When our daughter Anya, was first diagnosed with CMPA (cow’s milk protein allergy) and eczema at 6 months old we were advised by our doctor, allergist and dietician that most children grow out of their allergies and eczema by the age of 2.
In December last year we visited our daughter’s allergist at Birmingham Children’s Hospital to review her condition with skin prick tests and discuss food challenges.
The age of two had come and gone, but her skin prick test results remained the same. There would be no challenges for milk and whilst we discussed reintroducing egg (in a desperate bid to make decent tasting cakes), we were advised against it. The allergist asked me about any reactions Anya had in the last 9 months and I dutifully reeled them off: licked by dogs, wheals from tree sap in the garden, cross contamination from my sticky nieces and nephews, the usual things allergy parents have to contend with. Then I told her about the suspected hay fever she had started to get during the end of summer. And then I told her about the diagnosis of asthma in the winter.
The allergist was overly gleeful at this information, which I choose to believe is enthusiasm for her work and she told me that Anya was going very quickly through the ‘Allergic March’ and that this was a good thing.
I was very disappointed that things hadn’t improved for Anya, and the allergist gave me a hug which threw me a bit, so I never really questioned her further about ‘The Allergic March’. So here is what I found out.
The Allergic March or Atopic March as it is sometimes called is a pattern which some children follow; it is a useful way to describe clinically observed progression of atopic diseases in certain children.
Atopic diseases, including atopic dermatitis, allergic rhinitis and asthma, have increased in frequency in recent decades and now affect approximately 20% of the population in the developed countries.
In this ‘march’, children often develop one set of allergies and symptoms in an order related to their age and development. The word ‘march’ suggests that children pass through each of these stages, but children generally take the allergies and symptoms from one stage with them to the next and develop other allergies and symptoms. In this way, allergies and atopic diseases can overlap.
The first sign of the Allergic March may be the appearance of eczema in babies. A typical pattern of allergy would be to develop food allergy, followed by rhinitis and then asthma. However, this pattern does not apply to every child, and it is hard to predict how each child will experience this progression.
If your child has eczema or a food allergy it doesn’t necessarily mean that they will go on to develop other, more serious, allergic conditions. However, it does mean that they have an increased risk of following the allergic march. For example, in a study of children with peanut allergies, up to 20% of children with eczema went on to develop a peanut allergy by the age of 3, and it is predicted that 80% of those children will remain allergic for life.
First Stage – Eczema and Atopic Dermatitis
Eczema is a general term for any kind of dermatitis which causes itching, redness, blistering, weeping and/or peeling, but is not infectious. Eczema has a negative effect on the quality of life of children and their families, most commonly disturbing sleep.
Atopic dermatitis (AD) is the most severe and long lasting kind of eczema. It mostly begins in childhood, 90% of patients experience it before the age of 5. It mostly affects insides of elbows, back of knees, ankles and the face, but can cover most of the body.
In general, eczema or atopic dermatitis is the first clinical manifestation of the IgE (Immunoglobulin E) response, with the highest incidence during the first three months of life.
On the basis of several studies, about two thirds of eczema patients will develop allergic rhinitis and half will develop asthma.
Second Stage – Food Allergies
Food allergy can be mild, causing stomach or respiratory problems, or more severe, with swelling of limbs and face or in some cases, case anaphylaxis (swelling of the airways) and death.
Eczema or AD can be an excellent indicator of food allergies, once identified and if the offending food is avoided eczema may reduce due to the reduced level of histamines in the body.
Eczema and food allergies commonly co-exist, particularly in children with early onset, severe and persistent eczema. Having a food allergy is a known provoking cause of eczema and the prevalence of IgE-mediated food allergy among children with AD is about 35%.
Third Stage – Allergic Rhinitis
Rhinitis is a general term used to describe symptoms of hayfever, reactions to smoke and other chemicals which cause runny nose, watery eyes, itching, sneezing and congestion due to blocked sinuses. Severe congestion can result in facial pressure and pain and dark circles under the eyes.
Usually two seasons of exposure to pollen allergens are required before the typical symptoms of hayfever appear in children.
Final Stage – Asthma
Asthma is a chronic (persistent or long lasting) lung disease that causes narrowing and inflammation of the airways. Asthma causes periods of wheezing, chest tightness, shortness of breath and coughing at night or in the early morning.
Studies have consistently showed strong associations between rhinitis and asthma. Studies on the prevalence of asthma in patients with rhinitis varies considerably, but has been reported to be as high as 80%.
Those who have persistent wheezing show an association with early food sensitisation (e.g. food allergy or intolerance) and subsequent sensitisation to environmental allergens. There is a strong link between a family history of atopic diseases and asthma in first-degree relatives.
How does this information affect my daughter?
I was told by our allergist that early onset of asthma and rhinitis in my daughter (by the age of three) means that she may grow out of these conditions by the time she is a teenager or adult. The allergist would expect a much improved general condition by the time Anya reaches seven. I have been unable to back up this statement with evidence from studies, but I assume that the allergist sees many children like Anya and from her experience is hopeful of a good outcome for her.
At the moment the causes of all these conditions are unknown and theories are still being tested as to how the march in children can be halted in the earlier stages. So we treat Anya as we go along and try to get proper medical diagnosis as each condition arises.
What have I learnt about the Allergic March in caring for my daughter?
- Be aware of what comes next in the march and watch out for symptoms
- Use appropriate steroid creams to improve the condition of the skin and then use emollients four times a day (I used to put them on every time I changed a nappy when she was a baby)
- Keep trying to find the best combination of creams, I found ones that worked when she was a baby were no longer any use as she went from baby to a toddler, so we kept trying new ones until I was happy her skin had improved
- Early intervention and improvement of the skin condition is supposed to reduce the likelihood of going on to the next stage of the march
- Be aware of the top 8 allergen groups and allergies that go together (like dairy and eggs)
- Find out if any first relatives have food allergies or intolerances
- Keep a food diary to note new foods and symptoms as non-IgE allergies and intolerances; a reaction may be up to 72 hours after ingestion
- Prevention is key, avoid food and ingredients which will cause reactions
- Try to get a dietician referral to help you with weaning without certain food groups if you are at that stage and to help you later if an allergy encompasses a whole group of food that may leave your child lacking in nutrients (e.g. dairy allergy requires an alternative calcium source for growth)
- Read labels carefully every time you buy as companies often change ingredients without it being on the pack that it is a new recipe
- Have the right medication to hand in case of accidents
- Cross contamination with young children is hard to avoid!
- Get the condition diagnosed by a GP and get the right anti-histamines and dosage that work for your child, there is more than one anti-histamine and different children do better on different medicine.
- Anti-histamines prescribed by your GP for food allergy may not be as effective for reducing the symptoms of hayfever
- Get a correct diagnosis from your GP and get the right medications, in the UK brown inhalers, called preventers, contain steroids and blue inhalers, called relievers, contain bronchodilators; we always have a spare handy and have some at Nursery so that we never run out and risk a severe asthma attack.
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