Paediatric Clinical Guideline
Emergency
1.9 Anaphylaxis
Short Title: / Anaphylaxis and Acute Allergic ReactionsFull Title: / Guideline for the management of anaphylaxis and acute allergic reactions in children and young people
Date of production/Last revision: / May 2008
Explicit definition of patient group to which it applies: / This guideline applies to all children and young people under the age of 19 years.
Name of contact author / Dr David Thomas, Consultant Paediatrician
Ext: 64231
Revision Date / May 2011
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
Anaphylaxis and Acute Allergic Reactions
Background
Acute allergic reactions are moderately common affecting 1 – 3% of children. Reactions vary in severity (see Table 3). Mild and moderate reactions are much more common than anaphylaxis.
Anaphylaxis is a term widely used by the public for any allergic reaction; medically it is generally reserved for life-threatening reactions which are most commonly, but not exclusively, IgE driven. Anaphylaxis generally occurs within minutes of exposure to an allergen and may progress rapidly, and in children is more likely to present with upper airways problems than hypotensive collapse/shock.
In fatal cases 50% die in the first hour and most occur as a first reaction. In around 20% of anaphylactic reactions there is a biphasic response. Rarely manifestations may be delayed by a few hours, or persist for more than 24 hours.
Causes of anaphylaxis are listed in order of frequency in Table 1. Idiopathic anaphylaxis is rare in childhood. Idiopathic urticaria however (a mild reaction) is not uncommon.
Table 1 Causes of Anaphylaxis (in order of frequency)Foods / Tree Nuts
Peanut
Milk
Egg
Wheat
Fish
Shellfish
Soya
Sesame
Drugs / Penicillin
Cephalosporin esp. IV
NSAIDS
Hymenoptera stings / Honeybee
Wasp
Hornet
Latex
Exercise
Vaccination
Miscellaneous / Chemotherapy
Radiocontrast
Aeroallergens
Idiopathic / Uncommon
Clinical Assessment
The key to diagnosis is a detailed history twinned with tests of sensitisation
Table 2 Symptoms and signs of anaphylaxisOn the “Outside”
Skin/Mucous membranes Angio-oedema
Urticaria
Conjunctivitis
Tingling tongue/ abnormal taste
On the “Inside”
Respiratory Dyspnoea / Wheeze / Stridor
Rhinitis
Cardiovascular Hypotension and pallor
Loss of consciousness or drowsiness
Gastro-Intestinal Abdominal pain
Vomiting
Diarrhoea
Other Sense of impending doom
History
A detailed history includes:
· Symptoms at onset
· Co-incidental illness and exercise
· Progression of symptoms including timing with probable allergen
With particular attention to:
o Wheeze and stridor
o Swelling – lips tongue generalised
o Fall to ground / Loss of consciousness / Drowsiness
· Preceding possible allergens
o Concentrate on the previous 60 minutes
o Ask for labels of processed foods
o Quantity of food ingested
· Drugs given
· Description of the recovery – timing and response to treatment
· Circumstances – environment; activity; intercurrent viral illness
· Personal history of atopy: asthma, eczema or hayfever
· Previous allergic reactions, including nature and severity.
· Reactions to antibiotic;nsaids;latex;blood products;heat or cold
· Dietary history i.e. special diet or dietary exclusions
· Family history of atopy
Physical Examination
General physical examination
Assess severity of reaction – mild, moderate, severe (Table 3)
Table 3 Categorisation of Acute Allergic Reactions after Dr P EwanGrade of Reaction / Description / Type
1 / Local skin – red/ hives/ swelling / itch / MILD
2 / General skin - red/ hives/ swelling / itch / MILD
3 / Grade 1 or 2 with gut or nasal reaction / MODERATE
4 / Voice change / mild wheeze / MODERATE
5 / Significant respiratory distress or collapse / SEVERE
Document any rash or swelling.
Note any physical signs of chronic allergic disease
E.g.:
· Shiners – periorbital blue grey discolouration (venous congestion)
· Salute – upwards nasal rub giving transverse nasal crease
· Harrisons sulci – semi-permanent in drawing at insertion of diaphragm
· Rhinorrhoea
· Eczema
Common Presenting Patterns of Allergic Reaction:
Cross-reactivity including Oral allergy Syndrome
Once the immune system has been sensitised to one allergen there may be cross-reactions with other allergens. Patterns or associations in Table 4
Some people with hay fever develop oral allergies to fruits, vegetables and nuts. The reaction occurs when the person comes into contact with the allergens in their RAW states. Typically hay fever symptoms occur in spring or summer, and then will develop swelling of the lips/mouth, itching and tingling on exposure to an allergen (see Table 4). The reaction usually remains localised to the mouth and throat and is mild.
