• Physical and chemical irritants
• Viral or bacterial infection

• Recurrent upper respiratory tract infections
• Rhinitis medicamentosum
• Drugs that cause nasal congestion
  • Oral contraceptives
  • Reserpine
  • Guanethidine
  • Propranolol
  • Thioridazine
  • Tricyclic antidepressants
  • Aspirin
• Airway irritants
  • Smoke
  • Environmental pollution
  • Cold air
• Kartagener syndrome
• Cystic fibrosis
• Sinusitis

• Intrinsic asthma
• Airway irritants
  • Smoke
  • Environmental pollution
  • Cold air
• Gastroesophageal reflux
• Foreign body aspiration
• Anatomic defect in airway
• Cystic Fibrosis
• Kartagener syndrome
• Immune deficiency

• Viral exanthams
• Autoimmune disorders
• Physical and chemical irritants

• Otitis
• Myringotomy Tubes
• Hearing Loss

• Frequent URIs
• Sinusitis
• Polyps
• Epistaxis
• Snoring
• Sneezing
• Rhinitis
• Deviated septum
• Obstruction
• Itch
• Mouth breathing
• Nasal discharge

• Sore throat
• Throat clearing
• Postnasal drip
• Palate itch
• Tonsillitis
• Tonsillectomy
• Croup

• Day cough
• Night cough
• Sputum production
• Pain
• Wheeze
• Shortness of breath
• Cyanosis

• Itching
• Tearing
• Discharge
• Swelling
• Redness
• Rubbing

• Anorexia
• Nausea
• Vomiting
• Diarrhea
• Constipation
• Gas
• Belching
• Abdominal pain
• Fatty or foul-smelling stools

• Eczema
• Hives
• Angioedema
• Contact dermatitis
• Seborrheic dermatitis
• Skin infections
• Pruritis

• Dysuria
• Burning
• Polyuria
• Hematuria
• Enuresis

• Location
• Character
• Frequency
• Duration
• Nausea
• Vomiting
• Scotomata

Other important questions include:

Question: Does your child have food or drug allergies?
Significance: Be sure to ask what type of reaction the child had (many types of intolerances are called allergies by parents). Generally, allergies are IgE mediated reactions resulting in wheezing, allergic rhinitis, hives, angioedema, eczema, or anaphylaxis. Intolerances generally include a non-specific rash, diarrhea, gas, headache, or hyperactivity. Specifically ask about peanut, nut, and shellfish allergy (allergy to any of these is an indication for an EpiPen (Center Labs, Port Washington, NY), and life-long avoidance).

Question: Has your child ever been stung by a bee, and, if so, what was the reaction?
Significance: Systemic reactions are an indication for referral to an allergist for venom desensitization. Venom desensitization can be potentially lifesaving. Ask the parent if they know the type of bee involved with the reaction. (Honey bees are the only bees that leave their stinger at the sting site.)

Question: Does anyone in your family have hayfever (allergic rhinitis), asthma, or eczema?
Significance: Familial history of atopy increases the likelihood of atopy in other family members.

Questions to ask regarding the environment:

Question: Do you have a basement?
Significance: Damp basements are a source of mold spores.

Question: Are there any damp areas in your home?
Significance: Damp areas serve to propagate mold growth in the home.

Question: Do you have forced air or radiator heat?
Significance: Forced air heat tends to blow allergen laden dust around the home.

Question: How do you cool your home?
Significance: Opening outside windows lets the pollens from outside into the house.

Question: Do you have a humidifier?
Significance: Molds can grow in the water, and increased ambient humidity will raise the dust mite population in the home.

Question: Are there any smokers in the home?
Significance: Cigarette smoke is an airway irritant and can exacerbate respiratory difficulties.

Question: Are there any pets in the home, at school, or in daycare?
Significance: Animal dander is a common aeroallergen. Pets should be excluded from the bedroom (a pet that sleeps on the patient's bed is a common problem).

Question: Are there many stuffed animals or books in the bedroom?
Significance: Dust mites love these dust collectors, and they should be removed from the bedroom. Environmental control efforts should be focused on the bedroom. Patients can have significant allergen exposure during sleep.

Question: Does the bedroom have carpeting?
Significance: Hardwood or tile floors are best to keep the dust mite population under control.

Question: How often do you wash the bedding, what type of pillow do you have, and is the mattress encased in plastic?
Significance: To keep the dust mite population under control the bedding should be washed in hot water at least once every two weeks (hot water kills dust mites), the pillow should be fiber filled, and the mattress should be encased in plastic.

