Prevalence and risk factors for allergic rhinitis in primary school

International Journal of Pediatric Otorhinolaryngology (2007) 71, 463—471
www.elsevier.com/locate/ijporl
Prevalence and risk factors for allergic rhinitis in
primary school children
Zeynep Tamay a,*, Ahmet Akcay b, Ulker Ones a, Nermin Guler a,
Gurkan Kilic a, Mehmet Zencir c
a
Department of Pediatrics, Division of Allergy and Chest Diseases, Istanbul School of Medicine, Istanbul
University, Istanbul, Turkey
b
Department of Pediatrics, Pamukkale School of Medicine, Pamukkale University, Pamukkale, Turkey
c
Department of Public Health, Pamukkale School of Medicine, Pamukkale University,
Pamukkale, Turkey
Received 13 June 2006; received in revised form 15 November 2006; accepted 17 November 2006
KEYWORDS
Allergic rhinitis;
ISAAC;
Risk factors;
Children
Summary
Objective: Allergic rhinitis is a common chronic illness of childhood. The aim of the
study was to evaluate the prevalence and risk factors of allergic rhinitis in 6—12-yearold schoolchildren in Istanbul.
Methods: A total of 2500 children aged between 6 and 12 years in randomly selected
six primary schools of Istanbul were surveyed by using the International Study of
Asthma and Allergies in Childhood (ISAAC) questionnaire between April and May 2004.
Results: Of them 2387 (1185 M/1202 F) questionnaires were appropriately completed
by the parents with an overall response of 95.4%. The prevalence of physiciandiagnosed allergic rhinitis was 7.9% (n = 189). A family history of atopy
(aOR = 1.30, 95% CI = 1.00—1.68), frequent respiratory tract infection (aOR = 1.36,
95% CI = 1.08—1.70) and sinusitis (aOR = 2.29, 95% CI = 1.64—3.19), antibiotic use in
the first year of life (aOR = 1.26, 95% CI = 1.01—1.57), cat at home in the first year of
life (aOR = 2.21, 95% CI = 1.36—3.61), dampness at home (aOR = 1.31, 95% CI = 1.04—
1.65) and perianal redness (aOR = 1.26, 95% CI = 1.01—1.57) were significant for
increased risk for allergic rhinitis. Frequent consumption of fruits and vegetables
were inversely, and frequent consumption of lollipops and candies were positively
associated with allergic rhinitis symptoms.
Conclusion: Our study reconfirmed that family history of atopy, frequent respiratory
tract infections, antibiotics given in the first year of life, cat at home in the first year
of life, dampness at home, perianal redness and dietary habits are important
* Corresponding author at: Department of Pediatrics, Istanbul Medical Faculty, Capa 34390, Istanbul, Turkey.
Tel.: +90 212 4142000/32349; fax: +90 212 6319301.
E-mail address: [email protected] (Z. Tamay).
0165-5876/$ — see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2006.11.013
464
Z. Tamay et al.
independent risk factors for AR. Researchers worldwide should be focused to these
factors and try to develop policies for early intervention, primary and secondary
preventions for allergic diseases.
# 2006 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Allergic rhinitis (AR) is a very common disease in
childhood as well as in adults and impairs the quality
of life if left untreated [1]. AR is characterized by
nasal itching, sneezing, watery rhinorrhoea and
nasal obstruction [1]. The prevalence of childhood
AR shows wide variation throughout the world, ranging from 0.8% to 39.7% [2].
The prevalence of allergic diseases has increased
predominantly in developed countries, which indicates that environmental risk factors and life style
rather than genetic predisposition seem to be the
major determinants of allergic diseases [2—4]. Various risk factors have been described for AR according to different stages during life. Family history of
atopy, month of birth, parental smoking, male sex,
early exposure to allergens or pollutions were considered to be potential risk factors by epidemiological surveys [1,4—6]. But major determinants
contributing development of AR is still not clear.
