The ABC of Food Allergy in Children or 10 point plan - A/Professor Michael Gold Department of Allergy and Immunology Women's and Children's Health ...
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The ABC of Food Allergy in Children
or
10 point plan
A/Professor Michael Gold
Department of Allergy and Immunology
Women’s and Children's Health Network
Discipline of Paediatrics
School of Medicine
University of Adelaide
J Allergy Clin Immunol. 2007 Oct;120(4):878-84.
Dear Dr...... Please review AG a 6 year old who presented to the WCH ED with generalised rash, persistent cough and wheeze after her first apparent exposure to cashew nuts. She was treated with an anti-histamine and Ventolin and advised to stop ingesting all nuts. She has troublesome eczema and asthma and I performed some blood tests – she was positive to cashew, peanut, cheese, dairy, and wheat so I have advised that she no longer have these foods in the diet. The school have asked for a plan but I have indicated I cant do this until she has been reviewed by you.
1. Know how to diagnosis anaphylaxis
Anaphylaxis Definition
What is anaphylaxis?
Any acute onset of hypotension or bronchospasm or
upper airway obstruction where anaphylaxis is considered
possible, even if typical skin features are not present
OR
Any acute onset illness with typical skin features
(urticarial rash or erythema/flushing, and/or angioedema),
PLUS involvement of respiratory and/or cardiovascular
(and/or persistent severe gastrointestinal symptoms)
Ref: ASCIA 2010 1.6
Signs and symptoms of allergy and anaphylaxis
Some individuals experience anaphylaxis without prior mild or
moderate symptoms
Ref: ASCIA 2010
1.7Cutaneous symptoms
Urticaria, erythema and angioedema may be transient,
subtle and easily overlooked
In 1 out of 6 fatal food induced
anaphylaxis cases, severe
cardiovascular symptoms
developed without skin or
respiratory symptoms
Ref: Sampson et al. 1992; Brown, Mullins, Gold. 2006
1.8Signs and symptoms of mild or moderate allergic
eactions
1.52. Know how to manage anaphylaxis
IgE mediated food allergy
1.4Mast Cell Actions
T Lymphocyte Constriction
Histamine, Kinins, Chymase ,
Chemotaxis Allergen LTC4, PGD
Bronchi
IL5, IL6, LTC4, TNFa
Adhesion
Eosinophil IL-4, IL-5, LTC4,
Secretion
Activation Histamine, Kinins, LTC4, PGD
IL-5, IL-6, TNFa
Mucous
Neutrophil Degradation Cells
Mast Cell
Tryptase, Chymase
Dilation and Leak
Histamine, Kinins, LTC4, PGD Production Stimulation
IL4, IL13 Histamine, Kinins, LTC4, PGD
Extracellular
Vascular IgE Nerves MatrixAdrenaline a-Adrenergic Actions - Adrenergic Actions Increased cardiac output Increased heart rate Peripheral cutaneous Reduced diastolic blood vasoconstriction pressure Increased systolic blood pressure Reduced mucosa oedema Bronchodilatation
Action for anaphylaxis in clinical settings
• Remove allergen (if still present)
• Call for assistance
• Lay patient flat (if breathing difficult allow to sit but not
stand or walk)
• Give IMI ADRENALINE without delay
– 1:1000 IMI into mid lateral thigh
– Repeat every 5 minutes as needed
– If multiple doses required or a severe reaction consider adrenaline
infusion if skills and equipment available
• Call ambulance to transport patient
4.2Adrenaline ampoule dosages 1:1000
Dose 0.01 mg per kilogram (up to 0.5 mg per dose)
4.6
Source: Adapted from the Australian Immunisation Handbook 9 th EditionAdrenaline - possible adverse effects
• Well tolerated in children as well as adults
• Transient adverse effects include anxiety, fear,
restlessness, headache, dizziness, palpitations, pallor
and tremor
IV boluses of adrenaline are NOT recommended
4.7After giving IM adrenaline
• Check pulse, blood pressure, ECG, pulse oximetry
• Give high flow oxygen and airway support if needed
• Obtain IV access in adults and hypotensive children
4.8Additional measures to consider if IV adrenaline
infusion is ineffective
For upper airway obstruction:
•Nebulised adrenaline (5mL i.e. 5 ampoules of 1:1000)
