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Dr. Turck:
This is Clinicians Roundtable on ReachMD, and I'm Dr. Charles Turck. Joining me to discuss strategies for diagnosing and treating allergies associated with house dust mites, grass, and ragweed in pediatric patients is Dr. Brian McDonough. He's a Clinical Professor of Family Medicine at Temple University School of Medicine and the Chairman of the Department of Family Medicine at St. Francis Hospital in Wilmington, Delaware. Dr. McDonough, welcome to the program.

Dr. McDonough: 
Oh, it's great to be here. Thanks for having me.

Dr. Turck: 
Well, so jumping right in, Dr. McDonough, from your vantage point, why might clinicians not feel fully equipped to properly diagnose pediatric allergies that are related to dust mites, grass, or ragweed?

Dr. McDonough: 
Oh my gosh, there's so many reasons. But the first is a child comes in, and they’re in the office and you're looking at so many different aspects of their care. I mean, you're worrying about, okay, they've got some symptoms, is this viral? Is it allergic? Is there a bacterial infection? And then, in many cases, it’s hard to get a good history. So what we tend to do is we rely on mom or dad or the caregiver and say, ‘Hey what's going on? What's been happening?’ And it really is history dependent. In other words, there's nothing that's going to usually jump out at you and say there's dust mites in the home or ragweed or allergies. You might know the time of year or the particular area or those things, but there's nothing really that stands out. So your first barrier is probably what is going on? Am I even thinking of it? So if I was going to say that when I'm seeing a patient, do I even think of it? Is it top of mind? And the thing we have to all do that I think probably is the most important thing is think about it.

And then the second thing is really take time to get a good history. Now as you know, the problem right now we have is so many physicians and healthcare providers are trying to see a certain number of patients in a limited amount of time, the history takes a great deal of time. So there's two ways, I think, around it when you're looking at it; one is to ask the questions. But also, if you have electronic medical record, maybe you have those things built in so that the patient may actually look at something like allergies, dust and those things built into your EMR. So it makes you think about it.

So that, I would say is the biggest barrier. It's thinking of it, recognizing it, and then saying, ‘Oh, that's in my differential.’

Dr. Turck: 
And as a follow-up to that, what can happen when we have a pediatric patient with undiagnosed or poorly managed allergies? Would you outline the range of some potential complications?

Dr. McDonough: 
Sure. First thing you think of is just the fact that it'll make a child irritable, uncomfortable, which as a parent, makes everybody else in the house irritable and uncomfortable because they just don't feel well. The second thing is you start to wonder is there something else going on? Are you almost setting up the child to be in a sick role, ‘Oh, this is my child who always has this or that.’ But then you start thinking about more serious things. They're rubbing their eyes, they're rubbing their nose, they’re at increased chance of introducing bacteria and causing some other infection on top of the allergy. We see people with uncontrolled allergies that end up actually over time, developing asthma. We don't know necessarily whether the asthma is a result or something on a path or they're just more predisposed to have asthma. But we definitely see respiratory issues that can occur when things are not controlled.

And then finally, and this might be the most important thing, the child doesn't feel comfortable, so they're not sleeping well. They don't get the right sleep, they may not be eating well; if they're of school age, they go to school, but they hadn't slept well the night before, so they may be acting out a little more in school. It's just a cycle that can develop. So something as simple as an allergen that is bothering you from the environment can really cause a downward spiral.

Dr. Turck: 
For those just joining us, you're listening to Clinicians Roundtable on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Brian McDonough about the importance of properly diagnosing and managing pediatric allergies related to house dust mites, grass, and ragweed. So, Dr. McDonough, now that we have a better understanding of the complications that may arise from poorly controlled allergies, let's take a closer look at strategies for effective management. First, how can pediatricians detect allergies associated with dust mites, grass, and ragweed earlier?

Dr. McDonough: 
Well, the first thing is to think about it and to ask those critical questions in the history. So you might literally point out in your home, are things dusty? Do you have pets? What is it like in the environment?’

Sometimes what we suggest, if we can do it, is a home visit. And if you can't do your own home visit, you have someone go out to the home, you might have a nurse practitioner or someone who works with you go out to the home and look at it, if we see that’s an issue. You also think of what time of the year you're in. Is it Spring? Is it Fall? Do the problems occur right after the lawn is mowed or when the windows are open? And you start to really dial in on those questions. I think that's the big thing because otherwise, there's really nothing. I mean, there's some things but there isn't much about allergies that will tell you what the precipitating factor is, you just know the symptoms. I mean, you can recognize them and say, ‘Oh boy, itchy eyes, runny nose, the child's having this and that going on, okay, it's allergies.’ But as far as the cause, before we get to any testing or whatever, that would be what we'd be looking at, the history. And most pediatricians, most family doctors probably only have to take it to that point if it's something that's not long lasting or chronic, they just say, ‘Okay, what's going on? Maybe we can address it.’ And hopefully, over a period of time, with some mild symptomatic treatment, it can go away.