The aim of the study was to evaluate the prevalence and risk factors of allergic rhinitis in 6—12year-old schoolchildren in Istanbul.
2. Methods
This survey was held in children aged between 6 and
12 years in randomly selected six primary schools in
Istanbul. A total of 2500 questionnaires were distributed to the children to be completed by their
parents at home. The return visit to the school was
done within a 2-week period to try to collect data
from children formerly absent. The standardized
ISAAC Phase I written core questionnaire was translated into Turkish and used. There have been quite a
few studies carried out in Turkey using the ISAAC
questionnaire [7—10], therefore it is well known and
validated in Turkish studies. An additional questionnaire was prepared to identify demographic features and potential risk factors, including: sex,
family history of atopy, the presence of physiciandiagnosed eczema or food allergy, frequent upper
airway infections and sinusitis, history of tonsillectomy or adenoidectomy, antibiotic or paracetamol
use in the first year of life, exposure to tobacco
smoke at home, maternal and paternal smoking, cat
or dog ownership in the first year of life, home
dampness, heating system, born in and living period
in Istanbul, exposure to diesel trucks, perianal redness and diet.
Dietary intake was estimated by using additionally a semi-quantitative food frequency questionnaire. Consumption of protective foods including
starch such as potatoes, rice, cereals, pasta, vegetables, fish, other sea foods, fruits, nuts, olive oil,
fish oil, and some traditional foods made from
grapes and mulberries, fermented drinks made from
millets and various seeds; aggravating foods including fast-food, potato chips, crackers, chocolates,
lollipops, candies, cookies, muffins, margarine;
other foods including eggs, animal fats, milk and
dairy products, meat, polyunsaturated fatty acids
(butter), sun-flower oil, corn oil, tea, olive and were
asked [11]. Analysis of diet variables were determined by frequency of consumption of foods in three
groups including: ‘‘never or occasionally’’, ‘‘once or
twice per week’’ and ‘‘three or more times a week’’.
Having a problem with sneezing or a runny, or
blocked nose in the absence of a cold or a flu in the
past 12 months was assessed as ‘‘current allergic
rhinitis’’ [2,12]. Positive response to the question
about having had allergic rhinitis diagnosed by a
physician was considered to be ‘‘ever doctor-diagnosed allergic rhinitis’’. Severity of allergic rhinitis
was assessed among children with current rhinitis
from the responses the questions on the presence of
accompanying itchy-watery eyes and about interference with daily activities because of nose problem.
2.1. Ethical consideration
The study was approved by the Ethics Committee of
Istanbul University, Istanbul School of Medicine.
2.2. Statistical analysis
Statistical analysis included percentages, odds
ratios (OR), 95% confidence interval (95% CI), chisquared test and backward logistic regression. Prevalence estimates were calculated by dividing positive responses to the given question by the total
number of completed questionnaires. The 95% CI of
these prevalence rates was also calculated. According to ISAAC policy, missing and inconsistent
responses were included in the denominator for
Prevalence and risk factors for allergic rhinitis
the prevalence calculations, but excluded from subsequent bivariate analysis [13—17]. The relation
between risk factors and current AR prevalence
was performed by univariate analysis using chisquared tests and univariate odds ratio (uOR) and
its 95% CI. A p value less than 0.05 was considered
significant. Risk factors significantly affecting current AR prevalence were family history of atopy, the
presence of physician-diagnosed eczema or food
allergy, frequent upper airway infections and sinusitis, history of adenoidectomy, antibiotic or paracetamol use in the first year of life, cat or dog
ownership in the first year of life, home dampness,
exposure to diesel trucks, perianal redness. These
risk factors were tested in a backward logistic
regression analysis with adjusted odds ratio (aOR)
and its 95% CI. Consumption of foods were analysed
by the same method, separately. The SPSS software
package Version 12 was used for all statistical analyses.
3. Results
Of the 2500 questionnaires distributed, 2387 questionnaires were appropriately completed by the
parents with an overall response of 95.4%. There
were 1185 (49.6%) boys and 1202 (50.4%) girls with a
M/F ratio of 0.99.
