There is a particular kind of exhaustion that comes with a child who has been sneezing every morning for six months, whose nose runs constantly, who wakes up tired, and who is described at school as inattentive. These parents are often told the child has a cold. They treat it, wait, and the cold comes back. The truth, in the majority of these cases, is that it never was a cold. It was allergic rhinitis, and the distinction matters because a cold resolves in ten days and rhinitis does not. I am Dr. Kirti Shrotriya, Pediatrician and Allergy Asthma Specialist at Kinder Care Clinic, Dhanori, Pune, and allergic rhinitis in children is one of the most commonly misunderstood and under-treated conditions I see in my daily practice. This guide is designed to give parents everything they need to understand what allergic rhinitis is, why Pune's specific allergen environment matters, how the diagnosis is made, and what the full treatment pathway looks like from antihistamines through to immunotherapy.
Is it a cold or is it allergic rhinitis? How to tell the difference
This is the first question I ask parents to think through systematically, because the answer shapes everything that follows. A cold is caused by a virus. It lasts seven to ten days. It usually begins with a scratchy throat or low-grade fever, and the nasal discharge starts clear before becoming thick and coloured. It is not triggered by specific environments and it does not come back at the same time every day. Allergic rhinitis works very differently. It is caused by the immune system's overreaction to a specific allergen. The nasal discharge is clear and watery throughout. There is no fever. Sneezing often comes in runs, particularly in the morning. The eyes itch and water. The nose and the roof of the mouth itch. Symptoms are better in some environments and worse in others, and in many children they follow a consistent pattern across weeks, months, or even years. If your child has had more than four to five colds per year, or if their cold does not resolve within ten to fourteen days, or if symptoms are consistently worst on waking, the diagnosis of allergic rhinitis deserves formal evaluation.
The Pune allergen landscape: what is your child reacting to?
One of the most valuable things I can offer a family at Kinder Care Clinic is an understanding of the specific allergens that are prevalent in Pune, because trigger avoidance is only possible when the trigger is known. Pune's allergen landscape is driven by four main categories.
House dust mites are the most prevalent perennial allergen in my patient population. They live in mattresses, pillows, upholstered furniture, and soft toys, feeding on the shed skin cells of the household's occupants. They are not visible to the naked eye and thrive in the warm, moderately humid Pune climate. Every breath a sleeping child takes is filtered through bedding where dust mite concentration is highest. Dermatophagoides pteronyssinus and Dermatophagoides farinae are the two species most clinically relevant, and skin prick testing with both extracts is standard in my allergy evaluation.
Cockroach allergen is the second most important indoor allergen in urban Pune. Cockroach saliva, faeces, and shed body parts become airborne particles that are inhaled by the child. Cockroach sensitisation is strongly associated with both allergic rhinitis and asthma, and in apartment and older housing environments in Pune, cockroach exposure is significant. Mould, particularly Cladosporium, Alternaria, and Aspergillus, proliferates during the monsoon months in Pune and in damp areas of the home year-round. Mould-sensitive children typically show worsening symptoms during the June to September period.
Parthenium hysterophorus, the invasive weed that colonises roadsides, empty plots, and the periphery of new construction areas throughout Pune, produces pollen that is a particularly important seasonal rhinitis trigger in this region. Parthenium season in Pune runs roughly from July to November, overlapping with and extending beyond the monsoon, and children sensitised to Parthenium pollen show a predictable seasonal worsening that correlates directly with pollen counts. Knowing whether your child is sensitised to house dust mite, cockroach, mould, Parthenium, or some combination of these shapes the avoidance strategy completely - which is why testing matters.
Skin prick testing: what it is, how it works, and what the result means
The most important diagnostic step in evaluating a child with suspected allergic rhinitis is a skin prick test. I perform skin prick testing at Kinder Care Clinic for children from around three years of age, and it is one of the most informative investigations I have available. Small amounts of standardised allergen extracts are placed on the inner forearm using a lancet that barely penetrates the surface of the skin. After fifteen to twenty minutes, any raised, red, itchy weal at a test site indicates that the child's immune system has produced IgE antibodies against that specific allergen. The test takes under thirty minutes in total, is very well tolerated by most children, and produces results immediately in the clinic.
