As variants of SARS-CoV-2 continue to appear, much of the world has returned to somewhat normalcy. The school bells are ringing and children – some masked, some not – are learning again. All of this begs the question, “How will COVID-19 affect the fall allergy season, and are there new tools in the pediatrician’s arsenal?”
Stanley M. Fineman, MD, a pediatric immunologist at Atlanta Allergy and Asthma in Georgia and a spokesperson for the American College of Allergy, Asthma and Immunology, says the school season is always a struggle when kids get together and get allergies and the cold and flu season meet.
“Last year’s kids were socially distanced and most weren’t in school or wearing masks, so the number of upper respiratory infections dropped significantly,” Fineman said. Even some patients who normally had allergies to pollen reported fewer symptoms, possibly also due to masking, he added.
No one knows how bad the pollen season will be this fall, but kids with severe respiratory allergies will be in the same boat they’ve always been — with a higher risk of other respiratory infections, more asthma flare-ups, and more hospitalizations.
“Those are serious concerns we have,” Fineman said. “We just need to be extra careful and warn our patients. They need to know what their allergies are, and you should get a skin test if you’re at risk.”
Skin testing is the best way to pinpoint allergens, Fineman said, and most allergists agree that knowing one’s triggers and tracking local pollen counts are essential to managing allergy flare-ups.
Rachel Dawkins, MD, medical director of the pediatric and adolescent health clinics at Johns Hopkins All Children’s Hospital in St. Petersburg, Florida, agrees that it’s going to be a tougher fall allergy season than usual. “As pediatricians, we expect a very serious fall. The students are back in person at school and in many cases exposed in the classroom,” Dawkins said. “In addition, we are seeing outbreaks of respiratory syncytial virus (RSV) and COVID-19, as well as other viral diseases. It will be difficult to decide what is viral versus allergic in the office and how to decide who should be sent back to school and who should be quarantined.”
Dawkins encourages her patients with known seasonal allergies to restart their antihistamines as fall approaches rather than until they have symptoms.
“Especially in our younger or unvaccinated patients, they will likely need to be tested for COVID-19 if they are symptomatic before school, even if they have a history of seasonal allergies,” she said. “In areas like mine [Florida], where community testing sites are closed, the number of sick children to be seen and tested will be a challenge.”
Allergies or COVID-19?
The biggest challenge in the coming allergy season may be to differentiate between respiratory allergy symptoms and infectious diseases such as COVID-19.
“If there’s a family or personal history of allergies, it’s possible it could be allergies,” Fineman said. “But in the school environment, if they have a fever, all bets are off.”
The presence of a fever is a major red flag in distinguishing allergies from infections, he explained, adding that good assessment skills can help clinicians be judicious when testing for diseases such as the flu and COVID-19.
The COVID-19 pandemic has had interesting effects on allergies and other infectious diseases, according to Mitchell H. Grayson, MD, chief of the Division of Allergy and Immunology at Nationwide Children’s Hospital in Columbus, Ohio. For example, there is a huge RSV season underway, even if it is not the normal season for the virus, he said: “RSV clearly has the ability to not stick to its seasonal barriers, but I wonder how it is with the flu.”
Masking has helped reduce the spread of respiratory viruses and maybe even some pollen, but building protection requires exposure. “We saw a dramatic decrease in children’s exposure to allergens and exacerbations a year ago, presumably due to masking and not collecting,” Grayson said. “I suspect masking in the fall would have similar results.”
Most areas began phasing out mask mandates in the spring, when there was an increase in both allergic exacerbations and viral illnesses, he said. It makes sense that masking helps to reduce the amount of pollen and other allergens absorbed into the body, but not much has changed in terms of indoor allergies. Many other factors could come into play, Grayson said, but masks seem to be the main reason for the reduction in allergy, disease and asthma problems last year. Fewer office visits could have been a factor, but not to the extent that most areas saw, he said: “I find it hard to believe that people with asthma had severe exacerbations and drove at home. [during the pandemic].”
Dawkins’ practice predated the fall allergy season by creating a list of frequently asked questions for the call center and triage nurses. This guide helps staff keep healthcare providers informed about any recommendations from organizations such as the Centers for Disease Control and Prevention, American Academy of Pediatrics, and local governments. “In this way, we have a shared message for families,” Dawkins said.
Asymptomatic children exposed to COVID-19 are referred to community testing sites, and Dawkins said her practice has decided not to write mask waiver letters and encourages all children who can receive the vaccine.
There are no new medications in the offing for seasonal relief, but Fineman noted that in recent years there has been increased push toward the use of inhaled nasal steroids as a first-line treatment for upper respiratory allergies. These should be started 3 to 4 weeks before the new allergy season starts.
For patients who prefer oral antihistamines, second-generation options are preferred. These drugs, such as loratadine and cetirizine, are highly effective and fast-acting and don’t cross the blood-brain barrier, Fineman said. This means that, unlike drugs such as diphenhydramine, they have no narcotic effects on the central nervous system.
Currently, there’s a lot of research on biologics and immunology that trickles down from adult medicine to pediatric practice, Grayson said.
Fineman emphasized the benefit of immunotherapy, especially in children with severe allergies. “We know that children with severe allergies benefit from allergen immunotherapy,” he said. Children with upper respiratory allergies may be prone to lower or reactive asthma, and immunotherapy can reduce that risk, Fineman explained.
While primary care pediatricians can arrange a lot, Fineman emphasized that children with severe allergies are best served with a referral to an allergist and possibly immunotherapy to reduce symptoms and complications.