Allergies and School

Developing allergies in school is commonly seen in young infant and children who start spending more time away from home. Frequent health ailments such as repeated coughing, watery nasal discharge, skin rashes and tummy troubles can occur following school attendance. In some, the child can even be cranky, crying, refusing to go to school due to the uncomfortable symptoms. These can be tell-tale signs of allergies.

This article is written to improve awareness of potential allergies that children can be exposed in school. Early detection of allergies in children helps to improve the child's quality of life, minimizing absenteeism from school and prevent disruption of daily learning school experience.

Understanding Atopy in Children

Atopic diseases are constellation of medical conditions that can affect various organs including the respiratory system, the skin, and the gut. Atopic diseases are complex immune conditions that remain partially understood medically. In atopy, there is a genetic predisposition of susceptible person to develop allergy. This is further triggered by afterbirth environmental stressors- such as infection, irritants, surrounding allergens/ proteins and etc.

The immune system of an atopic person is able to mount an immense inflammatory exaggerated response when it is exposed to a usually harmless protein/ allergen in the environment, resulting in allergic symptoms clinically. Atopy in early infants and children is also explained by the 'hygiene hypothesis' whereby due to 'more hygienic environment' and less exposure to 'allergen/ trigger-proteins', the child is more predisposed in developing atopic diseases.

Childhood atopic conditions include atopic dermatitis, food allergy, allergy rhinitis and allergic asthma. In those children with atopic conditions, they are at risk of developing another atopic condition during their childhood, a common term known as 'atopic march'. This is due to the association and interlinkage of these atopic conditions. 3 out of 4 children with atopic dermatitis will develop allergic rhinitis, and 1 out of 2 with atopic dermatitis will develop asthma.

Atopic Diseases in Children

Atopic Dermatitis

Atopic dermatitis (also known as eczema) is one of the most common recurring non-infectious, inflammatory skin condition presenting in the early childhood. One suffers from recurring flaky, dry, red, itchy, oozy, crusted skin rash. The rash can affect any part of the body. Atopic dermatitis is frequently associated with allergies due to genetic innate skin barrier dysfunction and further triggers from environmental factors such as stress, irritants, infections, heat, humidity and allergens. 1 in 4 children with atopic dermatitis have concurrent food allergies.

The relapsing and chronicity of skin inflammation can take a toll on a child's growth development resulting in poor sleep quality, psychosocial impact in school (due to skin physical appearance), reduced quality of life, and increases risk of skin infection complications.

Allergic Rhinitis

This is the most common childhood diseases due to allergies. It is also known as 'hay fever'. Affected children presents with upper airway symptoms such as nose congestion, watery nose, sneezing, post-nasal coughing, frequent mouth breathing, itchy and watery red eyes, even ear infections.

When allergic rhinitis is not managed, it can affect a person's breathing, resulting in poor sleep quality, constant mouth-breathing and poorer growth of the teeth and facial bone structures. Recurring upper airway infection such as sinusitis, ear infection can result in hearing impairment and poor speech development. In some cases, allergic rhinitis may progress to allergic asthma as part of the atopic march - as a progression of the allergy disease.

Food Allergies

A person with food allergy can experience allergic symptoms such as rashes, lip swelling, eye swelling, breathing difficulty or even anaphylaxis. Presentation of food allergies in children can be much subtler with symptoms such as poor feeding, refusal of food, abdominal cramps, diarrhea, vomiting and failure to thrive. It is important for parents and physicians to pick up food allergies in children as their symptoms can differ compare to adults and their symptoms are commonly mistaken as a stomach infection/ flu.

Undiagnosed food allergies can lead to prolonged poor gut absorption, malnutrition, failure to grow, and stunted childhood development.

Allergic Asthma

Sensitization of airborne allergens and food protein allergens can contribute to allergic asthma in children. Symptoms of allergic asthma is often described as persistent cough, wheezing (musical sound) when breathing, shallow/quick and labored breathing. Those with other forms of atopic diseases such as food allergies, atopic dermatitis and rhinitis have increased risk of developing allergic asthma- as part of the atopic march progress.

Chronic allergic asthma can be associated with poorer quality of life of the child, frequent school absentees due to asthma attack episodes and weaker school performance, weaker lung function and more side effects from asthma long-term medications.

Potential Allergens Found in School

Children who have started schooling can be exposed to various environmental allergies. As school is the main channel to cultivate and nurture a child's learning, children are encouraged to interact with people (teachers, schoolmates), various activities and both indoor and outdoor surroundings. During this journey, one may be inadvertently in contact with allergens in the school environment.

