The atopic march is a term used to describe the allergic progression that begins in early childhood. Atopic illnesses in childhood include atopic dermatitis (eczema), food allergies, asthma and allergic rhinitis (hay fever).
Atopic illnesses are caused by a problem with the immune system, and children with one atopic illness have a good chance of getting another atopic illness sometime during childhood or adolescence. It is estimated that 75 percent of kids with atopic dermatitis will develop environmental allergies and more than 50 percent will develop asthma. As these kids march through childhood, they are likely to get other allergic illnesses.
Eczema and Allergy Triggers
The atopic march usually starts in infancy with atopic dermatitis (eczema). As food is introduced into an infant’s diet, allergic reactions to certain foods may occur. Respiratory infections in the first two years and exposure to allergens inside the home and environment usually lead to the beginning of wheezing in childhood. Later in childhood as the exposure to outside allergens increases, children on the atopic march will start to have nasal allergies.
There are two main factors that put a child at risk for becoming allergic. Family history of allergies is the biggest risk factor for a child developing any one of the atopic illnesses. If one parent has or has had allergies, the child is more likely to have them, too. This genetic risk allows a child’s body to react to some allergic trigger, and the atopic march begins.
The second factor associated with atopic illness is the child’s living environment. Exposure to certain triggers at home, childcare and other places add to the risk of becoming allergic. The “hygiene hypothesis” suggests that too much cleanliness and avoiding things that may cause an allergy early in life might cause more allergies. It’s known that kids who live on farms and have early exposure to plenty of grasses, weeds and animals have less asthma than children who live in the city. Early exposure to peanuts may actually decrease the risk of a life-threatening peanut allergy. Those who are exposed to viruses and bacteria in childcare and school may also be protected from the progression of the atopic march.
Eczema is often referred to as the itch that rashes. It is the most common chronic skin disease of childhood. The skin becomes ashy, red, scaly, irritated and even more itchy. About 30 percent of kids with atopic dermatitis have a food allergy; however, eating those foods does not cause the skin to get worse. Contact with other allergens or irritants such as sweat, fragrant soaps and lotions, perfumes and wool can make skin symptoms worse.
Your provider can recommend hypoallergenic, fragrance-free soaps, creams and ointments. When a child with eczema gets sick with a virus or bacteria, the eczema will generally get worse during and after the illness.
Having a child with atopic dermatitis can be quite frustrating. It is a chronic disease, and there will be times that it’s under control and times that it’s difficult to control. Although atopic dermatitis requires a lot of ongoing care during childhood, it’s reassuring to know that most children outgrow atopic dermatitis by adolescence.
Food allergies are common in childhood, and often are the next step of the atopic march. Peanut, nut and egg allergies are the most common and least likely to go away over time. Milk, soy, egg and citrus allergies tend to go away as a child gets older. Allergies to peanuts, nuts, fish and shellfish may last longer and can become quite severe.
The most severe food allergic reaction is called anaphylaxis, and it usually happens within 15 minutes of exposure to an allergen. It can also be caused by medications, animal venom (bees) or latex. Anaphylaxis causes hives, facial swelling and tightening of the airways that leads to wheezing, coughing and difficulty breathing, which may become life-threatening. Swelling of the mouth and throat can make swallowing difficult and make a child’s voice sound strange. Hives might occur around the face and mouth or anywhere on the body. Some food allergies can cause severe vomiting and diarrhea, which are also considered a serious food reaction.
Anaphylaxis must be recognized early and treated immediately. The best way to avoid a severe allergic reaction to food is to avoid any contact with an offending food(s). Your provider can see to it that you have the right medications at home and at school should your child have a severe allergic reaction.
Asthma, the most common chronic lung disease in kids, is the next part of the atopic march. The diagnosis of asthma is usually not given to a child under four years who has wheezy illnesses. At age four, many kids stop having respiratory illnesses with wheezing, while others go on to have chronic asthma problems.
Asthma causes inflammation (swelling) inside the small airways of the lungs, squeezes the muscles around the airways and produces a lot of mucus. These changes cause coughing, wheezing, chest tightness and difficulty breathing. Respiratory infections, changes in weather, exposure to secondhand smoke and allergens are the major triggers of an asthma attack. Preventing these attacks and avoiding the need for albuterol and oral steroids are the goals of asthma treatment. Together with your provider, you and your child can create an asthma care plan to stay as healthy as possible.
The next step of the atopic march is allergic rhinitis (hay fever). Allergies cause inflammation in the nose, eyes and throat after exposure to an environmental trigger, such as house dust mite droppings, cockroaches, animal dander, pollens, molds and secondhand smoke. This kind of allergic illness can be seasonal — for example, during the spring and fall — or year round.
The most common symptoms are watery eyes, a runny nose, a stuffy nose, hives, itching and sneezing. During peak allergy season, allergic rhinitis can become quite severe, leading to difficulty sleeping, fatigue and feeling miserable. Avoiding what can trigger allergic symptoms is the most important part of treating allergic rhinitis.
There are many prescription and over-the-counter remedies for symptoms of allergic rhinitis. Eye drops containing antihistamines and non-steroidal anti-inflammatories can elevate and prevent eye symptoms. Nasal allergy sprays can clear congestion, treat nasal swelling and make the skin in the nose less reactive to allergens. Sedating the non-sedating oral antihistamines treat all symptoms at the same time. Showering and shampooing after exposure, applying cool compresses to itchy eyes and taking appropriate medications should help kids with hay fever feel better. With all of the options available, children should not have to suffer from allergic rhinitis.
Atopic illnesses are very common in childhood. The good news is that families can manage most of them with the help of their provider. A referral to an allergy specialist might be in order if symptoms are not being adequately controlled or are getting worse, or if allergy or other testing is needed.
Ann Petersen-Smith, PhD, APRN, CPNP-PC, CPNP-AC, is currently working in the Pediatric Call Center at the Children’s Hospital Colorado. She has had the honor to teaching and mentoring many PNP students during the last quarter century. Ann also does consultant work that includes writing, editing, teaching in online programs, and committee work for the Society of Pediatric Nurses and the Colorado State Board of Psychologist Examiners.