•Consider intubation
For persistent hypotension/shock:
•Give normal saline – max 50mL/kg in first 30 minutes
•Adrenaline infusion (ECG monitoring)
• In patients with cardiogenic shock, consider IV glucagon bolus
of 20-30μg/kg up to 1mg (can be repeated or followed by
infusion of 1-2mg/hr IV in adults)
• In adults, selective vasoconstrictors metaraminol (2-10mg) or
vasopressin (10-40 units)
4.10Additional measures to consider if IV adrenaline
infusion is ineffective
For persistent wheeze:
• Bronchodilators: 8-12 puffs of 100µg salbutamol
using a spacer OR 5mg salbutamol by nebuliser
4.11Antihistamines and Steroids
• Antihistamines
• Ineffective for treating anaphylaxis
• Oral non-sedating antihistamines - urticaria
• Do not use;
• Oral sedating antihistamines SE may be similar
to signs of anaphylaxis
• Injectable promethazine worsen hypotension
and cause muscle necrosis
• Steroids
• Underlying eczema/asthma
4.143. Know what to do after the acute
management of anaphylaxis• Observation • Provide advice about prevention – Dietary advice • Provide Adrenaline Autoinjector (Epipen) – Anaphylaxis Action Plan – Education • Referral
Biphasic reactions
Ref: Tole, Lieberman. 2007 4.13Adverse Reactions to Cows Milk
Protein Allergy Lactose intolerance
Immediate Delayed
< 24 hours > 24 hours•After a reaction do not exclude;
• Previously tolerated foods
• “may contain traces” “manufactured on same
machinery”
5.15Guidelines for prescribing an adrenaline autoinjector
Always recommended if…
•History of anaphylaxis (and continued risk)
May be recommended if…
•History of a generalised allergic reaction and one or more risk
factors:
– Asthma
– Age (children >5 yrs, adolescents, young adults)
– Specific allergic triggers -nuts
– Co-morbidity (e.g. ischaemic heart disease)
– Geographical remoteness from emergency medical care
5.15Guidelines for prescribing an adrenaline autoinjector
Not normally recommended...
• Asthma with no history of anaphylaxis nor generalised
allergic reactions
• Positive allergy test without a history of clinical
reactions
• Family history of anaphylaxis or allergy
5.16Adrenaline autoinjectors – EpiPen®
• Junior devices (150µg) recommended for
children 10 to 20 kg (aged ~1-5 years)
EpiPen Jr
• Higher dose devices (300µg) recommended for
children over 20 kg (aged over ~5 years) and
adults
EpiPen
5.2EpiPen with orange needle end and blue safety release
Viewing window Instructions on Blue safety
how to use release
(on other side)
Orange needle end Expiry date
• Available in Australia mid 2011
5.5Epipen accidents »
PBS supply of adrenaline autoinjectors in Australia
• Maximum of 2 (EpiPen) for both children and adults
• Initial supply:
– When risk and clinical need has been assessed by, or in
consultation with a clinical immunologist, allergist,
paediatrician or respiratory physician
– After hospital or emergency department discharge for acute
allergic anaphylaxis treated by adrenaline
• Continuing supply for anticipated emergency treatment of acute
allergic reactions with anaphylaxis, where the patient has
previously been issued with an authority prescription for this
drug
5.14Action plans at www.allergy.org.au
• Action Plan for Allergic Reactions – Green
• Action Plan for Anaphylaxis (personal) – Red
6.2Adrenaline
Patient’s autoinjector
photo and brand name
personal
details Signs, symptoms,
action for mild or
moderate
Confirmed allergic reactions
allergens
Contact details
for family and
doctor
Signs, symptoms,
action for
Instructions anaphylaxis
on how to
use the
device
Additional
information
6.3ASCIA Travel Plan for Anaphylaxis
• Provides
documentation for
patient to carry
adrenaline
autoinjector in
aircraft cabin
• Can be printed from
the ASCIA website
6.74. Know how to provide accurate information about food allergy
Anaphylaxis deaths in Australia1997-2005
• Drug and insect allergies most
common causes of fatal
anaphylaxis
• Most insect allergy deaths
occur in adults
• Drug allergy deaths occur
mostly in hospitals
