Dr. R. Arvind Kumar

When a child with asthma is not getting adequate benefit from their inhaler, there are three questions I ask before changing the medication. The first is whether the technique is correct. This is by far the most common cause of poor asthma treatment response in children in my Chennai practice. A metered dose inhaler without a spacer delivers only a fraction of the dose to the airways  -  most of the medication impacts the back of the throat rather than reaching the bronchi. Using the inhaler through a spacer device appropriate to the child's age and size dramatically improves drug delivery. I assess and correct inhaler and spacer technique at every consultation where an inhaler is prescribed, and in many cases where the family has been told the inhaler is not working, the technique has been the problem all along. The second question is whether the child is using a controller inhaler regularly. A reliever bronchodilator opens the airways within minutes but does not treat the underlying inflammation  -  a child using only a reliever several times a week has undertreated asthma. A daily controller inhaled corticosteroid, used consistently even when the child feels well, is the foundation of asthma management. The third question is whether the allergen driving the airway inflammation has been identified. A child sensitised to house dust mite in Chennai's climate, sleeping in a bedroom with high mite concentrations, is being re-exposed to their trigger every night  -  which is why their asthma is not well controlled despite treatment. Allergy evaluation identifies this, and addressing the exposure and considering immunotherapy changes the disease trajectory in a way that adjusting the inhaler dose alone cannot achieve.

Sublingual immunotherapy  -  SLIT  -  and subcutaneous immunotherapy  -  SCIT, the conventional allergy injection  -  are both forms of allergen immunotherapy, and they share the same fundamental mechanism: small, gradually increasing doses of the specific allergen are administered over time to shift the immune system from an allergic response toward tolerance. The difference is the route and the setting. SCIT requires injections given in a clinical setting  -  in my clinics this means attending for regular appointments during the build-up phase, followed by less frequent maintenance injections  -  with a waiting period after each injection to monitor for reactions. SLIT is administered as daily drops placed under the tongue and held there for one to two minutes before swallowing, or as dissolving tablets, and is taken at home rather than in clinic. The advantages of SLIT include the absence of injections (making it particularly well accepted by children and by adults who find clinic visits difficult to schedule regularly), and a strong safety profile that allows home administration without clinic supervision after the initial doses. The effectiveness of SLIT is strongest for house dust mite sensitisation, which is the most prevalent sensitisation in my Chennai patient population, and the evidence base is well established. SLIT does not produce instant symptom relief  -  it is a disease-modifying treatment over a three to five year period that reduces allergic reactivity and produces benefits that persist after the treatment course is completed.

Yes  -  both a child and one of their parents can be assessed for allergy in the same clinic visit at NIRA Child Clinic, and this is a service I specifically offer because of how frequently I see the pattern: the parent brings their child for an allergy evaluation and during the consultation it becomes clear that the parent has the same underlying sensitisation and untreated allergic disease. My AASC training  -  the Advanced Allergy, Asthma and Clinical Immunology Specialist Course  -  encompasses allergy evaluation and management across all ages, not only paediatrics, which means I can perform skin prick testing and interpret allergy results for adults with the same clinical framework I apply to children. The practical benefit for families in Chennai is significant: rather than attending a paediatric allergy clinic for the child and then a separate adult allergy or respiratory clinic for the parent  -  which often means different locations, different appointment wait times, and incomplete information-sharing between clinicians  -  both can be assessed together. The allergen sensitisation profiles often overlap, which means the avoidance advice and the allergen immunotherapy considerations can be discussed for the family as a unit rather than separately. At both the Kolathur and Perambur clinics, I welcome families where both children and adults need allergy evaluation.

Prosopis juliflora, commonly known as velvet mesquite or the invasive thorny shrub that has colonised roadsides, railway embankments, vacant plots, and open land across Tamil Nadu over the past few decades, is one of the most clinically important but least-discussed allergens in Chennai's allergy landscape. Unlike house dust mite and cockroach, which are recognised in standard allergy panels, Prosopis juliflora pollen is a region-specific sensitiser that is frequently omitted from allergy test panels because it is not a major allergen in Europe or North America where many allergy testing standards are set. In my clinical practice at NIRA Child Clinic, I test for Prosopis juliflora pollen as part of the Chennai-specific allergy panel because the sensitisation is genuinely prevalent in the Tamil Nadu population and because patients sensitised to it have a characteristic seasonal pattern of worsening rhinitis and asthma that corresponds to Prosopis flowering seasons. A child or adult who has rhinitis and wheeze that worsens at certain times of year, lives in an area with visible Prosopis shrubs nearby, and tests positive to Prosopis pollen extract has been given an explanation for a seasonal pattern that generic allergy testing may have missed entirely. For patients managing allergy in Chennai, identifying Tamil Nadu-specific allergens like Prosopis is as clinically important as identifying house dust mite.