Treating Children With Seasonal Allergies

When pollen counts are running high adults aren’t the only ones that suffer. Children get seasonal allergies too. In this article we will go over the dos and don’ts of treating allergies in kids, drugs that are safe and effective, products that should be used sparingly, and which drugs should be skipped altogether.

Sections

Choosing a medication for seasonal allergies

Mild allergy symptoms

Allergy medications to avoid

Moderate and severe allergy symptoms

Overview of treatment options

References

Choosing a medication for seasonal allergies

Before we start talking about medications it’s really important to make sure you are in the right place. Children under 12 with allergy symptoms should be seen by a healthcare provider first to make sure the diagnosis of seasonal allergies (allergic rhinitis) is correct and to rule out other conditions like asthma. The recommendations below assume you have been given approval from your doctor to treat your child with over the counter products.

Children 12 and older are treated just like adults, but you can use any of the chewable or liquid products if swallowing tablets is an issue.

For product selection in adults and children 12 and older check out my in-depth review on seasonal allergies in adults.

With the preflight check out of the way we are ready to start talking about treatment.

Mild allergy symptoms (non-drowsy oral antihistamines)

For mild symptoms (sneezing, runny nose, etc.) non-drowsy oral antihistamines should be the first thing you try. There are four different active ingredients on the market: loratadine (Claritin), fexofenadine (Allegra), levocetirizine (Xyzal), and cetirizine (Zyrtec). Any of them will work, but I’ve listed them in the order in which I would recommend trying them, so start with loratadine first.

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Pharmacist Favorite

Most of these products come as either chewable tablets, dissolvable tablets, or in liquid form. You can shop around for various flavors, but you will find that grape and berry are the most common. I’ve compiled a chart you can use to compare options, flavor, and dosing.

Medication administration

Follow the package instructions on whatever product you choose. Most are dosed once daily, with the exception of Allegra (fexofenadine), which is dosed twice daily. If you end up using Allegra (fexofenadine) also make sure to avoid giving it with fruit juices. Juices like orange, apple, and grapefruit can reduce the effectiveness of Allegra.

You can give your child antihistamines daily throughout the allergy season or just during peak days.

What to expect

The non-drowsy antihistamines are very well tolerated and start working about an hour after you take them. One side effect to watch out for in your kids is headache. You can try switching medications if needed.

Even though these products are labeled as non-drowsy, drowsiness can still be a side effect in some people. It’s more common when using Zyrtec (cetirizine) and Xyzal (levocetirizine).

Allergy medications to avoid

Skip over any products that include any of the older antihistamines. Examples include things like Benadryl (diphenhydramine) and Dimetapp (brompheniramine). The first generation antihistamines require more frequent dosing, aren’t any more effective than non-drowsy products, and have more side effects. In adults we often warn of drowsiness, but in kids it can go either way. Many kids get drowsy, but some get hyperactive and irritable.

Another group of allergy medicines to avoid are combination products that contain the active ingredient phenylephrine. Phenylephrine has been marketed for years as a nasal decongestant, but isn’t very effective at doses used in over the counter products.

Moderate and severe allergies (nasal steroid and/or oral antihistamine)

For moderate or severe allergies nasal steroids are the preferred choice, but there are some important points to consider.

• Smaller children will need help administering a nasal spray and may be frightened or resistant to putting medication in their nose. The spray itself can cause brief stinging, sneezing, or discomfort.

• The packaging for all steroid nasal sprays includes a warning about the potential risk for decreased growth rate in some children.²

The package warning sounds scary, but the risk of decreased growth rate is fairly small if you use the product as directed on the packaging.

Use nasal steroids for the shortest duration possible to relieve symptoms. Daily use during the allergy season is fine, but if you find your child continues to need a nasal steroid after 2 months consult with your doctor. Also don’t use more medication than what’s given in the directions for the age of your child. Using more won’t be more effective and will only increase the risk of systemic side effects.

All of the steroid nasal sprays seem to work equally well at treating allergy symptoms, but there are data that suggest Nasonex (mometasone furoate), Flonase Sensimist (fluticasone furoate), and Flonase (fluticasone propionate), are least likely to cause a decrease in growth rate.³ Nasonex (mometasone furoate) can be used safely in children as young as two and has the easiest dosing, so it’s my preferred choice.

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Medication administration

As the parent you will likely need to help administer the nasal spray, but older kids should be monitored as well to make sure they are using the correct technique. Follow the directions as written on the package and read my administration tips below. Proper technique is important to avoid the risk of injuring the sensitive tissues in the nose and to make sure the medication gets where it needs to go.

What to expect

Nasal steroids take a few days to start seeing symptom improvement and up to a few weeks for maximum benefit, so give it time and make sure your child is using it daily. After two to three weeks of daily use if your child still has symptoms you can add on a non-drowsy antihistamine see mild allergies above. This combination of products is safe and can help in severe cases.

Steroids have a very bitter taste to them. If any of the medication runs down the back of your child’s throat and they complain of a bad taste in their mouth be assured this is normal and not something to worry about.

Side effects from nasal steroids are generally mild. The medication itself can cause you to sneeze or may sting when it’s first put into the nose.

Nose bleeds are more common when using a nasal steroid. If your child has frequent nosebleeds while using a steroid nasal spray stop using it and schedule an appointment to have your child seen.

Non-steroid nasal sprays

If you are hesitant to use a nasal steroid or need to try something else there are a few options.

Astepro (azelastine) is an antihistamine nasal spray that is effective at controlling allergy symptoms and can be used in children that are 6 and older. It can also used as an add-on for nasal congestion that’s not relieved by oral antihistamines or nasal steroids.

NasalCrom (cromolyn) is another option that can be used in children as young as 2, but there are a few things to keep in mind. NasalCrom has to be given 3-6 times per day, it works best when started before the allergy season starts, and like nasal steroids can take weeks to get the maximum benefit. It’s not very practical for kids in school and takes a long time to work, so I don’t often recommend it.

Overview of Treatment Options

Oral antihistamines

Notes:

• Claritin (loratadine) and Zyrtec (cetirizine) offer chewable products in multiple strengths. Be sure to pick a product that has dosing listed for the age of your child.

• If your child falls into the ‘ask your doctor’ section and you have already been instructed to use one of these products your local pharmacist should be able to look up a dose for you based on your child’s weight.

Nasal Sprays

Administration Technique

There are a few things you need to know about how to administer nasal sprays to get maximum benefit and reduce the risk of injuring the sensitive tissues in the nose.^{4, 5} Parents: You can use the steps below to administer a nasal spray to your child or guide an older child through the process. When helping with administration be sure to position yourself so that you are at eye-level with your child. This will help ensure the placement and angle of the sprayer are correct.

1. Start by gently blowing your nose to clear out any mucus. The medication needs to contact and get absorbed by the tissues in your nose.

2. Shake and/or prime the sprayer if needed. Steroid nasal sprays should be shaken vigorously to make sure the medication is uniform and well mixed. The first time you use your sprayer you will need to prime it, which just means spray into the air till you get a nice mist.

3. Position your nose in line with your toes. Your head should be neutral. Not tilted back or tucked in.

4. Always spray the nostril opposite from the hand holding the sprayer. (left hand sprays right nostril, right hand sprays left nostril) The goal is to point the tip of the sprayer away from the center of your nose and slightly towards your ear.

5. Sniff not snort. A gentle sniff as you depress the sprayer or just after is what we are looking for.

Steroid Nasal Sprays

Non-steroid Nasal Sprays

References