By DR SARAH KARABUS, Paediatric Allergologist
Allergic rhinitis (AR) can be seasonal or be present throughout the year. Seasonal AR is often called hay fever and is typically caused by pollens, and sometimes moulds, found in the air.
Allergy symptoms that present all year round, rather than seasonally, are often due to animals, dust mites, moulds and fungal spores. Here we focus on seasonal AR which in South Africa usually starts in August/September through to February/March.
Hay fever can start at any age but is more common in older children and adolescents. Under the age of two, the most common cause of blocked/runny nose and sneezing is a viral infection. Although rare, AR may occur in toddlers; it is usually caused by indoor allergens such as house dust mites or pet allergies, rather than seasonal pollen allergy. Children need to be exposed to a few pollen seasons before they become allergic to the pollen. Small babies who have only been exposed to one or two pollen seasons in their lives are very unlikely to develop pollen allergies.
The pollens that cause hay fever vary from season to season, as well as from geographic regions. In South Africa, our grass season is very long – from spring to early autumn – so this causes symptoms for many months. The pollen seasons in Europe and elsewhere are much shorter, so hay fever often lasts only a few weeks of the year. The pollens triggering hay fever in Cape Town are slightly different from those elsewhere in the country. With global warming on the rise resulting in longer flowering seasons for plants, pollen seasons seem to get longer and more severe every year.
Common grass pollens causing hay fever include ryegrass, Bermuda grass and kikuyu. Tree pollens include acacia, willow, oak, plane, poplar and cypress. Weed and flower pollens are less important in Cape Town, but are common triggers in Gauteng.
Hay fever is not usually caused by colourful, flowering plants because the pollen from these plants is too heavy to be airborne. In general, if you can see the pollen with your eyes, it is not the cause of your hay fever, as it is too big to be airborne.
An allergy test is not always necessary but can be useful to determine the true cause of the symptoms. Allergy tests are done either by skin-prick testing (‘the scratch test’) or a blood test. Allergy tests are safe and relatively accurate, even in small children and babies. It is a myth that children have to be over a certain age to be tested.
Your GP or paediatrician will be able to diagnose and treat most cases of hay fever, but referral to an allergy specialist may be useful for difficult-to-manage cases.
Treatment of Allergic Rhinitis
Appropriate treatment is important; untreated it may worsen asthma and cause dental problems, sinusitis and post-nasal drip. It affects sleep and can cause poor concentration, fatigue and irritability which may contribute to problems at school.
Treatment of hay fever includes avoiding known triggers by staying indoors on hot windy days when pollen levels peak, driving with windows closed, and avoiding freshly-cut grass. Change your child’s pollen-covered clothing after they come in from school or playing outside. Pollen can collect on your washing on the line so, if possible, dry the allergic child’s linen inside. Second-hand smoke from cigarettes or fires, chemicals/fragrances and other air pollutants can also make hay fever worse.
It is impossible to avoid pollen completely and so using over-the-counter saline sprays are imperative to rinse the allergens out of the nose and eyes multiple times a day during pollen season.
If medication is required, medicated nasal sprays and antihistamines are the most effective treatments.
An allergy specialist may recommend allergy immunotherapy. Immunotherapy involves giving a gradually increasing amount of the allergen until the patient becomes tolerant, or desensitised, to the allergen. This takes about three years to complete but the benefit is that it can reduce allergy symptoms on a long-term basis.
When to start the treatment
If you already know that your child has hay fever, start using the nasal spray a few weeks PRIOR to the start of pollen season. This will help minimise symptoms by protecting and preparing the membrane of the nose and sinuses by the start of pollen season. It takes a few days/weeks for nasal sprays to work optimally so, starting only once pollen season has begun, will not be as effective, and it will take much longer to see a response.
It is best to use the sprays daily during pollen season, and not as-needed. The way in which the nozzle of the nasal spray is positioned is important to maximise the response, so ask your doctor to show you the correct technique. (Aim slightly backwards, not upwards, and tilted away from the nasal septum, towards the outer corner of the eye on the same side.)
Hay fever or a cold?
Both hay fever and a cold start with a blocked nose. To differentiate between the two, note that, while a cold takes 10-14 days to clear, allergies last longer. Also, an allergy won’t show by way of fever or discoloured mucus – as with a cold.
With an allergy, sneezing and itching of the throat, palate and ears are common symptoms. Children often wiggle their noses (like a rabbit!), and push up the tip of the nose (called ‘the allergic salute’). The nose is runny with profuse, clear, thin mucus and the eyes may also become itchy, red and watery.
Paediatrician and Paediatric Allergologist, Dr Sarah Karabus, practices in the Chest & Allergy Centre at Christiaan Barnard Memorial Hospital in Cape Town. A graduate of the University of Cape Town Medical School, Sarah specialised in paediatrics with a further subspecialist fellowship in allergology at the Red Cross War Memorial Children’s Hospital.
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