The misery of hay fever.

Exam time is a period of considerable stress for many young people and their families. But in addition to the rigour of the exams themselves, revision and examination periods coincide with the peak hay fever season. This includes not only GCSE's and A levels, but also most university and college examinations. Crucial learning periods prior to exam taking are also adversely affected by uncontrolled symptoms.

Seasonal allergic rhinitis afflicts up to 10% of school-age children and 21-30% of adolescents (Ricketti 1985). Absences from school and poor performance in the classrooom are considered to be among the most serious personal and societal consequences of the disease (Sly 1980). A recent survey of 96 hay fever sufferers aged 11-19 years found that the condition had a major impact on the lives of 93% (Allen and Hanburys 1995).

Children attending school while symptomatic are frequently described as apathetic, absent-minded and uninteresated in educational or social actvities (Avner and Kinsman 1968). Sleep disturbance and, therefore, over-tiredness is coomon, leading to impaired concentration, poor school or work performance, irritability and general depression. Untreated hay fever symptoms can compound exam stress; appropriate, timely treatment can transform a patient's life.

Identifying susceptible individual's before the hay fever season starts is important for practice, school and student health nurses. Since rhinitis is found in more than 90% of patienst with asthma (Cross 1996), nurses need to be on the lookout for any neglected rhinitis symptoms during a routine consultation with an asthma patient.

Referral to a GP for preventative medication is an important second step for many rhinitis patients with moderate to severe symptoms. Over the counter treatments and self-medication do not always provide adequate relief in the coming season.

Including parents in an active management plan is paramount in young patients. Motivating, managing and sustaining a young patient through the hay fever season at a time of high academic pressure demands considerable communication skills from the practice/school nurse.

Correctly identified and diagnosed, rhinitis can be simply and effectively managed from first presentation. Two key patient misconceptions need correcting from the outset if future self-management is to be achieved.

The first is the perception of their condition. Many patients feel their symptoms are perceived as trivial by the medical team, while a recent survey suggested that 42% of paediatric patients considered hay fever to have a major impact on lifestyle (Cross 1997). However, patients might also underestimate the condition's potential seriousness (Cross 1996). At the first presentation, the nurse needs to convey a clear appreciation that rhinitis, though common, is not a trivial condition.

The second preconception is patients' low expectations of treatment efficacy. Advising on the appropriate first line management of hay fever demands a current knowledge of the best non-sedating therapies. Studies show that inappropriate medication might further impair scholastic performance (Guy 1986). However, a holistic approach to the problem is key to management success.

Rhinitis is the commonest condition seen in general practice (Davies 1989) and affects about one in six of the UK population (Scadding 1996). Outside the UK, more cases are being reported. Allergic rhinitis is the commonest immunological disorder in humans and is increasing in prevalence (Burkholter 1995).

Chronic rhinitis can be defined as a non-infective nasal disorder lasting more than eight weeks and charcaterised by inflamation of the nasal mucosa (Scadding et al 1995). Symptoms include congestion, sneezing and nasal discharge. There are two main types, allergic and non-allergic.

Allergic rhinitis symptoms tend to be seasonal and include sneezing, nasal itching and discharge, watering of the eyes, itching, erythema and congestion. In addition, headache, malaise and irritation of the ears and throat might occur.

A diagnosis of allergic rhinitis can usually be established from the patient's history followed by nasal examination and, if possible, skin prick tests. Specific antigens such as pollens or animal antigens are usually readily identifiable.

Two questions can be helpful:

• Do you have two or more symptoms for more than two hours on most days?
• Does this interfere with your quality of life?

Non-allergic rhinitis is characterised by paroxysmal sneezing and watery rhinorrhoea, discharge and blockage. Inhaled allergen tests are negative.

Rhinitis is a bilateral problem. If only one nostril appears affected, the patient should be referred to the GP.

Pollen is the main culprit in hay fever. Close contact with insect-pollinated plants will result in allergic symptoms in a susceptible person. However, wind-pollinated plants produce the greatest volume of pollen and are of most clinical significance to patients with hay fever.

The amount of pollen can vary according to the season and from year to year. Grass pollen allergy occurs from May to July, tree pollen allergy is seen between the months of February and April and certain mould spores during the autumn months. Although predominantly found outdoors, however, pollens are also presnt in significant concentrations in house dust (Platts-Mills 1987). Being aware of the specific local pollen seasons can make patient care more effective. This information should be obtained by anyone caring for a patient with hay fever.

