With the onset of fall and winter season, my clinic in the Bronx braces for a flood of worried parents. A toddler coming in with itchy, watery eyes and a runny nose becomes a far too common sight. Parents share of their battles against poorly ventilated apartments, mould and cockroach infestations, housing insecurities; adding to this, the threat of RSV, flu, and COVID-19 exposures in day care and school causes worsening congestion and frequent ER visits.

With robust livelihoods demanding attention, jumping to get their child tested with an allergy panel at the first sign of a sneeze may seem like the best course of action. The impulse is understandable. But in much of pediatric practice, allergy panels drive up unnecessary costs and lead to parents facing confusing results.

In my opinion, what we need instead is a balance: Recognizing true allergic disease, avoiding excessive needle pricks, and empowering families with practical home tools and solutions to manage allergies effectively and early.

Landscape of pediatric allergies

According to the CDC’s 2021 data, 18.9 percent of U.S. children have a diagnosed seasonal allergy. Boys (20.0 percent) are slightly more likely than girls (17.7 percent). Racial and ethnic differences persist: Non-Hispanic Black (21.3 percent) and non-Hispanic White (20.4 percent) children have higher reported rates than Hispanic (15.3 percent) or non-Hispanic Asian (11.0 percent) children. These differences may reflect a combination of genetic predispositions, environmental exposures (indoor allergens, pollution, housing conditions) and disparities in access to diagnosis and specialty care.

So why not just test for the environmental allergens?

Well, in practice:

• Positive results don’t always mean clinical disease. Children may show IgE positivity levels without symptoms creating falsely positive results and heightened anxiety.
• False reassurance: Negative tests can lead families into inaction.
• Cost and access burden: Panels may not be covered by insurance and may overburden families financially.

Recognizing allergies with clinical presentation and focused signs

Before jumping to testing, a better approach lies in recognizing allergies via thorough history and exams.

Symptom patterns:

• Do symptoms recur in the same season each year?
• Are they triggered or worsened by pollen seasons, windy, dry days, or known allergen exposures?
• Itchy eyes or nose, sneezing, clear nasal discharge, postnasal drip, and nasal congestion, especially without fever.
• Persistence beyond 10-14 days or recurrence across seasons.

Any associated features:

• Eczema, asthma, family allergy history.
• Response to previous prescription medications (e.g., antihistamines, nasal steroids).

Physical signs:

• Nasal exam: pale or boggy mucosa, cobblestoning of the posterior pharynx, allergic shiners.
• Eyes: dark circles under eyes, itchiness, excessive clear, watery discharge.

Practical home-based first-line strategies families can use

AAP’s guidance encourages allergen avoidance and symptomatic treatments as the first steps with testing reserved for selected patients. Some of these steps look like:

Environmental controls and avoidance

• Close windows during high pollen days.
• Run HEPA filters indoors.
• Wash bedding weekly in hot water.
• Use allergen-impermeable covers on pillows/mattress.
• Reduce indoor humidity to less than 50 percent.
• Minimize carpeting in bedrooms.
• Pet management: If pets trigger symptoms, try limiting pet access to bedrooms, consider keeping their interactions limited to only specific areas of the house or sleeping in kennels.
• Exhaust fans and mold control: Ensure ventilation in bathrooms/kitchens, regularly check and repair for molds in highly sensitive areas.
• Shower before bed, rinse off pollen, and change clothes after being outdoors.

Over-the-counter (OTC) medications

• Use non-sedating antihistamines for sneezing, itching, rhinorrhea/runny nose: Begin therapy as soon as symptoms emerge; consider daily preventive use during peak pollen month.
• Saline nasal spray is a safe adjunct, particularly for nasal congestion or thick secretions.

These strategies often reduce symptom burden significantly, sometimes making testing completely unnecessary. Consider talking to your child’s pediatrician to understand risk vs. benefits.

When does testing make sense?

Testing with standard environmental panels adds value only when:

• Symptoms persist despite optimal first-line drug therapy.
• A child is a candidate for monthly allergen immunotherapy.
• Unusual or multiple triggers are suspected.
• There is diagnostic uncertainty or overlapping conditions.

What test to use when?

Always choose targeted testing, not a broad/”shotgun” panel approach.

• Skin prick testing is preferred for inhalant allergens.
• IgE blood panels may be used, especially if skin testing is not feasible, like for children with uncontrolled asthma/eczema or recent/current use of OTC drugs.

Your physician will interpret results in a clinical context; a positive test without symptoms does not necessitate major treatment. Allergy panel results should guide immunotherapy decision-making or environmental targeting rather than broad avoidance.

My approach for the season ahead

This allergy season, my goals in practice are to shift our clinic’s culture from reflexive panels to judicious care. Here’s how I plan to approach it:

• Educate upfront: At annual asthma or well-child visits, I remind families that not every sniffle is allergic, and testing is not the first step.
• Empiric therapy trials: Start with environmental controls and age-appropriate OTC or prescription therapy, monitoring response over 2-4 weeks.
• Escalate thoughtfully: If symptoms persist, focused testing is the rule with clear documentation of previously tried methods and response to each allows for prompt referral or consideration of immunotherapy.

This approach can offer families clarity, reduce unnecessary diagnostics, and ultimately help children breathe easier. It is our duty as pediatricians to make sure children enjoy a healthy, carefree childhood without turning every sneeze into a painful and expensive endeavor.

Tanya Tandon is a pediatrician.