The belief that first-generation antihistamines still have value is one of multiple misconceptions that pediatricians should educate families about, David Stukus, MD, a professor of clinical pediatrics in the Division of Allergy and Immunology at Nationwide Children’s Hospital, Columbus, Ohio, told attendees of American Academy of Pediatrics (AAP) 2025 National Conference.

Stukus reviewed common “myths” about allergy that pediatricians should feel comfortable discussing with families, from claimed benefits of organic local honey to the nuances of managing hives.

First- vs Second-Generation Antihistamines

First-generation antihistamines include medications such as diphenhydramine (Benadryl), brompheniramine, doxylamine, chlorpheniramine, hydroxyzine, and promethazine. But alternatives to these offer better, faster treatment and fewer side effects, Stukus said.

First-generation antihistamines have a longer onset and shorter duration of action with less efficacy than second-generation antihistamines, such as cetirizine (Zyrtec), desloratadine (Clarinex), fexofenadine (Allegra), and loratadine (Claritin). They also have more side effects.

Local Organic Honey Cannot Treat Allergies

Honey does not contain the same pollen that causes allergy symptoms, and even if it did, then consuming the honey would cause an allergic reaction, not relief. Instead of honey, effective treatments for allergic rhinitis include intranasal corticosteroids and intranasal antihistamines, with montelukast reserved for cases with inadequate response from or intolerance to those therapies.

Penicillin Allergies Are Rarer Than One Might Think

Getting a rash while taking penicillin does not necessarily mean that the person has a penicillin allergy. “Ten percent of people have been reported to have penicillin allergy, but 95% of those folks aren’t allergic to penicillin,” Stukus said. That’s a problem because “just having the label alone leads to unnecessary avoidance, increased medical costs, and poor outcomes.”

Stukus encouraged pediatricians to consult the 2022 guidelines on drug allergy and noted that doctors can stratify patients into high- and low-risk categories for penicillin allergy based on their clinical history. Those with known side effects, delayed onset maculopapular rash, and a family history of penicillin allergy are low risk. High-risk patients are those with immediate onset symptoms, prior anaphylaxis, severe skin blisters, or specific end organ involvement. People who had symptoms over 10 years ago, had only gastrointestinal symptoms, or received the drug again without adverse effects are also low risk.

Use skin testing for patients with anaphylaxis or a recent immunoglobulin E (IgE)-mediated reaction and use a direct amoxicillin challenge for those with a history of benign cutaneous reactions, he said.

Hives Do Not Require Steroid Treatment

Sometimes, Stukus said, “hives can just be hives.” Not all are an allergic reaction, and most acute urticaria, lasting < 6 weeks, is self-limiting and viral or idiopathic, with a minority being allergic.

“The key question I ask is, ‘What do you think is causing your child’s hives?’ When the parent says, ‘I have no idea,’ I know they’re not allergic to anything because they’re really good at teasing out what’s causing allergic reactions.” If symptoms occur within an hour after a certain food, then diet histories can help determine if a food allergy is involved, but generally, it’s not necessary to change a patient’s diet or environment.

Chronic urticaria is episodic and self-limiting, with 30%-50% of cases resolving within a year and about 1 in 5 cases lasting longer than 5 years. Most chronic cases are idiopathic, though some can be associated with autoimmune conditions. Few are allergic, but they still require treatment because they can be debilitating.

Stukus advised using second-generation antihistamines, not steroids, except during extremely severe manifestations. If patients don’t respond, it’s because either the condition isn’t caused by histamines or the patient isn’t receiving the right dose, so it’s safe to give up to four times the normal dose, he said. For patients with chronic hives still not responding to antihistamines, refer to an allergist.

Be Thoughtful About Diagnosing and Managing Cow’s Milk Allergy

Milk allergy, including milk-induced allergic proctocolitis (FPIAP), is “both overdiagnosed and underdiagnosed,” Stukus said. If a milk allergy is suspected, Stukus refers pediatricians to guidelines in the World Allergy Organization Journal, which recommend complete, strict elimination of cow’s milk for 2-4 weeks to see if symptoms completely resolve.

If they do, add milk back to the diet to see if symptoms return. If they don’t, there’s no cow’s milk allergy. If symptoms return, eliminate milk for another 1-2 months; if symptoms don’t fully resolve again, it’s also not a milk allergy and milk can be added back.

“If we take this approach, not only are we going to identify those that truly have this condition but we can also get milk back into the diet lot sooner than waiting,” he said.

For the management of allergic proctocolitis, “we want to avoid formula roulette and reassure families that it can take about 72 hours for that bleeding to completely resolve,” Stukus said. They shouldn’t immediately switch formulas if they find blood in the next diaper after first eliminating cow’s milk. “The vast majority of these infants can tolerate soy-based formula,” but it takes time for symptoms to resolve. Rarely will infants need extensively hydrolyzed or amino acid formula.

No Need for Breastfeeding Elimination Diets

Stukus explained that breastfeeding mothers do not typically pass allergens to their infants in breastmilk, so it’s rare that a mother would need to eliminate anything from her diet if her baby experiences atopic dermatitis, colic, gastroesophageal reflux disease, or similar symptoms. He referred clinicians to a paper in JACI In Practice, which includes an extensive algorithm to determine if a mother should remove something from her diet. Even if it’s determined she should, it should initially be for just 2-4 weeks before reassessing.

This was a key takeaway for Annette Rosling, MD, a general pediatrician in private practice in Grand Junction, Colorado, who attended the session.

“The most surprising thing for me was that I do not have to advise moms to remove foods from their diet, even if their baby has been proven to be allergic to it when they’re breastfeeding,” Rosling told Medscape Medical News. She also thought the message to leave behind first-generation antihistamines was important. “There’s definitely some people that still use Benadryl or diphenhydramine,” she said.

Other Unnecessary Restrictions

Several misconceptions Stukus covered involved unnecessary restrictions:

• There’s no need to wait a certain number of days between introducing new foods to infants. Let babies explore new foods and textures at each mealtime and reassure families that 95% of children never develop food allergies. Also, Stukus said, anaphylaxis is unlikely to be a baby’s first reaction to a new food or medication. In reality, early and ongoing consumption of different foods has the greatest likelihood of preventing food allergies.
• True red dye allergies are rare. Artificial food colorings do not bind IgE to stimulate an allergic reaction, Stukus said. Carmine, a naturally derived red dye, can be a rare cause of allergy or hives. Stukus said to remind families that correlation does not equal causation, that there’s no test for this allergy, and that the “Feingold diet” — removing all food additives and dyes to reduce a ttention-deficit/hyperactivity disorder symptoms — is not well supported by the evidence.
• Egg allergy is not a contraindication to the flu; measles, mumps, and rubella; or yellow fever vaccines. Despite concerns about a theoretical risk that vaccines made using chick embryos could cause an allergic reaction, the evidence has shown otherwise, and allergy to a vaccine ingredient is not usually a contraindication to receiving it.
• Shellfish allergy is not a contraindication to undergoing imaging with contrast and does not increase the risk for an allergic reaction. There’s no need to ask about shellfish allergy before contrast imaging.

Ultimately, many of Stukus’s key messages centered on reassuring parents and helping them understand that many issues will resolve on their own. It’s not usually necessary to take drastic steps — such as eliminating certain foods permanently from a child’s diet, putting expensive air purifiers in every room, or tossing out all the carpet and curtains in their home — to manage most issues presenting with allergic-like symptoms.

Stukus reported receiving research support from DBV Technologies and royalties from Springer Publishing. Rosling had no disclosures.

Tara Haelle is a science/health journalist based in Dallas.