Question: Where does the patient spend most of his time?
Significance: Allergenic exposure where most of the patient's time is spent is most important.

Question: Does the patient attend daycare?
Significance: Daycare is a major source of upper respiratory tract infections, which can mimic allergies and exacerbate reactive airway disease.

Finding: Ocular allergic signs
Significance:

• Allergic shiners are due to passive congestion in the nose, which impedes the venous return to the vessels under the eyes.
• Cobblestoning of the conjunctiva is associated with allergic conjunctivitis.
• Dennie sign (Morgan line), infraorbital folds associated with suborbital edema secondary to atopy.
• Clear stringy discharge is the characteristic eye discharge seen in allergic conjunctivitis.

Finding: Nasal allergic signs
Significance:

• Pale edematous nasal mucosa is characteristic of allergic rhinitis.
• Nasal crease across the bridge of nose is secondary to repeated upward rubbing of the nose.
• Clear nasal discharge with or without occlusion is characteristic of allergic rhinitis.

Finding: Ears allergic signs
Significance: Fluid in the middle ear, or retracted tympanic membranes may be associated with eustachian tube dysfunction seen with allergic inflammation.

Finding: Throat allergic signs
Significance: Cobblestoning of posterior pharynx secondary to submucosal lymphoid hyperplasia can be seen in allergic patients.

Finding: Lungs allergic signs
Significance: Wheezes, rhonchi, decreased air entry, and chronic obstruction can be secondary to allergic responses.

Finding: Skin allergic signs
Significance: Eczema, hives, angioedema, and dermatographism are all characteristic of allergic skin.

Test: Immediate hypersensitivity
Significance:

• Skin prick tests to suspected allergens based on history. These are the study of choice because of their low cost, high sensitivity, rapid results, and documented excellent correlation with clinical sensitivity especially to pollens and animal dander.
• Intradermal skin tests are reserved for patients who have a negative prick test and a suspicious history. This study is more sensitive than prick tests, but less specific and they pose a greater risk of systemic reactions.
• RAST tests (Radioallergosorbent tests) measures free serum IgE to a specific antigen to which a particular patient may be sensitized. These tests are primarily reserved for patients at risk for a severe systemic reaction from skin testing (i.e., Latex allergic patients), or in patients in whom skin testing is not feasible (i.e., patients with extensive skin disease). These tests are less sensitive than skin prick and intradermal tests.
• Serum IgE levels have a low sensitivity and, generally, are of little help.
• Presence of blood eosinophilia. Eosinophils in the blood or respiratory secretions may be indicative of an allergic diathesis.

Test: Baseline laboratory
Significance: Baseline pulmonary function studies should be obtained on asthmatic children.

• Subcutaneous Epinephrine 1:1000
• Diphenhydramine
• Ranitidine
• Methylyprednisolone
• Volume expander to correct hypotension

• Oxygen
• Inhaled B-agonist
• Subcutaneous Epinephrine 1:1000
• Steroids

Q: Do children outgrow allergies?
A: No. Actually, once a patient is sensitized they are sensitized for life. In addition, the older the patient becomes the greater the chance to develop other sensitivities.

Q: Can allergic children acquire more allergies?
A: Allergic children have the biologic potential to become sensitized to many environmental allergens. The goal should be to limit exposure to these antigens to prevent sensitization.

Q: If a parent is allergic to a specific allergen can the child inherit this allergy?
A: Children inherit the tendency to be allergic, but they do not inherit specific allergies.

Q: What treatments are available?
A: Specific environmental control (as determined by skin testing), antihistamines, topical steroids, and immunotherapy.

• Patient failing medical management of upper respiratory or ocular allergies with routine antihistamine/decongestant medications. The allergist can help identify triggers contributing to the allergic symptomatology.
• Poorly controlled asthma not responding to intermittent inhaled B-agonists or an asthmatic who is symptomatic between exacerbations, or one that has an atypical pattern of exacerbations.
• Asthmatics with frequent hospitalizations or steroid-dependent asthmatics should also be referred.
• Patients who miss school frequently due to allergic or asthmatic symptoms.
• Patients with limited activities due to allergies or asthma.
• Strong seasonal history to respiratory complaints
• Systemic reaction to bee sting
• Difficult to manage eczema (atopic dermatitis)
• Recurrent croup
• Food allergy
• History of anaphylaxis
• Egg allergic patient who require Influenza vaccine
• Drug allergy
• Latex allergy