The prevalence for lifetime rhinitis, rhinitis in
last 12 months, rhinoconjunctivitis in last 12 months
and physician-diagnosed rhinitis were 44.3%, 28.9%,
7.8% and 7.9%, respectively (Table 1).
No significant relation was observed between sex
and prevalence of AR ( p = 0.34, uOR = 0.92, 95%
CI = 0.77—1.10).
A family history of atopy ( p < 0.001, uOR = 1.78,
95% CI = 1.44—2.19), physician-diagnosed food
allergy ( p = 0.005, uOR = 1.51, 95% CI = 1.13—
2.03), physician-diagnosed eczema ( p = 0.016,
uOR = 1.77, 95% CI = 1.11—2.83) were significant
for increased risk for AR. Of the children with AR,
62 (34.6%) had family history of atopy, 87 (48.1%)
had asthma, 19 (10.6%) had eczema, and 37 (20.8%)
had food allergy.
Table 1 Summary of parental-completed allergic rhinitis questionnaire data
465
Frequent upper airway infection and sinusitis
were significant risk factors for AR ( p < 0.001,
aOR = 1.36, 95% CI = 1.08—1.70 and aOR = 2.29,
95% CI = 1.64—3.19, respectively). Of children with
AR, 62.1% had frequent upper respiratory infections
and 21.7% had frequent sinusitis.
History of tonsillectomy was not correlated with
AR. Although history of adenoidectomy was significant by univariate analysis, it lost its significance
when evaluated by multivariate analysis.
Antibiotic and paracetamol use in the first year of
life increased the risk for development of AR by
univariate analysis ( p < 0.001); antibiotic use in the
first year was a significant risk factor by multivariate
analysis (aOR = 1.26, 95% CI = 1.01—1.57).
AR prevalence was neither associated with exposure to tobacco smoke at home nor with maternal
and paternal smoking. Cat or dog ownership during
the first year of life significantly affected the development of AR ( p = 0.001, uOR = 2.02, 95% CI = 1.32—
3.09 and p = 0.044, uOR = 1.91, 95% CI = 1.00—3.62,
respectively). Especially cat at home during the first
year of life was an independent risk factor for AR
(aOR = 2.21, 95% CI = 1.36—3.61). Dampness at
home was significantly and independently associated with AR ( p = 0.001, uOR = 1.42, 95%
CI = 1.16—1.74 and aOR = 1.31, 95% CI = 1.04—1.65).
Although exposure to diesel truck was a significant risk factor for AR ( p = 0.002, uOR = 1.35, 95%
CI = 1.12—1.62) by univariate analysis, it lost its
significance when it was evaluated by multivariate
analysis. Heating system, born in Istanbul or time
lived in Istanbul did not affect the AR prevalence.
Perianal redness was a significant independent
risk factor for AR ( p < 0.001, uOR = 2.21, 95%
CI = 1.77—2.75 and aOR = 1.83, 95% CI = 1.43—
2.36). Risk factors for AR were shown in Table 2.
Among the protective foods rice, vegetables and
fruits were relatively less consumpted; among the
aggravating foods lollipops, candies were relatively
more consumpted and among other foods meat and
sun-flower oil were consumpted three or more times
a week by children with allergic rhinitis (Table 3).
When these risk factors were tested in a backward
logistic regression analysis with adjusted odds, only
fruit, vegetable and lollipop, candy consumption
were independently and significantly affected AR
prevalence (Table 4).
Questionnaire
Prevalence (%)
Lifetime rhinitis
44.3
4. Discussion
12-Month prevalence
Rhinitis
Associated itchy eye
28.9
7.8
The present study showed that nearly one third of
6—12-year-old Turkish children had rhinitis, defined
as sneezing, runny or blocked nose in the absence of
a cold or the flue.