David Thomas Page 1 of 12 May 2008
Paediatric Clinical Guideline
Emergency
1.9 Anaphylaxis
Table 4 Cross reactions between allergens
Birch Pollen
(Usually a predictably mild reactionTingling in buccal cavity
“Oral Allergy Syndrome”) /
Hazelnut, Apple, Peach, Cherry,
Walnut, Pear, Almond, Plum, Kiwi, Potato peel, Brazil nuts, Cashew nuts, Carrot, Tomato.In their raw state
Grass
(summer asthma & rhinitis)Typically moderate reaction / Bean Lentil
Green Pea
Latex
Reactions are more commonly severe, multi-system and anaphylactic /
Banana
Kiwi
AvocadoChestnuts
Cows Milk Protein (CMP) Allergy
Cows milk allergens are multiple and complex. Illness generally presents in infancy. Symptoms may occur in the gut; faltering growth, diarrhoea, vomiting; airways or skin. These effects are not necessarily immediately related to ingestion. Immediate systemic reactions (anaphylaxis) may occur.
A personal and family history of allergic disease supports the diagnosis. Lactose intolerance must be considered. Other diseases to consider; urinary tract infection, other infections, coeliac disease, cystic fibrosis, and metabolic disease.
Diagnosis and further management must be managed with a paediatric dietician and depends on clinical suspicion with resolution-recurrence-resolution after withdrawal-exposure-withdrawal.
Sensitisation: Skin prick tests and specific IgE (RAST) tests may have a role.
o An adequate diet with a fully hydrolysed hypoallergenic milk will be required with subsequent planned milk challenges.
o Soya based milks are not used in the first year but may be used later.
o Calcium supplements may be required in collaboration with Paediatric Dietician. Most infants will tolerate beef.
o Most CMP allergic infants become tolerant by around 3 years age.
o A standardised food challenge may be required at home or as a day case.
Detailed information regarding Cow’s Milk Hypersensitivity can be found in the Cow’s Milk Hypersensitivity in Children Pathway (Appendix X)
Egg Allergy
Generally presents in infancy (< 6months) with an immediate reaction on apparent first exposure. Typically skin reactions are prominent (urticaria + angiooedema), and there may be wheeze. Severe generalised reactions may occur.
Diagnosis depends on an accurate history. Skin prick tests may have a role. Further management should involve a paediatric dietician as egg is a constituent of many foods, baked and processed.
A food challenge will often be required after an interval of about 6 months in liaison with a paediatric dietician. Further skin prick tests will be considered.
Egg Allergy is NOT a contra-indication for MMR vaccination.
It is effective and no more allergenic in these infants than those tolerant of egg. It can safely be given with no alteration to protocol in the family doctors surgery although infants with moderate or severe asthma and those thought to have had a severe systemic reaction to egg should be considered for immunisation in a hospital setting.
Influenza and yellow fever vaccines are contraindicated in patients with anaphylaxis to egg. (2006 Immunisation against Infectious Diseases HMSO) In practice a risk/benefit decision must be made in those children with minor reactions to egg. For further advice discuss with Dr Bhatt or Dr Thomas.
Wheat Allergy
A spectrum of intolerances to wheat is seen;
§ coeliac disease – malabsorbtion , raised endomycial + antigliadin and antitransglutaminase antibodies with subtotal villous atrophy
§ wheat allergy – with involvement of the skin (urticaria, angioedema) and airways (wheeze) typically immediately after exposure, without evidence of coeliac disease.
Urticaria
Uritcaria is the medical word for the skin rash we know as “hives” or “nettle rash”. It can last from hours to years:
· < 6 weeks - acute urticaria
· > 6 weeks - chronic urticaria
It is very common affecting 1 in 10 children, and 1 in 3 adults.
Urticaria is the commonest symptom in an allergic reaction. It can, however, occur alone when it is also called “idiopathic” urticaria. In a third of patients it is caused by allergic reactions, in another third by viral illnesses, and is idiopathic in the rest. Recognised triggers for chronic urticaria include heat, cold, exercise and emotion.
Antihistamines are the treatment of choice for urticaria. Steroids are occasionally used when symptoms are unresponsive to antihistamines.
Management/Follow Up Guidance: Table 5
Mild-Moderate Reaction Grade 1-3No cardio-respiratory intervention / Severe/Life Threatening Reaction Grade 4/5 - Respiratory Reaction/Hypotension or Collapse.
Often have received just oral Chlorphenamine
Many cases will be idiopathic
Consider common food allergens
Also physical causes: cold, light, chemical contact / Often have received adrenaline or nebulized drugs
Allergen may be obvious from history
Observe for minimum 2 hours CSSU
/ Admit CSSU
Compose Management Plan for family:
· Identify possible allergen and advise avoidance
· Information/dietary advice leaflets as appropriate
· Written Medication Management plan (see appendices)
· Consider referral to a paediatric dietician / Compose Management Plan for Family
· Identify possible allergen and advise avoidance
· Consider specific allergy tests
· Avoidance advice
· Medication options
o Antihistamine (see medication table)
o Epipen (CONSULTANT-ONLY DECISION) see table & prescription advice. One-to-one training backed up with written information (use epipen pack)
Follow up plan choice from:
· GP
· Paediatric Emergency Department Clinic
· General Paediatric Clinic
· Allergy clinic referral
Copy of written medication management plan to:
· G.P., Community Paediatrician and School Nurse for school training.