A critical point for parents to understand is that a positive skin prick test result identifies immune sensitisation to an allergen, but a positive result alone does not diagnose allergy. The result must be interpreted alongside the child's clinical history. If the child is sensitised to house dust mite and has perennial morning sneezing that is worst in the bedroom, the sensitisation is almost certainly clinically relevant. If the child is sensitised to an allergen they have never encountered in meaningful quantities, the sensitisation may not be driving their symptoms. This interpretation is the clinical work that sits around the test, and it is why a positive allergy panel report from a laboratory, without a clinician evaluating the result in the context of the child's history, is of limited value. Specific IgE blood testing is an alternative for children who cannot stop antihistamines or who are too young to cooperate fully with skin prick testing, and both methods measure the same underlying immunological sensitisation.
Intranasal corticosteroids: the most effective medical treatment, explained for parents
Of all the treatments for allergic rhinitis in children, intranasal corticosteroid sprays are the most effective for controlling nasal symptoms, and they are also the treatment that parents are most frequently worried about. The word 'steroid' carries associations with side effects that are not relevant to intranasal sprays used correctly, and it is important that I address this clearly. Intranasal corticosteroids work locally in the nasal lining, where they reduce the inflammatory response to allergens - the swelling, the mucus production, the itching. The amount of steroid that reaches the body's circulation from a correctly used intranasal spray is extremely small, and the safety profile of modern preparations used at recommended doses in children is very well established.
The most important determinant of how well intranasal steroids work is correct technique. The spray must be directed toward the outer wall of the nostril, angling slightly away from the nasal septum, and the child should not sniff sharply after spraying as this carries the medication away from the nasal lining before it can act. I demonstrate technique at every consultation where I prescribe an intranasal spray, and I ask the child or parent to demonstrate it back to me before they leave the clinic. A spray used incorrectly will not work well, and a parent who concludes that 'the spray didn't help' after using it incorrectly for three weeks has not had a fair trial of the medication. Intranasal steroids typically take three to seven days to reach their full anti-inflammatory effect, and families need to understand that the first day of use will not produce the same benefit as consistent use over two weeks.
Antihistamines: what they do well and where they fall short
Antihistamines are the most commonly used treatment for allergic rhinitis because they are available over the counter, work quickly, and are familiar to parents. They block histamine receptors and reduce sneezing, itch, and runny nose effectively. However, there are important limitations to understand. Antihistamines are better for itch, sneeze, and runny nose than for nasal blockage, which is primarily driven by histamine-independent inflammatory pathways. They also need to be taken regularly to maintain effect, and second-generation antihistamines such as cetirizine, loratadine, and fexofenadine are preferred because they cause significantly less sedation than older first-generation preparations.
The key limitation of antihistamines is that they manage symptoms without modifying the underlying immune response. A child who takes an antihistamine every morning for rhinitis season will have better days than one who does not, but when the antihistamine is stopped, the symptoms return in exactly the same way as before. No disease modification has occurred. This is the critical distinction between antihistamines and allergen immunotherapy, and it is the reason that antihistamines, however well used, are not a long-term solution for a child whose rhinitis is causing significant impact on sleep, school performance, and quality of life. They are an important part of the treatment toolkit, but they do not represent the ceiling of what is achievable.
Comorbid asthma and the unified airway: why rhinitis and asthma must be treated together
One of the most important clinical frameworks in paediatric allergy is the unified airway concept. The nose and the bronchial airways are not separate systems that happen to share a respiratory tract - they are one continuous mucosal surface from the nostrils to the smallest air passages in the lung, and they respond to allergic inflammation through the same immune mechanisms. The consequence of this is clinically significant: untreated allergic rhinitis drives airway inflammation that worsens asthma, and poorly controlled asthma coexists with and contributes to ongoing nasal disease. A child treated for asthma whose rhinitis is not addressed will have more poorly controlled asthma than a child whose both conditions are managed together.
In my practice at Kinder Care Clinic, any child with allergic rhinitis receives an assessment for asthma symptoms, and any child presenting with asthma receives an assessment for rhinitis. The overlap is substantial. Many children with 'just a runny nose' turn out to have airway changes on spirometry consistent with subclinical asthma, and many children with 'just asthma' have significant rhinitis that is driving their bronchial disease. Treating the whole airway produces better outcomes for both conditions than treating each in isolation, and this integrated approach is what an allergy-trained paediatrician provides that a general practitioner managing the two conditions separately may not.