Physician-diagnosed allergic rhinitis
7.9
466
Z. Tamay et al.
Table 2 Potential risk factors for allergic rhinitis
Factors
Children with
current allergic
rhinitis symptoms
n (%)
Sex
M
F
332 (28.0)
358 (29.8)
Family history for atopy
Yes
No
192 (39.2)
485 (26.6)
aOR (95% CI)
0.92 (0.77—1.10)
1.00
<0.001
80 (37.2)
584 (28.1)
Physician-diagnosed eczema
Yes
No
31 (41.3)
636 (28.5)
1.78 (1.44—2.19)
1.00
0.005
370 (36.3)
302 (23.6)
Frequent sinusitis
Yes
No
109 (53.2)
563 (26.9)
Tonsillectomy
Yes
No
45 (33.1)
637 (28.8)
Adenoidectomy
Yes
No
61 (36.3)
624 (28.7)
1.30 (1.00—1.68)
1.00
NS
1.51 (1.13—2.03)
1.00
0.016
Frequent respiratory
tract infection
Yes
No
NS
1.77 (1.11—2.83)
1.00
<0.001
1.85 (1.54—2.22)
1.00
1.36 (1.08—1.70)
1.00
3.09 (2.31—4.13)
1.00
2.29 (1.64—3.19)
1.00
<0.001
0.26
1.23 (0.85—1.79)
1.00
0.037
NS
1.42 (1.02—1.96)
1.00
<0.001
430 (33.2)
241 (24.1)
Paracetamol given in the
first 12 months of life
Yes
No
503 (31.4)
171 (23.9)
Smoking at home
Yes
No
407 (30.4)
272 (27.1)
Smoking of child’s mother
Yes
No
183 (30.4)
496 (28.6)
Smoking of child’s father
Yes
No
408 (30.1)
267 (27.5)
Cat at home in the first
12 months of life
Yes
No
uOR (95% CI)
0.34
Physician-diagnosed
food allergy
Yes
No
Antibiotics given in the
first year of life
Yes
No
p value
1.57 (1.30—1.89)
1.00
1.26 (1.01—1.57)
1.00
NS
<0.001
1.45 (1.18—1.78)
1.00
0.08
1.18 (0.98—1.41)
1.00
0.41
1.09 (0.89—1.33)
1.00
0.17
1.14 (0.95—1.37)
1.00
0.001
40 (44.4)
640 (28.4)
2.02 (1.32—3.09)
1.00
2.21 (1.36—3.61)
1.00
Prevalence and risk factors for allergic rhinitis
467
Table 2 (Continued )
Factors
Children with
current allergic
rhinitis symptoms
n (%)
Dog at home in the first
12 months of life
Yes
No
17 (43.6)
668 (28.8)
Dampness at home
Yes
No
200 (34.8)
477 (27.3)
Heating system
Stove (wood or coal)
Central heating
335 (30.3)
321 (27.2)
Born in Istanbul
Yes
No
568 (29.2)
113 (28.0)
Time lived in Istanbul
5 years or more
0—5 years
628 (29.3)
55 (27.6)
p value
uOR (95% CI)
0.044
aOR (95% CI)
NS
1.91 (1.00—3.62)
1.00
0.001
1.42 (1.16—1.74)
1.00
1.31 (1.04—1.65)
1.00
0.11
1.16 (0.97—1.39)
1.00
0.63
1.06 (0.84—1.35)
1.00
0.62
1.09 (0.79—1.50)
1.00
Trucks passed on weekdays
Frequently almost
through the day
Never or seldom
247 (33.3)
0.002
1.35 (1.12—1.62)
NS
435 (27.1)
1.00
Perianal redness
Yes
No
180 (43.5)
486 (25.9)
<0.001
2.21 (1.77—2.75)
1.00
1.83 (1.43—2.36)
1.00
uOR, univariate odds ratio; aOR, adjusted odds ratio; CI, confidence interval; NS, no significant association in multivariate analysis.
The reported prevalence rates for rhinitis ranged
between 4.5% and 39.9% in different regions of
Turkey in school-aged children [8—10,18—21].
