Brief Answer:
levocetirizine + montelukast, allergy testing

Detailed Answer:
Hello XXXXXXX

Thank you for asking at HCM.

I went through your daughter's history and would like to know more details like -

a. Since when does she have symptoms?
b. Does she have nose congestion, running nose, cough?
c. Has she ever had wheezing? Has she ever required nebulization?
d. Does she have any other problems? digestion/food-related or skin allergies?
e. Does she have anyone in family with allergies?
f. Does anyone from home smoke?
g. What is the frequency of her symptoms?
h. What are the worst seasons for her?
i. Does she have fever with symptoms?
j. Has she tasted for allergies? How allergies to dust, pollen, smoke and sprays were diagnosed?
k. How frequently she needs to use levolin syrup? since how long?

Please provide above details so that I can be more helpful to you and your daughter.

At present, I would like to make following suggestions for her:

1. Were I treating her, I would prescribe her daily montelukast and levocetirizine for at least 1 month.

2. I would suggest her to avoid exposure to dusts, smokes and air pollution as much as possible.

3. I would also prescribe her vitamin C for 2-3 months.

4. I would like to review allergy testing reports, if not done, I would suggest her allergy testing for air born allergens (house dust mite, common molds & pollens in your region, animal dander if you have a pet) and common food allergens.

Based on the above reports, allergen avoidance measures can be suggested.

Hope above suggestions will be helpful to you.

Should you have any other concern, please feel free to ask on the follow-up. It will be my humble pleasure to help her with best of my knowledge and experience.

Wish her the best of the health.

Thank you & Regards,

Dr. Parin N. Parmar

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Brief Answer:
continue medicines & allergen avoidance

Detailed Answer:
Hello XXXXXXX

Thank you for your follow-up and details.

It gives me impression that she has perennial rhinitis with intermittent wheezing with reflux.

After reviewing the details, I would like to make following suggestions to her:

1. I usually treat my such patients with montelukast (4 mg) + levocetirizine (2.5 mg) once in a day. It helps both allergic rhinitis as well as wheezing. Commercial preparations containing both together are available both in tablet and syrup forms.

I am really sorry for not being able to mention brand names as it will be violation of rules of HCM.

2. In between when she has wheezing, I would suggest her inhaled levosalbutamol via nebulizer or metered dose inhaler with spacer with mask.

Levosalbutamol is same as Levolin syrup you are using, but in general, inhaled medications work quicker and have less side effects in my opinion.

You can also use syrup if you are comfortable with it.

3. It is important to remember that above medications will "control" symptoms of rhinitis and wheezing (or childhood asthma) but they do not treat "allergies". So she needs to continue medications as long as she has symptoms.

4. For identify her allergies I would suggest you allergy testing for following:

a. House dust mite (D.farinae & D.pteronyssinus)
b. Cockroach allergen
c. Common molds & pollens in your area
d. Animal dander (cat, dog, cow, XXXXXXX etc, only if she is exposed to pets/animals)
e. Common food allergens - peanut, milk, soy, wheat, rice, tree nuts, eggs, fish, shell fish

Please select food allergens according to her diet. Please do not involve the foods that she does not eat.

There are two types of allergy testing: allergy skin testing (reliably performed by Allergist-Immunologists but many times uncomfortable for children) and serum testing for specific IgE (convenient for children)

For a child of her age, I usually prefer serum testing for specific IgE via ImmunoCAP method.

5. Avoidance of allergy causing substances is the best strategy for treatment of allergies.

Depending upon allergy testing results, appropriate environmental measures can be suggested for air-borne allergens and she should avoid the food she is allergic to.

6. I would like to specifically mention here that treatment of reflux is also important simultaneously. I usually treat reflux with lasnoprazole daily before meals.

It is possible that reflux may be associated with food allergies and avoidance measures may also improve reflux symptoms.

7. Please avoid too cold and too hot foods/beverages. Please do not force her to eat. I would suggest you to let her eat her food according to her appetite only. This is very important for good digestion.

8. I would also suggest her a balanced diet rich in vitamins & minerals (adequate amounts of green leafy vegetables, fruits, sprouts, etc) which will improve her immunity in a long run.

9. I would suggest you to maintain her hemoglobin around 13-14 g% by appropriate food and medicines. This will improve her immunity and prevent repeated infections.

10. As advised previously, I would suggest her vitamin C, vitamin D and a multivitamin for at least 2-3 months.

Hope above suggestions will be helpful to you.

Should you have any further query, please feel free to ask on follow-up.

Wish your daughter the best of the health.

Thank you & Regards,

Dr. Parin N. Parmar

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