Dr. Turck: 
And after you've properly diagnosed these allergies, would you share some best practices for optimizing patient care?

Dr. McDonough: 
Well, I think the very first thing you do is you educate the patient in this case with the child, the parents, or the parent and the caregiver, and you tell them, ‘This is what we need to do.’ So for instance, let's use the example, it's dust mites. Well, they're very sensitive; dust mites are very sensitive to extreme heat. So what you would want to do, let's say the child's bedroom is you want to wash the sheets. Is there a carpet? Can you create a allergy-free environment to the best you can. I mean, people who have severe problems, we've done this with adults, they literally have hardwood floors, they take things out of the room that might be dust collectors, and they kind of create what I would call a dust-free haven where they can escape. And there are ways to do that with the air ionizers and those sorts of things without getting too expensive. It's your typical family in there, trying to get through the you know, the week. What you can do, though, is the simple things, which is try to get dust collectors and things like that out of the room. I often give the same analogy as when you talk to people about sleep hygiene, like you can tell them things they can do, and it gives them control. That's important.

The next step, of course, is there are over-the-counter products. And many of the over-the-counter antihistamines now are actually quite good in that they don't have the sedative effect like the ones that maybe generations ago had to use, and it's not going to make them fatigued at school or whatever. And then, of course, ultimately, if you have to you can get an allergist to see a child or if it's something that some people do in their practice is a skin test or a blood test to try to seewhat is necessarily going on and if they need to have a longer form of treatment.

Dr. Turck: 
Now education is another important aspect of allergy management. So how do you typically approach talking to patients and caregivers about their children's allergies?

Dr. McDonough: 
Well, I think the most important thing is to take time to do it. So what may happen is they're coming in on a regular visit, and it's a bang, bang, bang sort of a day, what you can do is you can either set up another appointment or set up a call. And personally, this is where I really like telehealth; it's one of those opportunities where, in the past, we might have called somebody on the phone, but you can actually now set up a telehealth visit designed specifically to talk to the caregiver in the family environment. And in fact, they can even give you a sense of what it's like. I mean, we can always look over each other's shoulder and see what the backgrounds are in our interviews and stuff. Well, you could ask if it's not too invasive, you say, ‘Hey, can we take a look at the house and see?’ You'll notice clutter or you'll notice other things potentially that can be helpful. So you can get a lot out of that.

I think you need the time to discuss it. And that's where you zero in on specific questions. And literally what is it that makes your child sneeze or have itchy eyes? What have they been doing? They can create a log. That's something we traditionally do in a lot of ways, write down when something happens and why. Or are there specific days it's worse than others? And usually what happens with children as they get older is parents even know, ‘Oh, it's that time of year, here we go.’ And you have a track record where you’ve seen it before. Or just, we in the clinic, will have seen four or five children with similar issues and it doesn't take you a long time to realize, ‘Oh, we're in allergy season,’ if that's the case.

So that's some of the tools that can be helpful. It's again, and I keep saying it and it sounds so obvious but it's so hard to do, keep those antennae up so that you're aware and you're thinking of it.

Dr. Turck: 
Now before we end our discussion today, Dr. McDonough, do you have any closing thoughts on diagnosing and treating dust mite, grass, and ragweed allergies in pediatric patients?

Dr. McDonough: 
I think the thing we know is they're always going to be with us, they're not going anywhere. My entire career, we're always going to lose to them, but we can control it. And I think that's the thing; you want to control it and get the child through that because like I said earlier, it can begin a downward spiral that we want to prevent and do everything we can to try to minimize the irritation or the damage. Because I guess the only other thing I did want to add is parents also may have suffered the same way because sometimes these are running in families. So it may be mom or another child or something, there's a couple that have it because a dusty house is a dusty house and a sensitivity is a sensitivity. So it doesn't mean everybody's going to have it. And certainly, you can have a unique outlier. But often things run in families, and we see it as a repeated pattern. So that's another thing that can help in the diagnosis. It all comes down as much as we can, spending the time talking to your patients. Patients will tell you what's wrong with them, and then you go, ‘Oh, you have this,’ based on the fact they told you. And in the case of allergies, that's really true.

Dr. Turck:
Those are some great comments for us to consider as we round out today's program. And I want to thank my guest, Dr. Brian McDonough, for joining me to discuss how we can take a more comprehensive approach to managing allergies related to house dust mites, grass, and ragweed in our pediatric patients. Dr. McDonough, it was great having you on the program.

Dr. McDonough: 
Thank you very much. It was great chatting with you.

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