Worldwide ISAAC Phase I study showed that the
12-month prevalence of allergic rhinoconjunctivitis
varied between 0.8% and 39.7%. Our 12-month prevalence of allergic rhinoconjunctivitis was moderate among those values.
The worldwide ISAAC Phase Three study, which
was a repetition of the ISAAC Phase I study after a
mean of 7 years, revealed a rising trend in allergic
rhinoconjunctivitis prevalence with a range of 2.2—
45.1% in most centers [22]. Another study from Hong
Kong examining the trend of allergic diseases prevalence in school children from 1995 to 2001 also
showed increasing prevalence of allergic rhinitis and
eczema [15]. This increasing trend of allergic diseases prevalence has been partly explained by
‘‘hygiene hypothesis’’, suggesting that declining
microbial exposure in early childhood skewing the
reciprocal balance between T helper 1 (Th1) and T
helper 2 (Th2) towards Th2-mediated allergic disorders.
Allergic disorders are caused by a complex array
of multiple gene interactions. Allergic disease
develops in individuals with a genetic predisposition
after they are exposed to environmental factors.
Many of the genes for the cytokines and receptors
that regulate allergic inflammation are clustered on
certain genes [23]. Family history of atopy increases
the risk of subsequent allergic diseases in children,
and this has been shown in long-term prospective
studies [5,24,25]. Our study also verified that family
history of atopy to be a risk factor for allergic
rhinitis.
Frequent upper airway infections and sinusitis
may be expected in respiratory allergies. Children
with allergic rhinitis usually have congested nose,
which causes mouth breathing leading frequent
upper airway infections. Allergic children may have
much tendency to upper airway tract diseases since
their airways are more vulnerable due to allergic
inflammation. Lee et al. [15] reported a significant
correlation between AR and frequent upper respiratory infections in Chinese children. An epidemiological survey performed on Italian school children
468
Z. Tamay et al.
Table 3 Univariate analysis of dietary habits of children with current allergic rhinitis symptoms
Protective foods
Potatoes
Rice
Cereal
Pasta
Vegetables
Fish and other sea foods
Fruits
Tomatoes
Nuts
Olive oil
Fish oil
Traditional foods made
from grapes and mulberries
Fermented drinks made from
millets and various seeds
Mix pickles
Never or
occasionally n (%)
Once or twice
per week n (%)
Three or more
times a week n (%)
p value
68
114
77
97
141
409
78
99
245
257
424
308
209
247
85
273
173
171
124
136
234
147
25
172
382
299
474
289
341
43
463
424
153
179
32
132
0.093
0.028
0.103
0.851
0.021 *
0.135
0.009 *
0.122
0.708
0.439
0.233
0.406
(32.9)
(35.0)
(32.0)
(30.4)
(34.8)
(30.4)
(36.8)
(33.2)
(29.7)
(30.0)
(30.2)
(29.2)
(26.3)
(27.1)
(33.6)
(29.1)
(28.3)
(26.6)
(31.6)
(30.6)
(29.1)
(30.2)
(22.5)
(26.5)
(29.9)
(28.9)
(27.9)
(28.8)
(27.7)
(25.6)
(27.5)
(27.8)
(27.6)
(27.3)
(29.4)
(29.7)
493 (29.7)
19 (31.1)
3 (15.0)
0.347
427 (29.9)
131 (29.3)
41 (30.4)
0.962
Aggravating foods
Fast-food
Potato cibs, crackers
Chocolates
Lollipops, candies
Cookies, muffins
Margarine
488
140
106
254
158
328
(28.7)
(27.6)
(27.9)
(25.9)
(29.5)
(30.1)
95
183
191
167
197
138
(29.1)
(27.2)
(28.4)
(30.1)
(26.3)
(28.9)
26
331
359
205
296
133
(28.0)
(30.3)
(29.9)
(32.8)
(30.1)
(29.2)
0.973
0.305
0.915
0.009 *
0.202
0.885
Other foods
Eggs
Animal fats
Milk, dairy products
Meat
Butter
Sun-flower oil
Corn oil
Tea
Olive
85
399
57
227
351
244
244
138
117
(32.8)
(29.8)
(32.8)
(32.3)
(29.3)
(31.9)
(28.4)
(28.4)
(27.5)
149
21
99
281
126
105
117
106
157
(26.5)
(30)
(32.1)
(27.0)
(28.6)
(25.1)
(31.0)
(27.1)
(32.0)
425
8
504
146
128
211
191
407
377
(29.2)
(23.5)
(28.1)
(28.9)
(29.6)
(28.2)
(29.2)
(29.5)
(28.3)
0.208
0.728
0.179
0.050
0.947
0.037
0.655
0.636
0.223
*
p < 0.05 is considered significant
emphasized the possible relationship between
atopy and the upper respiratory infections [26].
