Pediatric emergency medicine trisk 1690 1690
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antihistamines ( Table 85.3 ). First-generation antihistamines (e.g.,
diphenhydramine, hydroxyzine) are no longer considered first-line therapies
because they have shorter half-lives and are more likely to cause CNS depression.
Antihistamines reduce rhinorrhea, pruritus, and coughing associated with allergic
rhinitis. Combination oral antihistamine–decongestant preparations are available
for children ≥12 years and adults, but are primarily appropriate for short intervals
as rescue therapy. Topical antihistamines such as azelastine can also provide
symptomatic relief to children and adults with intermittent allergic rhinitis, but
may have a bitter aftertaste and are considered second-line therapy. Other
nonpharmacologic measures such as saline nasal rinses may provide symptomatic
relief.
There is evidence supporting the use of montelukast in the management of
persistent allergic rhinitis in preschool children, seasonal allergic rhinitis in older
children and adolescents, and in the management of allergic rhinitis in patients
with asthma already using inhaled corticosteroids. Although there is little
evidence to support allergen avoidance for indoor allergens, it is logical to limit
exposures when possible in patients with significant allergic rhinoconjunctivitis,
especially during pollen seasons. Children with significant ocular symptoms may
also benefit from local ophthalmic treatment (see Table 123.2 ).
While there is a paucity of evidence to guide pharmacologic treatment of
allergic rhinitis in children, there is moderate evidence supporting subcutaneous
immunotherapy in the long-term management of allergic rhinitis in children and
adults. Sublingual and oral immunotherapy as well as treatment with omalizumab
may be used in select patients, although use in pediatrics is still under
investigation.
Suggested Readings and Key References
Anaphylaxis
Alqurashi W, Stiell I, Chan K, et al. Epidemiology and clinical predictors of
biphasic reactions in children with anaphylaxis. Ann Allergy Asthma Immunol
2015;115:217–223.
Brown SG, Stone SF, Fatovich DM, et al. Anaphylaxis: clinical patterns, mediator
release, and severity. J Allergy Clin Immunol 2013; 132:1141–1149.
Campbell RL, Li JT, Nicklas RA, et al. Emergency department diagnosis and
treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol
2014;113:599–608.
