12/17/2012
Wondering about how to counsel family of a teenager with significant developmental disability (non-verbal, autism spectrum) who has been experiencing seasonal rhinoconjunctivitis that is requiring oral anti-histamine, eye treatment, nasal steroid. Family interested in obtaining pre-seasonal subcutaneous immunotherapy to his relevant allergens (tree, grass). This teen would not be able to communicate early symptoms of a systemic reaction to the treating MD, so a similar issue to a young child (ie discussion around children <5 in the JCAAI guideline is the only relevant guideline I have been able to find). SCIT would include grass pollen so I believe important to consider this possibility of systemic reaction very carefully. Could you kindly advise?

Thank you for your inquiry.

Unfortunately there are no specific answers to your question. For the sake of our readers and to help clarify the issue, I have copied below two statements taken directly from the Allergen Immunotherapy Parameters by Cox, et al., to which you referred. Your analysis of your patient’s situation in regards to the similarities of instituting immunotherapy in a small child is valid, and I, like you, could find no other guidelines dealing with this issue. So, I am afraid the best we can do is simply use these quotes from the Parameters as the best source to come to a conclusion.

"However, allergen immunotherapy for inhalant allergens is usually not considered in

infants and toddlers because (1) there might be difficulty in communicating with the child regarding systemic reactions and (2) injectionscan be traumatic to very young children."

"Immunotherapy can be initiated in young children less than 5 years of age if indicated. Indications should be based on the severity of the disease, risk/benefit ratios, and the ability of the physician to correlate the clinical presentation with appropriate and obtainable allergy testing".

SOURCE: Cox L et al: Allergen immunotherapy: A practice parameter third update. Journal of Allergy and Clinical Immunology Vol. 127, Issue 1, Supplement, Pages S1-S55, 2011.

As you can see from these quotes, in the final analysis, the analysis of the risk/benefit ratio is made by the individual physician treating the patient. Thus, one might have varying opinions as to whether or not to institute injection therapy in your patient amongst practicing allergists. I can therefore only give you my opinion in this regard.

I have personally instituted allergen immunotherapy when I felt it was indicated in patients with autism who might have difficulty communicating their symptoms.I have in the past requested that such patients receive immunotherapy in our office, and that they are carefully observed after the injection.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.