12 years: 60 mg twice per day or 180 mg daily

Second generation antihistamine used to treat allergic rhinitis and chronic urticaria. Onset of action is 15 - 30 minutes. 

Common Side Effects: Dry mouth, sedation at higher than recommended doses.

Levocetirizine (Xyzal)

6 months to 5 years: 1.25 mg daily

6 to 11 years: 2.5 mg daily

>12 years: 2.5 to 5 mg daily

Second generation antihistamine used to treat seasonal and perennial allergic rhinitis, and chronic urticaria. Onset of action is 15 - 30 minutes. 

Common Side Effects: Dry mouth, sedation at higher than recommended doses.

Loratadine (Claritin)

2 to 6 years: 5 mg daily

>6 years: 5 mg twice daily or 10 mg daily

Second generation antihistamine used to treat allergic rhinitis and chronic urticaria. Onset of action is 15 - 30 minutes. 

Common Side Effects: Dry mouth, sedation at higher than recommended doses.

Azelastine (Astelin)

≥6 months to <6 years: 0.1% solution: 1 spray per nostril twice daily

6 to <12 years: 0.1% or 0.15% solution: 1 spray per nostril twice daily

≥12 years and Adolescents: 0.15% solution: 2 sprays per nostril twice daily

Intranasal antihistamine that blocks H1 receptors. Onset of action is 15 minutes. 

Common side effects: Bitter after taste, epistaxis, headaches, nasal irritation, sedation 

Fluticasone propionate (Flonase)

2 to 11 years: Intranasal: Initial: 1 spray per nostril once daily

≥12 years: Intranasal: Initial: 2 sprays per nostril once daily

Intranasal corticosteroid that decreases the influx of inflammatory cells and inhibit the release of cytokines. Onset of action is <30 min. 

Common Side Effects: bitter aftertaste, burning, epistaxis, headache, nasal dryness, throat irritation. 

Montelukast (Singulair)

12 - 23 mos of age: 4 mg oral granules (+asthma)

2-5 years: 4 mg oral tablet or granules 

6-14 years: 5 mg 

15 years +: 10 mg 

Leukotriene receptor antagonist that block leukotriene receptors. Onset of action is 2 hours. 

Common Side Effects: elevated levels of ALT, AST, and bilirubin. 

*Potential aggression, behavioral issues, suicidal ideation

  • Immunotherapy

    • Sublingual Tablets 

      • Grastek (Timothy Grass Pollen Allergen Extract) 
        • Approved for 5 - 65 year olds 
      • Odactra (Dust Mite Allergen Extract)
        • Approved for 5 - 65 year olds
      • Ragwitek (Ragweed Allergen Extract) 
        • Approved for 5-65 year olds
    • Subcutaneous Allergen Extracts (Allergy Shots) 

Clinical Pearls 

  • Bedroom Allergen Mitigation Checklist:

    • Wash bedding weekly in hot water (at least 130°F / 54°C) to kill dust mites.

    • Encase pillows and mattresses in certified allergen-impermeable zippered covers.

    • Keep humidity levels in the home below 50% to prevent mold growth and dust mite propagation.

    • Remove carpet from the child's bedroom if possible; vacuum remaining carpets with a HEPA-filter vacuum weekly.

  • The Nasal Saline Bridge:

    • Encourage a nasal saline rinse 10 to 15 minutes before administering nasal steroid sprays. This clears out mucus and physical allergens, allowing the medication to deposit directly on the nasal mucosa.

  • Climate change and extreme weather have been linked to worsening allergic and immunologic responses. 

Resources

SIG Member Publications