Hay fever has a reputation as a minor nuisance, but for children with moderate to severe symptoms during exam season — which coincides almost exactly with the grass pollen peak in the UK — it is anything but minor. Studies have consistently shown that hay fever during examination periods is associated with a reduction in academic performance. One influential study by Warner et al. (2015) estimated that children with untreated hay fever scored around 40 per cent lower in exams than would be expected from their usual performance.
The other underappreciated issue is sleep. Nasal congestion during the night means mouth breathing, disrupted sleep, and daytime fatigue — which compounds attention and learning difficulties on top of the direct effect of inflammation on cognitive function.
Healthbooq (healthbooq.com) covers allergy and seasonal health through childhood.
What Hay Fever Is
Allergic rhinitis is inflammation of the nasal mucosa caused by an immune response to inhaled allergens. Seasonal allergic rhinitis (hay fever) is specifically triggered by pollen — tree pollen (February to May), grass pollen (May to July), and weed pollen (June to September) are the main UK seasons. Perennial allergic rhinitis is triggered by year-round allergens like house dust mite, pet dander, and mould spores.
When an allergic individual inhales pollen, IgE antibodies on mast cells in the nasal mucosa recognise the antigen and trigger degranulation, releasing histamine and other inflammatory mediators. This causes the classic symptoms of sneezing, itching, runny nose, and nasal congestion, as well as itchy watery eyes (allergic conjunctivitis) in many children.
Hay fever commonly begins in childhood, often from age four or five onwards, though younger children can be affected. It tends to run in families alongside eczema and asthma (the atopic triad). A child with eczema or asthma is at higher risk of developing hay fever.
Symptoms
The cardinal symptoms are: nasal itching, sneezing (often in runs), clear watery rhinorrhoea (runny nose), and nasal blockage. Eye symptoms — itching, redness, watering — occur in 50 to 70 per cent of cases.
Children often rub their nose upward with the palm of the hand (the "allergic salute"), which over time can leave a horizontal crease across the nose. Dark circles under the eyes ("allergic shiners") can result from venous congestion. Oral allergy syndrome — tingling or itching in the mouth after eating fresh fruit or vegetables that share proteins with tree pollens — is common in pollen-allergic individuals.
Moderate to severe hay fever causes significant impairment: poor sleep, daytime fatigue, difficulty concentrating, irritability, and in children with asthma, increased asthma symptoms (poorly controlled allergic rhinitis is a risk factor for asthma exacerbations).
Treatment
NICE guidelines (CG134) recommend a stepwise approach:
Step 1 for mild intermittent symptoms: a non-sedating oral antihistamine (cetirizine or loratadine) as needed. These are available over the counter from age two (loratadine, as syrup) or age six (cetirizine tablets). Older first-generation antihistamines like chlorphenamine (Piriton) are sedating and should be avoided in school-age children.
Step 2 for moderate to severe or persistent symptoms: add an intranasal corticosteroid spray (such as beclometasone nasal spray, available over the counter, or fluticasone on prescription). Nasal steroid sprays are the most effective treatment for allergic rhinitis and are safe for children at recommended doses. They take a few days to reach full effect, so starting before the peak season is more effective than starting when symptoms are already severe.
Step 3: consider combining antihistamine, nasal steroid, and antihistamine eye drops for eye symptoms (sodium cromoglicate, or olopatadine on prescription).
Referral to allergy clinic for skin prick testing, specific IgE measurement, and consideration of immunotherapy is appropriate when symptoms are severe, not controlled by the above, or associated with difficult-to-control asthma.
Allergen Immunotherapy (Desensitisation)
Sublingual immunotherapy (SLIT, using drops or tablets) or subcutaneous immunotherapy (SCIT, injections) gradually desensitises the immune system to specific pollen allergens. NICE guidance supports immunotherapy for severe grass pollen rhinitis meeting eligibility criteria. It is the only treatment that modifies the underlying allergic process rather than controlling symptoms. It is typically given over three years.
Practical Measures
Reduce pollen exposure during high-count days (available from the Met Office and pollen tracker apps): keep windows closed in the morning when pollen levels peak, change clothes and shower after outdoor activity, wear wraparound sunglasses, apply petroleum jelly just inside the nostrils to trap pollen, and check daily pollen forecasts. These are adjuncts to treatment, not replacements.
Key Takeaways
Allergic rhinitis (hay fever) affects approximately 20 per cent of children in the UK. It is a common cause of poor sleep, reduced concentration, and school absence, particularly during the grass pollen season (May to July). First-line treatment is a non-drowsy antihistamine tablet (cetirizine or loratadine) combined with an intranasal corticosteroid spray. Nasal steroid sprays are more effective than antihistamines alone for moderate to severe hay fever and are safe for children. Allergen immunotherapy (desensitisation) is available for severe, refractory cases meeting certain criteria.