Allergen avoidance: what is genuinely helpful versus what is impractical
Once the responsible allergen is identified, allergen avoidance is an important component of management - but it needs to be practical to be useful. For house dust mite, the interventions with the strongest evidence include encasing the mattress, pillow, and duvet in mite-proof covers, washing bedding at 60 degrees Celsius weekly, and reducing soft furnishings in the bedroom. Reducing indoor humidity through ventilation and dehumidification reduces mite reproduction. For cockroach, sealing cracks and gaps in kitchen and bathroom walls, storing food in sealed containers, and professional pest management in affected households are effective strategies. For mould, reducing indoor damp through ventilation, addressing any water leaks promptly, and avoiding damp rooms or basements for the child are practical steps.
For Parthenium pollen, keeping windows closed during the peak Parthenium season in Pune and using air conditioning where available reduces pollen exposure indoors. Monitoring pollen counts during peak season and adjusting the child's outdoor activities on high-count days is advisable for sensitised children. Complete avoidance of airborne allergens like dust mite, cockroach, and Parthenium is not achievable in most households. The goal is reduction of the allergen load below the individual child's threshold for symptom generation, and this threshold varies between children. What allergen avoidance cannot do is modify the immune sensitisation itself - it manages the exposure, but the allergic immune response remains unchanged without immunotherapy.
Allergen immunotherapy: the only treatment that changes the disease, not just the symptoms
Every treatment I have described so far - intranasal steroids, antihistamines, allergen avoidance - works by managing the consequences of the allergic immune response. Allergen immunotherapy works differently. It is the only treatment that modifies the underlying immune mechanism, gradually training the immune system to tolerate the specific allergen rather than reacting to it. The effects of a completed immunotherapy course persist for years after treatment is stopped - which is a property that no other allergic rhinitis treatment possesses.
Allergen immunotherapy is considered when allergic rhinitis is confirmed by allergy testing, when the specific sensitising allergen has been identified, when symptoms are significantly impacting the child's quality of life or contributing to poorly controlled asthma, and when adequate trials of medical treatment have not produced sufficient control. I offer both subcutaneous immunotherapy, where injections of increasing allergen doses are given in clinic during a build-up phase followed by monthly maintenance injections, and sublingual immunotherapy, where daily drops or tablets are administered at home under the tongue. The choice between routes is made based on the specific allergen, the family's practical capacity, and clinical judgement.
For children with house dust mite sensitisation and allergic rhinitis, the evidence base for allergen immunotherapy is strong, and the earlier in the disease course that it is initiated, the greater the potential benefit - both in terms of reducing current symptoms and in terms of preventing progression from rhinitis to asthma, which is one of the most clinically important outcomes immunotherapy can deliver. My training in allergy and asthma through the AASC programme at the University of Colorado, combined with my FCPS and DCH training, informs the allergy evaluation and immunotherapy practice at Kinder Care Clinic, Dhanori, Pune.
When to bring your child to an allergy specialist
Parents often wait considerably longer than they need to before seeking specialist evaluation for a child with rhinitis, partly because they have been told it is just a cold, and partly because they are unsure what an allergy specialist can add to the management they are already doing. The situations that clearly indicate specialist evaluation include:
- Nasal symptoms persisting beyond two to three weeks without fever or any other feature of viral illness
- Sneezing that is consistently worst on waking or in specific environments
- Eye itching and watering alongside nasal symptoms, which is a strongly allergic pattern
- Symptoms that improve in some settings but worsen in others - better on holiday, worse at home; better outdoors, worse indoors; or the reverse
- A child on regular antihistamines whose symptoms are incompletely controlled
- A child whose rhinitis is clearly affecting sleep quality, morning energy, or school attention
At the consultation, I take a detailed history of the pattern of symptoms, identify potential triggering environments, perform a skin prick test where appropriate, and together with the family build a management plan that addresses the full picture. The outcome of that evaluation is rarely just a prescription - it is an understanding of what is driving the child's symptoms that allows targeted, effective management rather than repeated short courses of the same medication that has not been working.
To book a consultation with Dr. Kirti Shrotriya at Kinder Care Clinic, Dhanori, Pune (Mon, Tue, Fri, Sat: 10:30 AM to 12:30 PM and 6 PM to 8 PM; Wed, Thu: 11:45 AM to 12:45 PM), call +91 9850739388.
Written by Dr. Kirti Shrotriya, MBBS, FCPS Pediatrics (KEM Hospital, Pune, 2003), DCH Sydney (The Children's Hospital, Sydney, 2003), AASC (Colorado, US), PGPN (Boston, US), Senior Pediatrician and Allergy Asthma Specialist, Associate Allergy Consultant, KEM Hospital, Pune, Kinder Care Clinic, Palladium Exotica, 2nd Floor, 217, Dhanori, Pune 411015. Phone: +91 98507 39388.
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