Common allergens that can be found in school compounds- both indoor and outdoors include

• Dust mites
• Moulds
• Cockroach particles
• Grass and pollen
• Insect (bits and stings)
• Cat and dog dander
• Latex (balloon, rubber, gloves, school supplies etc)

School meals from canteen/ sharing of food with other classmates can potentially expose susceptible children to food allergies.

Common food allergens that can trigger allergy include

• Egg
• Cow's milk/ soya
• Wheat
• Peanut/ treenut
• Seafood/ shellfish
• Sesame

Allergies in school may not develop immediately. The allergen can be introduced into the body of the child through inhalation, direct skin contact or oral consumption. Over time, the immune cells in the body are sensitized and able to recognize the allergen, leading to a cascade of inflammatory immune response that can be clinically seen as allergic/ atopic symptoms.

Can school-acquired infections trigger atopy and allergy?

School environment can be a reservoir for various pathogens (bacteria, viruses, fungus) to thrive. Children who attend school can be exposed to these environmental microbes. Atopic children who acquire infections from school can have flare-ups of their atopic diseases due to triggering of underlying immune system following an infection.

On the skin, common bacterial infections such as staphylococcus bacteria infection, or viruses such as molluscum contagiosum and herpes viral infection can trigger a flare up of atopic dermatitis in susceptible children

As for respiratory symptoms, children that are exposed to common airborne viruses such as Influenza A/B, Covid virus, Adenovirus, RSV (Respiratory Syncytial Virus) can result in persistent respiratory allergies such as allergic rhinitis/ allergic asthma.

Symptoms of School Allergies

As young children or pediatric groups are less vocal and less able to describe their symptoms to the adult, as family member, school teachers or physicians, it is imperative to recognize the symptoms that the child is not well.

A child with allergy may present with subtle, non-specific signs such as cranky, crying, poor appetite, refusal/ withdrawal from engaging in school/ certain activities.

Other common symptoms include:

Symptoms of anaphylaxis should not be missed by any adults. The catastrophic allergic symptoms are characterized by acute unwell of a child, labored and difficult breathing, wheezing, choking, facial puffiness, eye, lip, tongue swelling, generalized hives and rashes over the body. In those situation, do immediately bring your child to the emergency department as this can be life threatening.

How can I check for possible school allergies for my children?

If you have concern of allergies that your child may have developed following attending school, do reach out to your healthcare providers for further evaluation.

Your doctor will usually evaluate your child's concern and symptoms, determine a correlation of your child's symptoms and certain triggers that can be found in school. In school allergies, your child may notice his/ her symptoms are better or resolved when he/ she is away from school, and symptoms may recur or worsen on school days.

In real world, symptoms association may be vaguer with potentially other confounding factors. In such cases, allergy tests can be beneficial in teasing out the underlying allergies.

Most allergy tests for school allergens can be done safely in outpatient settings under the guidance of your healthcare provider.

• Skin prick tests
• Blood RAST tests
• Food challenge tests (done in hospital)

Worth speaking to your doctor on which are the suitable tests for your child to understand any underlying allergies.

What can we do about School Allergies?

As A Parent, Managing Allergies in School

• Arrange an appointment with your healthcare provider with your child to identify the trigger allergens.
• Stock up prescribed medications from your doctor. Worth checking with your doctor whether there is a need for adrenaline pen in the event of severe allergic reaction.
• Obtain a letter from your healthcare providers on your child's allergies.
• Informrespective school personnel/ teacher/ nurse on your child's allergies.
• If your childhas a risk of anaphylaxis:
  • Do ensure yourchild always has access to adrenaline.
  • If your child is old enough to understand, ensure your child is aware of allergic symptoms and reach out for help when need, ensure they know how to use adrenaline pen.
  • Inform the school that your child has a history of anaphylaxis.
• Still encourage your child to get involve with school activities as much as possible (unless advised otherwise by your healthcare providers), to prevent them from feeling left out or being ostracized due to the allergy.

Medical Management of School Allergies

• Antihistamines and steroids remain the backbone mainstays of allergy treatment in managing allergy and atopy.
• Steroid medication in the form of cream, ointment, nose spray, inhalers, oral liquid solution may be offered to your child.
• Adrenaline injection may be required in those with severe anaphylaxis episodes. School children and parents should be counselled and taught how to use adrenaline injection, recognize the acutely distressed child and deliver adrenaline injection without delay.
• In certain chronic atopic conditions that are associated with airborne allergens, immunotherapy treatment can be offered safely and effectively as a long-term management of the atopic symptoms. It is suitable for a child above the age of 5 years old.

Contact DB Clinic

If you suspect your child has school-related allergies or needs a personalised action plan, don't wait to seek expert help. Our doctors specialise in accurate allergy testing and creating effective management strategies for children. Schedule a consultation today to ensure your child's safety and well-being.

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