Seasonal Allergic Rhinitis Is Associated With a Detrimental Effect on Examination Performance in United Kingdom Teenagers: Case-Control Study
Authors: Andrews Timothy , Banks James R. 
Published: October 2008

Walker S, Khan-Wasti S, Fletcher M, Cullinan P, Harris J, Sheikh A. J Allergy Clin Immunol. 2007;120(2):381–387
PURPOSE OF THE STUDY. Symptoms of seasonal allergic rhinitis (SAR) have been shown to impair learning ability in children under laboratory conditions. These investigators sought to study the effect of seasonal allergic rhinitis on actual examination performance in United Kingdom teenagers.
STUDY POPULATION. State schools in the United Kingdom with relatively large numbers of English-speaking students were invited to participate. These schools held practice examinations in the winter for the General Certificate of Secondary Education (GCSF). All students aged 15 to 17 years in the last year of study for their GCSF were invited to participate.
METHODS. Case status was defined by comparison of the performance of each student in winter practice with that of the final GCSF examination in May/June, which coincided with the grass-pollen season. GCSF examinations are critical for United Kingdom adolescents. Winter practice examinations are structured similarly to the final examinations. Both sets of examinations are marked on an 8-point scale. Any drop in grade on the final examination is unexpected. Students who dropped at least 1 grade in any of the 3 core subjects (math, English, and science) were considered cases. Controls were students whose grades in their final examinations were at least as good as those in their practice examinations in all 3 subjects. Two questionnaires were administered, 1 in April before the grass-pollen season and 1 on the day of each relevant examination. The first questionnaire determined if students had ever received a diagnosis of SAR. Information on potential confounders (eg, medication use, smoking status, history of asthma, etc) was also collected. The questionnaire administered immediately before the final examinations in May and June asked about SAR symptoms and treatment. The primary comparison was of the proportions of cases and controls with SAR symptoms and treatment, especially with sedating antihistamines. Pollen counts were reported daily.
RESULTS. A total of 1834 students (57% of the available population) agreed to participate. Between 38% and 43% of students reported SAR symptoms on any 1 of the examination days. There were 662 cases (36% of the students). Cases were significantly more likely than controls to have had allergic rhinitis symptoms during the examination period (odds ratio [OR]: 1.4 [95% confidence interval (CI): 1.1–1.8]; P = .002), to have taken any allergic rhinitis medication (OR: 1.4 [95% CI: 1.1–1.7]; P = .01), or to have taken sedating antihistamine (OR: 1.7 [95% CI: 1.1–2.8]; P = .03).
CONCLUSIONS. Current symptomatic allergic rhinitis and medication use were associated with a significantly increased risk of unexpected grade drop in summer examinations. These findings carry significant implications in clinical practice.
REVIEWER COMMENTS. The effects of uncontrolled SAR on school performance are most often insidious, and adolescents often have prolonged symptoms before proper medical intervention occurs. It is clear that proactive drug therapy and allergen avoidance can go a long way toward lessening symptoms of SAR. It is essential that the clinician educate parents on the value of intervening preseasonally and to then consider immunotherapy if avoidance and medication fail.