Beyond Symptomatic Treatment of Allergies in Pediatric Patients

Dr. Turck:
This is Clinicians Roundtable on ReachMD, and I’m Dr. Charles Turck. Joining me to discuss how we can pivot towards treating allergies at their root cause in pediatric patients is Dr. Brian McDonough. He is 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: 
It's great to be here. Thank you.

Dr. Turck: 
So to get us started, Dr. McDonough, why exactly is making the shift towards addressing the root cause of allergies in pediatric patients so crucial?

Dr. McDonough: 
What we're learning, and I think we kind of always knew it, but we're definitely learning in the last five to 10 years is there's a continuous path with allergies, where some people, they get better and it's fine, but others progress, and they get worse, and they continue to progress. And we're realizing more and more, is there anything we can do to stop that progression? In other words, yeah, we have medications and treatments for short-term results, and certainly, we can do things to try to change the environment, those sorts of things, but is there any way we can normalize things so that somebody with a particular issue is able to get away from it to return more to normal?

I think the other thing that has become important is we're seeing so many more people who have allergies and other issues that it becomes more important that we come up with better ways. The numbers are so high, what can we do? So I think there's a desire to find out what's happening. And then what can we do about it? As opposed to just, ‘Ooh, we'll put the Band-Aid on it.’

Dr. Turck: 
And as a follow-up to that, what are some of the barriers we clinicians run into when managing a patient's allergies, as far as symptomatic control is concerned?

Dr. McDonough: 
Well, I think the biggest thing is recognizing the cause and dealing with a treatment because what happens is most of these things are vague, we kind of can tell it's an allergic issue. But we're also thinking, is it bacterial? Is it viral? Is there some other infection going on? And you're walking down the path. And if you think about it,you’re a bit ahead of the game, but sometimes people don't even think about it. That's step one.

But then when you're trying to treat, are you treating an allergic issue? And do you get follow-up? In other words, somebody comes in, all best intentions, and then they're lost to follow-up, and you don't necessarily know what happened. That's the second thing.

And then finally, the third thing is people might get frustrated. Let's say they've come in several times, and you've tried certain things, and the more or less say, ‘This provider really isn't helping, here we are back again,’ and they go somewhere else. I see all those things as concerns. And that's really why we want to try to do what we can to get into the actual pathology of what's going on and addressing it.

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 need to shift from symptomatic control to treating the root cause of allergies in pediatric patients.

So, Dr. McDonough, now that we have a better sense of why a change in approach is so important, let's focus on how we can make the shift. First, what can you tell us about available approaches to allergy management that are more comprehensive and sustainable?

Dr. McDonough: 
Well, what we have seen, first of all, is a number, kind of an explosion of major medical centers and even smaller medical centers, hospitals that have actual areas dedicated to allergies, allergy testing, and follow-up. I think that's a very important thing because there was a time when you were in your office and you're on your own, and very few of us would be doing the blood tests or skin tests and those things because we don't necessarily have the expertise or the time. But what we now have is the ability to reach out to an allergist or a team that can help. And I think what we're starting to see is that a growing number of people are getting tested. And then they find the cause, if they find out there's an antibody, antigen reaction, that sort of a thing, and if they know what the root cause is and they address it, and then the symptoms occur as a result because of a test, we can begin treatments. And treatment, of course, is over a long period of time, not just a one-stop visit.

Dr. Turck:
Now what challenges might we face when transitioning from conventional symptomatic control methods to some of the more comprehensive approaches we've been discussing?

Dr. McDonough: 
Well, the biggest thing is the commitment. If you think about it, let's say someone has an allergy and you detect it through a blood test or a skin test and you know you have the IgE and it's isolated, and you know that symptoms are occurring as a result of that, which are two very important things, you then have to begin desensitization. And you just can't say, ‘Boom, I'm going to expose you to something and desensitize,’ because you can have a terrible anaphylactic reaction. What you have to do is you have to start out slowly with just a little bit of the offending agent. And then a week later, a little more of the offending agent. And not only that, you're watching the person, the patient, for 30 minutes or so after that to see if there's any symptoms, and you have to be ready to jump in if there are problems.

So as you're doing that, and this goes on for, it can be 24-weeks of just consistently doing this little by little, you have to have a person really buy in. In other words, they have to say, ‘I'm committing to this, and I'm going to do this every week or so.’ And then it just doesn't end there. It can be a month, and then several months. And that goes on for as much as three to five years. So what you get theoretically is basically, the resistance, the reaction, everything that occurs is eliminated, and you're free of it. But you've put a big time commitment in so there's expense, there's the expertise, and there's deciding to do that versus somebody saying, ‘Well, I’ll just take a medication, and that’ll get me through.’ It has to be something somebody's committed to.

So my point is, especially for the pediatrician, family doctor, or healthcare provider, you want to spend a lot of time in education. You've got to say, why is this worth it? What are you up against? And what can we do to try to make things better? And if you look at the organizations, the national organizations, I've read through the literature, and many of us have, I mean, you're talking about 60, 80, 90 pages of every detail of what can happen and how it happens. It's really intense. So we have to synthesize all that and say, ‘Okay, here's what you need to worry about.’ And that's our job to try to just sell the idea of eliminating this and not just treating it symptomatically.

Dr. Turck: 
And are there any other strategies or best practices you've employed in overcoming these challenges?

Dr. McDonough: 
Well, I think one of the things that I do is I let my patients talk to others who have been through it. I find that very helpful. I always say if there's somebody who will be willing to talk to them. I think it's worth it. And what I'm always doing is always talking to other providers, and saying, ‘What are you doing? Where are you going? What's going on?’ And I mean, that's valuable, we call it a curbside consult, that'svaluable about anything we're talking about. But when it comes to allergies in particular, it's important because we're all seeing more. One thing I will tell you is there's just more and more, especially children, we're seeing with allergies and issues associated with it. I mean, everybody has a theory why. I'm not sure why, but I just know that we're having more cases like that.

Dr. Turck: 
And are there any other strategies or best practices you've employed in overcoming these challenges?

Dr. McDonough: 
Well, I think this is the really important point. I think when you talk about quality of life, you're talking about eliminating, or at least dramatically controlling something that is an irritant; the symptoms won't be there, the fear won't be there, the endless cycle of, let's say, year after year after year of struggling through things won't be there.

The other thing that I think is really important is we have to start thinking that way. I mean, most of us in medicine are trained; there's an issue, we treat it. You almost have to look at allergies like you would look at somebody with type 2 diabetes or hypertension; this could be a long road for us to try to deal with this. Hopefully, it's not lifetime; hopefully, it's controlled three to five years or two years of treatment. But the point is it's not something where you say, ‘I have a sinus infection, and I'm giving you an antibiotic, and in 10 days, I hope you're better.’ This is quite different. And I think that's important.

And then the last thing is we cannot state enough the fact that people who have allergies also are more likely to run into other issues like asthma and things that can become far more serious. And there is a thought out there that the earlier you intervene and the better you do with treatment, the greater the chances of not running into these secondary issues that can, in fact, dwarf the initial symptoms and their severity.

Dr. Turck: 
Well, given the importance of this topic, I want to thank my guest, Dr. Brian McDonough, for joining me to discuss how we might better care for our pediatric patients by taking a more comprehensive approach and targeting the root cause of allergies. Dr. McDonough, it was great having you on the program.

Dr. McDonough: 
Thank you. I really enjoyed it.