The classic symptoms of rhinitis, asthma, and dermatitis may appear without any evidence of allergy. When the history and laboratory tests indicate that an allergic reaction is a probable factor in etiology, one must come to grips with identifying the specific allergen or allergens at fault.
The chart below was originally prepared to appear with the article "Diagnostic Approaches in Childhood Allergy," which appeared last month, but for technical reasons could not be published at that time. Note that wheal size is important in making the diagnosis.
Severity of symptoms, however, does not necessarily correlate with the size of the skintest reaction. One may see moderate responses to an allergen that induces marked symptoms. More rarely, one sees significant skin-test response to an allergen that cannot be correlated with clinical symptoms, which emphasizes the importance of history in determining treatment.
Institution of such environmental control measures as may be practical is always the first step in treatment and at times may be all that is required. If results are not satisfactory, one may use immunotherapy with those allergens deemed responsible for the symptoms.
Immunotherapy is generally for dusts, pollens, and molds, and - more rarely - for animal danders. For the latter, the preferred treatment is elimination, but this may be impossible in cases where the child lives on a working farm or when the child's father is a veterinarian, etc. In such instances, immunotherapy would be appropriate.
With cooperation and assistance from the allergist when needed, the pediatrician is the logical person to assume primary responsibility for the allergic patient. Referral should be considered, of course, for those patients who do not respond to treatment, who are doing poorly on injection therapy, who have multiple allergies and multiple manifestations, who have a history of hospitalizations for status asthmaticus, or who are intractable asthmatics.