antihistamines ( Table 85.3 ) First-generation antihistamines (e.g., diphenhydramine, hydroxyzine) are no longer considered first-line therapies because they have shorter half-lives and are more likely to cause CNS depression Antihistamines reduce rhinorrhea, pruritus, and coughing associated with allergic rhinitis Combination oral antihistamine–decongestant preparations are available for children ≥12 years and adults, but are primarily appropriate for short intervals as rescue therapy Topical antihistamines such as azelastine can also provide symptomatic relief to children and adults with intermittent allergic rhinitis, but may have a bitter aftertaste and are considered second-line therapy Other nonpharmacologic measures such as saline nasal rinses may provide symptomatic relief There is evidence supporting the use of montelukast in the management of persistent allergic rhinitis in preschool children, seasonal allergic rhinitis in older children and adolescents, and in the management of allergic rhinitis in patients with asthma already using inhaled corticosteroids Although there is little evidence to support allergen avoidance for indoor allergens, it is logical to limit exposures when possible in patients with significant allergic rhinoconjunctivitis, especially during pollen seasons Children with significant ocular symptoms may also benefit from local ophthalmic treatment (see Table 123.2 ) While there is a paucity of evidence to guide pharmacologic treatment of allergic rhinitis in children, there is moderate evidence supporting subcutaneous immunotherapy in the long-term management of allergic rhinitis in children and adults Sublingual and oral immunotherapy as well as treatment with omalizumab may be used in select patients, although use in pediatrics is still under investigation Suggested Readings and Key References Anaphylaxis Alqurashi W, Stiell I, Chan K, et al Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis Ann Allergy Asthma Immunol 2015;115:217–223 Brown SG, Stone SF, Fatovich DM, et al Anaphylaxis: clinical patterns, mediator release, and severity J Allergy Clin Immunol 2013; 132:1141–1149 Campbell RL, Li JT, Nicklas RA, et al Emergency department diagnosis and treatment of anaphylaxis: a practice parameter Ann Allergy Asthma Immunol 2014;113:599–608