· For pre-school child, send to Specialist Paediatric Allergy Nurse for training in the community/nursery
· Debra Forster air pager 07659 177966
/ Follow up plan choice from:
· General Paediatric Clinic
· Allergy clinic referral
Copy of written medication management plan to:
· GP, Community Paediatrician, and School Nurse
· For pre-school child, send to Specialist Paediatric Respiratory/Allergy Nurse for training in the community/nursery
· Debra Forster air pager 07659 177 966 (leave a brief message)
Referral Guidance
Allergy Clinic
Allergy Clinic referral usually required where:
§ Multiple allergens
§ Food allergy with moderate / severe asthma
§ Consider referral in persistent egg allergy (beyond 5 years of age)
§ Severe atopic dermatitis
§ Severe allergic reactions to vaccines
§ Bee or wasp venom allergy
§ Skin-prick testing required
General Paediatric Clinic
Usually managed in general paediatric setting with dietetic support
Isolated allergy by history to:
§ Egg
§ Milk
§ Wheat
§ Peanut
Immunotherapy
· Children with venom allergy and those with severe hayfever in secondary school may benefit from desensitisation. Please refer these children to the Nottingham Paediatric Allergy service who are working closely with the Adult Allergy service to deliver desensitisation.
· Those with severe intrusive symptoms who are largely monosensitised and without severe asthma may be appropriate for treatment subcutaneously or orally.
· Desensitisation is available for hymenoptera venom, grass, house dust mite and birch pollen.
Paediatric Dietician
Consider referral when:
· Multiple food allergens
· Very restrictive diet
· Parental concerns
Food challenges:
Indications for food challenge:
§ To investigate allergic reaction where history, skin prick tests and RAST still leave diagnosis unclear
§ When patient now wishes to try food to which previously allergic and situation unclear by other means
§ After an interval of about 6 months in previously egg allergic infants
§ Where allergic mechanism thought unlikely and other mechanisms may require pursuit
§ To confirm tolerance of food to which skin prick test are negative
Algorithm for Acute Allergic Reactions
TABLE OF MEDICATIONS
Adrenaline
(epinephrine) / IM / Epipen
Junior / 0.15 mg / From approx. 10 kg | 1year
Up to age 6 yr | 30 kg approx
IM / Epipen / 0.3 mg / Beyond age 6yr | 30kg
IM / 1:1,000 / 0.01 ml/kg
10mcg /kg / Dose calculated for hospital resuscitation
Salbutamol / NEB or
SPACER / 2.5 mg
5 puffs / Up to 5 years
NEB or
SPACER / 5 mg
10 puffs / 5 yrs and beyond
Prednisolone / PO / Soluble or
Enteric coated / 2 mg/kg
Max 40 mg / Use soluble preferably
Hydrocortisone / IV IO IM / 4mg/kg / 6 hly
max dose 100mg
(prednisolone not feasible)
Chlorphenamine / PO / 1mg / Up to 1 year | 10 kg
2 mg / 1 – 5 years | 10 – 20 kg approx
4 mg / 5 years + | >20 kgs
Cetirizine / PO / Syrup 5mg/5mls
Tablets 10mg / 5mg / 2-6 years
10mg / 6 years +
Adrenaline Pens
Adrenaline pens should only be prescribed after discussion with a Consultant Paediatrician
Self injectable Adrenaline may be required for children with:
· A previous severe reaction (Grade 4 or 5 – see Table 3) (unless allergen easily avoided as in penicillin allergy)
· Allergy especially involving peanut/tree nuts in a child with
o Moderate - Severe Asthma
o Secondary school age
o Severe reactions to small quantities of ingested or inhaled allergen
o Severe reactions to allergen from cutaneous / mucus membrane contact
· Bee/Wasp systemic reactions (not severe local reactions) - also consider referral to Paediatric Allergy Clinic for desensitisation
If a family are requesting injectable adrenaline after a mild reaction, liaise with the Consultant. Consider further evaluation in outpatients within 4 weeks.
Prescribing self-injectable adrenaline (epinephrine)
Training is available from Outpatients and the Children’s Short Stay unit
Contact Numbers CSSU 68425
Debra Forster pager 07659 177 966 COPD
Who will ensure:
· Family get opportunity to view Anaphylaxis campaign video - available in Out patients & Children’s short stay)
· Family are clear when and where to inject - (Appendix X – Using the Epipen Device)