Pollen counts vary each year but peak in June throughout the UK and on warm, dry days with light to moderate winds. Daily peaks occur in rural areas between 7am and 11am with a second smaller peak between 4pm and 7pm and in large cities in the late afternoon and early evening.

Although pollen counts might be four times higher in rural areas than in cities, the incidence of city hay fever is high, probably because of the influence of environmental pollution such as traffic fumes.

Grass pollen is the main cause of hay fever. Within the UK, the predominantly grassland areas of South Wales, the Midlands, East Anglia and central Sothern areas, including inland on the Isle of Wight, have the highest recorded levels.

Lowest pollen counts have been found on western coasts, especially in Scotland, and upland areas of moorland such as those found in Northern Ireland. Throughout the UK and Europe, coastal locations have fewer high pollen days than inland areas.

Tree pollen is the second largest cause of hay fever, affecting 25% of sufferers. Birch pollen is a particular problem. It has a two-year cycle and since last year's count was low, this year will be high. However the season is short (late April until mid July) and the symptoms easy to alleviate.

Allergen avoidance is a key part of management and although environmental controls are not possible, certain simple changes to your daily routine can help reduce allergen exposure (Table 1).

Any treatment advice should contain information on allergen avoidance, but if pharmacotherapy is necessary, the target organ should be the nose, since it is the key to virtually all other symptoms.

Topical corticosteroid nasal sprays are the current first-line treatment for allergic rhinitis. These may be combined with the newer non-sedating antihistamines. Topical sodium cromoglycate is an alternative to corticosteroids, particularly in young children.

Corticosteroids are indicated for patients with thick discharge and blocked nose. Fluticasone propionate is particularly useful in that it combines a once-daily dosing regimen and minimal side-effects with a licence for use in children as young as four years old. Budesonide and triamcinolone acetonide are also available in once-daily acqueous formulations and can be used in children from the age of six years.

One aspect of nasal therapy that has been explored is to improve the speed of action. Recent development of mometasone furoate has addressed this issue and might improve patient compliance.

Systemic corticosteroids are also used. Oral formulations might be given if symptoms are severe. Prednisolone 20mg/day can be given for up to 14 days. Topical treatment should be continued.

Depot intramuscular corticosteroids are not recommended for patients during the revision and exam period. Although they might appear to minimise the need for daily dosage, the dose cannot be monitored and can cause local and systemic side-effects.

Decongestants are for short-term use only. Rebound nasal blockage can result from longer treatment.

Antihistamines might produce less sedation in their newer forms, but they all interfere with skin-prick testing. Examples of commonly prescribed ones are loratadine and cetirizine. Reasons for treatment failure are shown in Table 2.

© Sue Cross BSc, RN, NPDip, PGCE. (1997) Nursing Standard 11, 37, 26-27.

References.
• Allen and Hanburys (1995) Hay Fever Survey. Data on file.
• Avner SE, Kinsman RA (1988) in: Bierman CW, Pearlman DS (eds) Allergic Diseases of Infancy, Childhood and Adolescence. Philadelphia PA, Saunders.
• Burkholter D, Schiffer P (1995) The epidemiology of atopic disease in Europe - a review. Allergy and Clinical Immunology News. 7, 113-125.
• Cross SA (1996) Hay fever: treatment and timing. Practice Nursing 7, 9, 34-36.
• Cross SA (1997) Hay fever: strategies for dealing with hay fever symptoms. Community Nurse. 3, 2, 56-57.
• Davies R (1989) Rhinitis. Pulse May 13, 47-60.
• Guy JJ (1986) in: Lessof MH (ed) Aspects of Allergy: a Symposium Report. Oxford, Medical Education Services.
• Platts-Mills TAE et al (1987) Seasonal variation in dust mite and grass pollen allergens in dust from houses of asthma patients. Journal of Allergy and Clinical Immunology. 79, 781-791.
• Ricketti AS (1985) in: Patterson R (ed) Allergic Diseases. Philadelphia PA, Lippincott.
• Scadding GK et al (1995) Rhinitis Guidelines. London, Allen and Hanburys.
• Scadding GK (1996) Rhinitis: common, debilitating and treatable. The Practioner. 240, 48-53.
• Sly RM (1980) in: Bierman CW, Pearlman DS (eds) Allergic Diseases of Infancy, Childhood and Adolescence. Philadelphia PA, Saunders.