Allergic rhinitis is a swelling of the inside lining of the nose as a result of an allergy to something in the air. The most common type is seasonal allergic rhinitis (better known as hay fever), which is the result of an allergy to grass or tree pollen. Symptoms may last all year round if they are caused by a ‘perennial’ allergen such as dust mites, or cat or dog fur.
Typical features of allergic rhinitis, as shown above, are sneezing, a blocked, itchy and runny nose, together with itchy eyes (allergic conjunctivitis). However, in more severe cases it may cause disturbed sleep, lethargy, sinusitis and glue ear. While often being thought of as a problem of adulthood, allergic rhinitis is becoming increasingly common in children, affecting around 10 per cent of 6 to 7-year-olds. As allergic rhinitis has become more common over time, it is also affecting increasingly younger children. It is particularly common in children with asthma. Around 50–80 per cent of asthmatics also suffer from allergic rhinitis.
In allergic rhinitis, as with food allergy, the swelling and symptoms are caused by an immunoglobulin E (IgE) mediated immune response to specific allergens such as pollen, mould, animal dander and dust mites. It is again important that you are able to give a clear account to your doctor of what your child’s symptoms are and most importantly what seems to cause them and when they are triggered.
Although symptoms of allergic rhinitis are not life-threatening, they can have detrimental effects on the physical, psychological and social aspects of your child’s life. Allergic rhinitis can significantly decrease quality of life and this is often under-recognised by healthcare professionals and non-sufferers alike.
Symptoms of allergic rhinitis and the associated effect on quality of sleep have significant effects on a child’s ability to perform well at school. Even uncomplicated allergic rhinitis may be associated with reduced ability to learn. This is a particular concern for older children because the timing of public examinations coincides with the grass pollen season. A study comparing adolescents’ examination performance during ‘mock’ examinations (conducted in winter) with formal examinations in spring/summer, revealed that having current symptomatic allergic rhinitis was associated with a remarkable 50 per cent increase in the risk of dropping an exam grade between winter and summer. Frustratingly, while even severe allergic rhinitis can be effectively treated, many patients often receive bad advice, resulting in unnecessary suffering.
The most effective way to reduce symptoms of allergic rhinitis is by avoiding the problem allergen. When it is unclear what the problem allergen is, allergy testing can be very helpful. The most common cause of year-round symptoms (or those that are worse in the winter) is dust mite faeces. Dust mites are tiny, spider-like creatures, invisible to the naked eye. They like warm, moist environments such as bedding and soft furnishing. They eat human skin particles and it is their droppings that cause allergic problems. If allergy to dust mites is causing allergic rhinitis (or asthma or eczema), then reducing exposure to them should help. The most useful measure is getting special covers for the mattress and bedding. These prevent the faecal particles getting up the nose while sleeping. It is essential to get the right covers, which are properly tested as being effective. A good example would be AllerGuard (www.allerguard.co.uk) or those approved by the Allergy UK ‘Seal of Approval’ as this means they have been rigorously tested. Other measures include reducing the amount of soft toys and furnishings, and regular damp dusting. Replacing carpet with hard floors is sometimes helpful but the effect is quite limited.
Last summer, when he was aged seven, Felix started getting really itchy eyes in spring and summer. The GP said it was hay fever and prescribed loratadine, which worked. We went to the GP last week for a new prescription, and I asked if we should allergy test but he said, if the antihistamine works then there is your answer! So his symptoms are mainly itchy eyes, sometimes a bit snuffly. It is definitely worse on sunny days and when he is outside, in the garden, on the school play field. etc. If I don’t give him the medicine (on a sunny day), I generally get called into school to give it so I am much better at remembering!
EMILY, MUM OF FELIX, FINN AND LEO
Unfortunately, with hay fever there is much less that can be done to avoid pollen. Pollen filters in cars, wrap-around sunglasses and nightly hair washes, to prevent transfer of pollen from the hair to the pillow, all may help.
In most cases, allergen avoidance measures are not enough and medication may be required. Over-the-counter antihistamines are useful but it is essential to ensure that a long-acting, non-sedating one is used otherwise the drowsy side-effects can make your child feel even worse. Cetirizine (Zirtek) or loratidine (Clarityn) are good choices. Beyond this, nasal sprays with tiny doses of steroids can be extremely effective. These need to be prescribed by your doctor.
For those with more severe allergic rhinitis, the combination of antihistamine and nasal spray may still not be enough and a referral to an allergy specialist is worth considering. Newer nasal sprays, containing both steroid and antihistamine (such as Dymista) are also effective and may be worth trying.
An allergist can use allergy tests to confirm what the cause of the problem is and may also recommend desensitisation (also known as immunotherapy), as discussed in Chapter 12. This is a highly effective treatment that aims to reduce the allergic response, preventing the symptoms in the nose and eyes from happening in the first place (as opposed to trying to suppress symptoms with antihistamines and steroids). To achieve this, your child’s immune system is gradually exposed to increasing amounts of the allergen, such as grass pollen. There are a number of very attractive benefits to this type of treatment. Firstly, it reduces symptoms and reliance on medication without using drugs. Furthermore, because immunotherapy treatment changes the underlying cause of the allergy, after three years, treatment can be stopped, but the effect continues for years afterwards. Children who have been desensitised have also been shown to be less likely to go on to develop asthma.
Desensitisation can be done by injection or using tablets or drops that are placed under the tongue. Both are safe, although there is a chance of having potential severe reactions to the injections and hence this needs to be done under very close supervision and is not really suited to those who already suffer from asthma. Both sorts of immunotherapy should be done under the supervision of an experienced doctor. Frustratingly, as there are so few trained allergists (particularly paediatric allergists) in the UK, while desensitisation treatments are used widely around the world, they have remained relatively inaccessible in the UK. There are UK centres that do carry it out, however, so if you are concerned about the severity of your child’s allergic rhinitis, ask your GP to refer your child.
The summer before Zach turned four, he developed allergic rhinitis. It seemed to start overnight almost, with a constant sniff, running eyes, rubbing his nose and sneezing. He has been referred for desensitisation. He has been given an inhaler for coughing and signs of asthma and seems to be following the pattern of the allergic march. The desensitisation starts from around five years of age. It is hoped that desensitisation will prevent the worsening of asthma in Zach and therefore prevent worsening of his food allergic reactions.
The link between allergic rhinitis and asthma is important. As mentioned there is a big overlap, with 50 per cent of children with allergic rhinitis developing asthma, while the majority of asthmatics have allergic rhinitis. The link becomes clearest in the summer when rising pollen counts lead to an increasing number of asthma attacks. The presence of allergic rhinitis symptoms has been clearly linked with loss of asthma control. Perhaps, most importantly, correctly recognising and treating rhinitis has been shown to reduce asthma attacks. In short, these conditions can’t be considered in isolation. If your child has one of these, you need to be on the lookout for the other.