Frequent antibiotic and paracetamol use early in
life was examined in several studies and a possible
link between antibiotic use and later asthma and
rhinitis was shown in several studies [27—29]. The
relation between antibiotic use and allergic diseases
was explained by antibacterial-induced alterations
in the intestinal flora and/or prevention of bacterial
infections leading to a skewing of the immune system of young children toward an atopic phenotype
[30,31]. An explanation for the association between
paracetamol use and allergic disease was the ability
of paracetamol to deplete antioxidant defences and
promote Th2 response [32]. We found a positive
relation between AR and frequent consumption of
paracetamol and antibiotics, of which the latter one
was an independent risk factor. However, these
associations may be explained by the reverse situation that frequent upper respiratory infections,
often early symptom of asthma and allergic rhinitis,
are usually treated with antibiotics and/or paracetamol [33,34].
Tonsils and adenoids are part of Waldeyer’s ring,
involved in the defence against microorganisms.
Surgical removal of these tissues may cause a reduction in stimulation of the Th1-type immune response
and may lead to a rise in Th2-type-mediated atopic
diseases according to ‘‘hygiene hypothesis’’.
Although a positive relationship between adenoidectomy and tonsillectomy in childhood and the
incidence of atopic disease in later childhood was
shown in British National Child Developmental Study
[35], no such association was found in our study,
Prevalence and risk factors for allergic rhinitis
469
Table 4 Multivariate analysis of dietary habits of children with current allergic rhinitis symptoms
Children with current allergic
rhinitis symptoms n (%)
Multivariant aOR (95% CI)
Fruits
Never or rarely
Once or twice/a week
Three or more/a week
78 (36.8)
124 (31.6)
463 (27.5)
1.00
0.79 (0.53—1.53)
0.64 (0.45—0.91)
Vegetables
Never or rarely
Once or twice/a week
Three or more/a week
141 (34.8)
173 (28.3)
341 (27.7)
Lollipops, candies
Never or rarely
Once or twice/a week
Three or more/a week
254 (25.9)
167 (30.1)
205 (32.8)
NS
1.00
1.26 (0.99—1.59)
1.44 (1.15—1.81)
aOR, adjusted odds ratio; CI, confidence interval; NS, no significant association in multivariate analysis.
which was in agreement with Dutch longitudinal
birth cohort study [36].
The presence of a cat home has been found to be
a significant risk factor for AR in Turkish children,
although the rate of pet ownership is extremely low
in our population. The association between pet
ownership in childhood and subsequent allergic diseases and sensitization is very controversial. Intriguing, but contradictory, reports have caused
considerable uncertainty [37—39]. Keeping a cat
in the home provides high-dose exposure to cat
allergens and increases the risk of sensitization to
cat in susceptible children. On the other hand,
endotoxin may be abundant in house dust particularly in houses with cats and dogs, and protect
against allergen sensitization by enhancing Th1
immunity. Contradictory results may be due to heterogeneity of the population, different immune
response to antigens in susceptible individuals.
