Search the website

index sitemap advanced

Introduction

From the moment of birth babies must adapt to independent life, and breast milk gives them the best start, unless they are reacting to traces of foods from the mother’s diet, such as cow’s milk or eggs. This is rare, but obviously traces of any food or drug that mother eats must appear in her milk. Unfortunately conflicting opinions may be given by nursing staff regarding infant feeding. Giving a bottle just after birth ‘to give mother a rest’ may still occur, being unaware that this can sensitise the baby to cow's milk before the first breast feed. As a result acute problems may occur without warning when changed from purely breast milk to cow's milk formula.

Asthma and rhinitis in children is more dominantly allergic in causation than later in life, hence an in-depth allergy investigation is more likely to be helpful for children. Unfortunately very few children’s specialists in the UK are interested or knowledgeable about allergy. Asthma is the commonest cause of children being admitted to hospital, but they are usually rescued and sent home again in a few days without any attempt to find the cause, which is often to be found in the home environment or in the food.

Seasonal rhinitis, or “Hay Fever” is caused by allergy to grass pollen which gets in the air in June and July, and less often tree pollens in the spring. There have been great improvements in antihistamine drugs which seldom cause sleepiness now, and steroid sprays are helpful if started at the beginning of the season and used regularly every day until the end. Unfortunately important examinations in England (not in Scotland) are held in the hay fever season and results may be affected either by the hay fever or by the sedative effects of antihistamines obtainable over the counter. In bad cases which cannot be controlled with the usual drugs oral steroids for a few days are fully justifiable, are guaranteed to give certain relief, and hence give no excuse for failure in examinations. There is no reason to fear side-effects from a few days on oral steroids.

Chronic Allergic Rhinitis—a Neglected Affliction

Chronic Rhinitis, with a chronically blocked and runny nose and sneezing, is very common in children but often not recognised as due to allergy, and simply endured and ignored. It is common to have asthma as well, but the nasal problems often cause more disturbance to the quality of life than the asthma by causing nasal blockage, tendency to sinus infections, snoring, mouth breathing, glue ears from blockage of the Eustachian tubes, and even orthodontic problems. If the cause is in the environment or the food repeated insertion of grommets gives only temporary relief. Nasal allergy cannot be removed surgically, yet surgery may be advised without benefit. Chronic perennial rhinitis is easily diagnosed because the sufferers are often sniffing, rub the nose upwards in a characteristic gesture, often have a crease across the tip of the nose, and heavy shadows under the eyes.

The photos below illustrate the characteristic appearances of children with allergy problems. Very few doctors are familiar with these obvious signs of nasal allergy which can have quite serious effects on health. The crease across the nose is one of the commonest signs of allergy and is due to rubbing the nose upwards to ease the itching, a gesture which is called the “allergic salute” in the USA. One of the main advocates of this ‘spot diagnosis’ of allergy was the late Dr Meyer B Marks of Miami, Florida, who published a monograph on the effects of nasal allergy illustrated with similar pictures. I always remember a small boy about thirty years ago with chronic rhinitis and an obvious nasal crease who took my comments so seriously that he went round his class at school and reported at his next visit that 10 out of thirty children also had nasal creases! I wonder what the count would be now, and if he went for a medical career!

Examples of the heavy shadows under the eyes which are a common feature of nasal allergy

Examples of the allergic salute and how the nasal crease is created

High palate and Malformed teeth	sniffing to ease itch	Extra folds on the eyelids are a sign of eczema

The Importance of Finding the Causes of Childhood Asthma

The prevalence of Asthma continues to increase year on year, and allergies are more important as a cause of asthma and eczema in children than in adults. If asthma is allowed to become chronic permanent changes will eventually become established by remodelling of the bronchial tubes whereby the walls become thicker and stiffer. Even if the cause can be found and completely avoided after an asthmatic child has grown up into an asthmatic adult it will be a long time before the irritability of the bronchi and the reaction to the allergen which triggered the asthma attacks will cease and the ‘remodelling’ reverts to normal. Unfortunately this logical approach is seldom followed in the UK today, where it is uncommon for any investigation to find and perhaps eliminate the cause is undertaken, and treatment depends almost entirely on drugs.

It is surprising how few Paediatricians, who specialise in children, appear interested in finding out why their hospital wards are crowded with wheezing children. Asthmatic children often do not get better spontaneously at age seven or fourteen years, yet parents may still be assured that they will do so. Even those children who lose their asthma in adolescence quite often relapse in later life. Even when asthma is effectively suppressed with drugs these children are still becoming permanently programmed to respond to common allergens such as dust mite. This is because the allergic reactions in the bronchi are only suppressed, not stopped altogether.. This also means that even if these allergy victims are properly investigated and their allergies sorted out after they have grown up into adults the prospect of really significant improvement is less than it would have been if they had had proper investigation and treatment when they were young and completely reversible. This suggests that in future the numbers of established chronic asthmatics will increase, unless the allergic factor is properly dealt with in childhood, not in adulthood when it may be too late.

Chest Deformities Caused by Asthma

Chronic asthma in children can produce deformities because the bony frame of the growing chest is soft and hence more easily distorted. The gross deformities shown have become uncommon since the introduction of effective treatment, particularly inhaled steroids, and most were seen many years ago. These changes are often reversible if effective treatment such as inhaled steroids is introduced before the growth spurt in adolescence.

Examples of the effects of chronic uncontrolled asthma on the shape of the chest in teenagers

The long-term effects of life-long chronic asthma, showing gross over-inflation of the deformed chest

Allergies may change as time goes by

The affected part of the body can also change with time. For example a baby could be intolerant or allergic to milk or egg causing eczema or colic which fades out, but may often be replaced by rhinitis and/or asthma, or all these problems may persist indefinitely. This is known as the ‘Allergic March’ which will seldom stop unless the causative allergies are identified. Advice to await growing out if it is unreliable, as the more severe the asthma in childhood the more likely that it will persist lifelong, and even when the asthma goes into remission it quite often returns in later life. There is evidence, from trials in Europe and the USA, that treating the seasonal hay fever with desensitisation seems to prevent the child acquiring other allergies in the early years, but of course British children are denied this chance.

Dangerous allergies causing anaphylactic shock in children are most commonly caused by peanuts or other nuts eaten accidentally. It is essential that these children always carry two special Epipen or Anapen syringes containing adrenaline, (Epinephrine in USA) and that the school teacher is willing to give the injection in an emergency if the child is too young to do this themselves. There can be problems in arranging for adequate precautions regarding diet at school, and teachers responsibility for dealing with a possible emergency.

It is obviously very important to find out exactly which foods must be strictly avoided, but finding a clinic in the UK where this can be investigated may be difficult. It is also potentially life-saving to wear a ‘Medic-Alert’ bracelet to warn doctors of a dangerous allergy, especially to drugs they might inject, especially If the patient is unable to speak. Information is available at www.medicalert.org.uk

It is also most important to join the Anaphylaxis Campaign at www.anaphylaxis.org because their newsletters are very informative and ensure that the patient is aware of the latest developments and new dangers, such as lupin flour. In my opinion the membership fee for both these organisations should be taken care of by the NHS because their service is so inadequate.