TOW #43: Seasonal allergies

May is designated National Asthma and Allergy Awareness Month. The pollen currently covering my car is definitely one indication it’s spring and allergy season! Indeed, many among us are suffering from the season’s blooms.

Materials for this week:

Here are take-home points about evaluating stuffy nose/allergic rhinitis:

  1. How many people are affected by allergic rhinitis? Allergic rhinitis (AR) is considered among the most common chronic diseases in children, with a prevalence of up to 40%. As with other atopic disease, prevalence of AR has increased rapidly in the past 30 years. Children who have one form of atopy (allergic rhinitis, asthma, eczema) have a 3x greater risk of developing a second. The mean age of onset in one study was 10 years; by 6 years, 42% had been diagnosed with AR.
  2. What is the clinical definition or AR? Rhinitis is defined as “Inflammation of the membrane lining the nose, characterized by nasal congestion, rhinorrhea, sneezing, itching of the nose and/or postnasal drainage.” AR is a hypersensitivity reaction to allergens due to IgE. Intermittent allergic rhinitis involves symptoms <4 days per week or for <4 weeks. Persistent symptoms occur >4 days per week for >4 weeks. It’s often tricky to evaluate relative to viral-induced symptoms, given there is so much frequency of both, but with AR, itching of nose and eyes is more prominent, rhinorrhea is clear.
  3. What do we see on physical exam? Nasal turbinates may appear edematous, with a pale to bluish hue. Cobblestoning from lymphoid hyperplasia may be seen on the posterior oropharynx. “Allergic shiners” are dark discolorations underneath the eyes due to venous engorgement and suborbital edema. Dennie-Morgan lines are folds under the eyes due to edema. The “allergic salute” is a transverse nasal crease in children who chronically push their palms upward under their noses (to wipe mucus)-(and they really happen – last year my daughter developed one of these!)
  4. What’s the appropriate work-up? You may decide to do skin testing to evaluate specific allergens and aid in environmental control strategies, such as for dust mites. Skin testing is preferred to blood testing, but is not 100% specific and requires clinical correlation with symptoms/triggers.
  5. How do we manage AR? Treatment options are allergen avoidance, pharmacotherapy, and immunotherapy (reserved for severe cases). Best medication class is intranasal steroids, which is approved for kids >2. Next best are non-sedating antihistamines (not as good at decreasing nasal congestion, specifically) or leukotriene receptor antagonists. Sometimes people develop tolerance to one group, so switching drugs can help. Decongestants are not recommended for young children due to side effects and rebound symptoms, and are only occasionally used in older children.

TOW #41: Hearing screening

This week’s topic is on hearing screening and common hearing disorders. I love the quote included in this week’s case discussion from Helen Keller: “Everything has its wonders, even darkness and silence, and I learn whatever state I am in, there in to be content.” Such a powerful reminder for us as we journey through whatever life brings.


Take-away points about hearing screening:

  1. How many children are affected by congenital hearing disorders? 1 to 3 per 1,000 well newborns and 2-4 of every 100 NICU patients are affected by hearing loss. Prior to mandated hearing screening (now in all 50 states), the average time of diagnosis for congenital hearing loss was as late as 14 months. We should pay close attention to any family history of hearing loss as there are strong genetic factors.
  2. What are the key timelines in early recognition? Early Hearing Detection and Intervention (EDHI) programs have created guidance to help us with early identification of children who are deaf and hearing-impaired. Early detection allows children to develop language skills and academic performance that is similar to their hearing 41peers. EDHI follows a 1-3-6 month guidance for screening, diagnosis, and intervention. By 1 month, we want all babies to have a hearing screen (this now happens in the hospital in most places, but if they need a 2nd screening, this should happen before 1 month). By 3 months, we want to confirm diagnosis. By 6 months, we want to intervene for the best outcomes.
  3. What are the types of hearing loss? There are conductive, sensorineural, mixed, and central types. Conductive hearing loss (CHL) is far more common in kids and results from problems in the mechanical transmission of sound through the external and middle ear-this is caused most often by congenital malformation of the ear structures or infections such as otitis media. Sensorineural hearing loss (SNHL) is a problem with the transmission of vibrations into neural impulses within the cochlea or down the vestibulo-cochlear nerve. SNHL causes include in utero infections (CMV, MMR-V, and syphilis are biggies), family history, severe hyperbilirubinemia, respiratory distress, prolonged mechanical ventilation, as well as childhood infections or trauma.
  4. What are the types of newborn hearing screening? Otoacoustic emissions (OAE) and auditory brainstem response (ABR) [also known as brainstem auditory evoked response (BAER)] are the most common newborn hearing tests. OAE tests the reflex response of the hair cell in the cochlea to sound and detects hearing loss up to and including cochlear function. ABR tests the auditory CNS response to sound and detects hearing loss through the entire conductive, sensory, and neural pathway. OAE is faster and is not affected by motion artifact, but is affected by debris in the canal and has a higher rate of referral than ABR. ABR/BAER is sensitive to motion artifact and requires the child be asleep when tested. False positives are common – only 2 to 7% of those who fail screening ultimately are found to have sensorineural hearing loss. After newborn age, we have a gap until age 4 when it can be difficult to detect hearing problems. Always refer for any language development issues.
  5. How do we interpret hearing tests? Hearing in the range of 0-15 dB is normal, 15-25 dB represents upper range of normal to minimal hearing loss, and 25-40 dB indicates mild hearing loss. We should refer if consistently at 25 dB or above on screening. When in doubt, refer to audiology!