Can Children’s Allergic Rhinitis Be Prevented?

Which children will develop seasonal allergic rhinitis is a complicated mix of environment and genetics, and data are adding to that picture, even suggesting that treatment of atopic disease might help prevent incidence.

“The ‘atopic march’ remains a widely accepted paradigm,” said Daisuke Harama, MD, PhD, of the National Center for Child Health and Development in Tokyo.

However, not all patients follow the classic trajectory from atopic dermatitis to food allergy, asthma, and rhinitis.

In Harama and colleagues’ nationwide birth cohort study from Japan, 9.4% of children developed allergic rhinitis by age 4 years without any preceding atopic conditions. By comparison, 14.6% had atopic dermatitis followed by development of allergic rhinitis, and 5.8% had allergic rhinitis preceded by food allergy or asthma, “indicating that the progression is not uniform across all patients,” Harama said.

The Japan Environment and Children’s Study was a prospective, multicenter birth cohort study that included 103,060 women recruited during pregnancy from 2011 through 2014 and 88,307 newborns delivered at term as singletons. A subset of 2,055 children were followed from birth to age 4 years using serial questionnaires with blood sampling and physical examinations and could be analyzed for allergic rhinitis status. Allergic rhinitis and asthma diagnoses were established using the International Study of Asthma and Allergies in Childhood questionnaire, while atopic dermatitis was diagnosed using the U.K. Working Party criteria. Food allergy was assessed by parents’ report of physician diagnosis.

In a 2025 publication in Allergy, Harama’s group reported that independent predisposing factors for the development of allergic rhinitis by age 4 years differed by phenotype.

The 301 children with a diagnosis of atopic dermatitis followed by development allergic rhinitis, in line with the atopic march, showed strong associations with male sex (adjusted OR 1.75, 95% CI 1.33-2.30), parental allergic history (adjusted OR 2.41 with both parents affected, 95% CI 1.52-3.75), and sensitization for aeroallergen. Those who went straight to allergic rhinitis without any of the conditions in the atopic march showed no significant link with those conventional risk factors.

Adjustments for socioenvironmental variables like household income, birth season, and breastfeeding did not “substantially alter” the associations, according to the research group.

Further reporting from the cohort at the 2026 American Academy of Allergy Asthma & Immunology (AAAAI) meeting also showed increasing frequency of fevers before 1 year of age trended toward lower risk of allergic rhinitis-only, whereas it trended toward higher risk in the other groups, “suggesting that environmental exposures and immune maturation may play protective roles,” Harama said.

His interpretation of the findings was “that allergic rhinitis with preceding atopic dermatitis is largely genetically determined, where allergic rhinitis without prior allergic diseases seems to be influenced mainly by environmental and infectious factors. Recognizing these distinct pathways may help develop preventive and therapeutic strategies for allergic rhinitis in childhood.”

There has been hope that treating atopic disease would prevent development of allergic rhinitis.

Indirect evidence in a meta-analysis of 12 randomized clinical trials showed that dupilumab (Dupixent) treatment for atopic dermatitis reduced the risk of new or worsening allergies by 34% (incidence rate ratio 0.66, 95% CI 0.52-0.84) and new allergies by 37% (incidence rate ratio 0.63, 95% CI 0.48-0.83) compared with placebo.

And those benefits did not disappear on treatment discontinuation in off-treatment follow-up. A separate claims-based study of 2,192 pediatric atopic dermatitis patients in the TriNetX US Collaborative Network also showed a significant reduction in risk of incident asthma or allergic rhinitis (HR 0.68) and new-onset allergic rhinitis alone (HR 0.69) during treatment with dupilumab versus conventional immunosuppressants.

Studies have also suggested that biologics that treat atopic disease also might lower infection risk in allergic rhinitis.

Wanda Phipatanakul, MD, of Boston Children’s Hospital, and colleagues presented data at the AAAAI meeting on respiratory infections among persons with allergic rhinitis while taking dupilumab off-label for that condition or on-label for other indications, like asthma or eczema.

Their analysis of real-world data from TriNetX’s US Collaborative Network from June 2019 through January 2026 included 24,498 adult patients with allergic rhinitis identified by diagnosis code. In comparison with propensity score-matched individuals not treated with dupilumab, risk in the year following dupilumab initiation was significantly lower for the following:

• Upper respiratory infection (risk ratio [RR] 0.537, 95% CI 0.491-0.586)
• Acute sinusitis (RR 0.529, 95% CI 0.474-0.59)
• Chronic sinusitis (RR 0.694, 95% CI 0.617-0.782)
• Middle ear infections (RR 0.614, 95% CI 0.515-0.732)
• Lower respiratory infections (RR 0.524, 95% CI 0.47-0.584)

Another biologic that targets type 2 inflammation, omalizumab (Xolair), has shown similarly in multiple studies that it restores antiviral response and has some antiviral properties, noted Phipatanakul. “When you work with the immune system and you block type 2 inflammation … or you block allergic processes, there can be an interaction with allergic [immunoglobulin E] and viral interactions,” she said. “And so it’s intriguing that potentially when you work on these pathways, you could reduce infections. It’s not completely implausible.”