Some investigators found a negative significant
association between the prevalence of allergic rhinitis and exposure to tobacco and parental smoking
[40,41]. This inverse relation was also explained by
‘‘hygiene hypothesis’’. Passive smoking might lead
to high infection rates in infancy, resulting with the
dominance of Th1-type immune response and less
allergic diseases. On the contrary, a positive association between tobacco smoke and rhinitis was
reported in a number of studies [6,40,42]. According to a meta-analysis data, no consistent association emerged between parental smoking and
allergic rhinitis, which was compatible with our
results [41].
Moisture at home may increase sensitization to
mould in susceptible children by stimulating Th2immune response. Moisture-related problems in
buildings were found to be a risk factor for asthma
and allergic symptoms among preschool children
[43]. In our study, home dampness was significantly
associated with symptoms of AR.
Istanbul is the biggest city of Turkey, with more
than 10 million inhabitants. Western lifestyle is
predominant in this city and adaptation of immigrants to this lifestyle can quickly occur. In our
study, born in or living in Istanbul was not significantly increased the risk for AR. Not classifying the
patients according to urban and rural parts of the
city might affect our results.
Motor vehicle exhaust from freeways could have
an inverse effect on respiratory health of children.
van Vliet et al. reported that cough, wheeze, runny
nose and asthma were more frequent in children
living within 100 m from the freeway, where exposure to diesel truck too much [44]. Exposure to
diesel truck may have irritant effect on airways
facilitating penetrating allergens to airways. In
our study, frequent exposure to diesel truck was
more frequently reported by parents of children
with symptoms of AR, but it was not an independent
significant risk factor.
Perianal redness has not been evaluated as a risk
factor for allergic diseases before. Iacono et al.
found that chronic constipation with perianal fissures or perianal erythema can be a manifestation of
cow’s milk intolerance [45]. We think that perianal
erythema can be a clue of mucosal inflammation due
to food allergy in infants and young children according to our clinical observations. In our study, perianal redness was a significant risk factor for AR.
Although there are other factors such as fungal
infections, thread worms that cause perianal redness, it may be also a sign of mucosal inflammation
due to concomitant subclinic food allergy in children
with AR.
Several studies have suggested that the increasing prevalence of symptoms of allergic diseases
470
could be associated with changes in the diet [46—
48]. Changes in the diet may mediate an effect,
through changes in gut flora. Intestinal flora of
allergic children differs from healthy children
[49]; different intestinal flora may induce Th2-type
immune response against antigens and preservation
of intestinal mucosal integrity by ‘‘healthy’’ gut
flora may be a protective factor against atopy and
atopic diseases [50]. Besides this effect, nutrients
like antioxidants, polyunsaturated fatty acids may
be needed for healthy immune system development. In our study, a significant inverse relationship
was found between symptoms of AR and the intake
of fruits and vegetables. Our results were in agreement with the previous studies [47,48]. Frequent
consumption of fruits and vegetables may be protective against allergic diseases due to their antioxidant effects [47,48]. We also found a dosedependent association between frequent consumption lollipops, candies and symptoms of AR.
Although allergies to food additives are rarely seen
in children, food additives existing in lollipops and
candies may act as non-specific adjuvant factors in
the development of allergic diseases.
There are several strengths of this study. First,
ISAAC questionnaire has been validated in a number
of Turkish studies. Second, the data is large enough
to reflect Istanbul population. Since potential risk
factors are influenced by the same social and environmental conditions and can also interact with each
other, they may affect the situation only when they
exist together. This may be the reason of the difference between the results of the univariate and
the multivariate analyses, which may be a limitation
of the study.
In conclusion our study reconfirmed that family
history of atopy, frequent respiratory tract infections, antibiotics given in the first year of life, cat at
home in the first year of life, dampness at home,
perianal redness and dietary habits are important
independent risk factors for AR. Researchers worldwide should be focused to these factors and try to
develop policies for early intervention, primary and
secondary preventions for allergic diseases.
Z. Tamay et al.
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