• All food deaths reported
occurred in individuals aged 8-
35yrs
Deaths from anaphylaxis are likely to be underestimated due to the difficulty of post
mortem diagnosis and under-reporting
Liew, Williamson, Tang. 2008 2.6Fatal anaphylaxis - associations
• Asthma
• Delayed or no administration of adrenaline
• Age:
– Teenagers and young adults (food allergy)
– Adults (insect and drug allergy)
• Upright posture during anaphylaxis
• Food allergic individuals eating away from home
• Initial misdiagnosis
• Systemic mastocytosis
Previous mild/moderate reactions may not rule out subsequent
severe or fatal reactions
2.7
Ref: Bock. 2010; Liew, Williamson, Tang. 2008; Bock. 2007; Pumphrey. 2003; Bock. 20015. Know how adverse reactions to food presents in infancy and childhood
Adverse Reactions to Food
Food Allergy Food Intolerance
IMMUNE - PROTEIN NON IMMUNE -
CHEMICAL
IgE-mediated Non IgE-mediated Toxic COH
•Caffeine malabsorption
Anaphylaxis EE •Lactose/fructose
Gen Allergic FPIES
Enteropathy
Colitis Pharmacological Aversion
•Natural substances
(salicylates/amines/
glutamates)
•Additives
AAAI/NIH 1984 (preservatives/colours/
flavours)Clinical Presentation of Food Allergy
• Any age - Syndromes (pattern recognition)
– Anaphylaxis
• Suggest food if abdominal pain, vomiting, loose stools
– Non-anaphylactic generalised allergy reaction
• Urticaria (< 24 hours) and beyond contact areas
• VomitingClinical Presentation of Food Allergy
• Infancy
– Irritability (> 6 weeks) PLUS vomiting, loose stools,
FTT, eczema
– Persistent loose stools PLUS vomiting, FTT, eczema
– CMP colitis
• Bloody stools, infant, otherwise well
– Food Protein Induced Entercolitis SyndromeFood Protein Induced Enterocolitis
Sicherer S, J Paed 1998;133(2), Levy Y et al.Paed Allergy Immunol 2003:14
• Symptoms 1-4 hours after ingestion of trigger food
• Triad
– Persistent and recurrent vomiting
– Hyporesponsiveness
– Pallor
• Metabolic acidosis and neutrophilia
• Foods;
– Cow’s milk, rice, chicken, oats, soy, vegetables, wheat, egg,
• SPT – negativeClinical Presentation in Infancy and
Childhood of Food Allergy and Intolerance
• Pre-school to Adolescence
– Oral Allergy Syndrome
• Itchy mouth, allergic rhinitis
– Eosinophilic OesophagitisEosinophilic oesophagitis Abundant intraepithelial eosinophils (>65 per hpf)
Eosinophilic Oesophagitis
Presentation and diagnosis
• Older – late childhood adolescence
• Symptoms
– Dysphagia,
– “GOR” symptoms – abdominal pain, heartburn, Food aversion,
Vomiting, Regurgitation, FTT
– Poor response to Rx,
– Often no history of worsening of symptoms following food
ingestion
– Atopic disorders
• Diagnosis
– Endoscopy > 15-25 Eo per HPFFood allergy and eczema
• Eczema is the most important risk factor for the
development of food sensitisation and allergy
– 70 % of infants with FA have eczema
• In some children food maybe a trigger for eczema;
– Infants and children < 5years
– Severe with poor response to topical treatment
– Eczema PLUS;
• Urticaria and/or angioedema (6. Know when to refer http://www.wch.sa.gov.au/services/az/divisions/paedm/gpreferral/for_gps.html#second_section
Waiting times P1 Allergy Clinics by referral year 2013 to 2015
7. Know when NOT to refer • Urticaria or angioedema > 24 hrs • Insignificant peri-oral facial rash in an infant (contact irritant to food) • Family history food allergy – including anaphylaxis • Lactose/Fructose intolerance • Hyperactive behaviour after red food colouring
Infection – the most common cause of urticaria and/or angioedema lasting > 24
hours (eg EBV)8. Know how to initially investigate food
allergyAdverse Reactions to Food
Diagnostic investigations
Food Allergy Food Intolerance
IgE-mediated Non IgE-mediated Toxic Metabolic
Specific IgE Challenge BHT
Challenge
Pharmacological Aversion
Challenge
AAAI/NIH 1984IgE prediction of clinical reactivity
IgE – Skin Prick Testing
Indications – Specific IgE testing
History of food trigger unclear AND IgE mediated allergy suspected
Exclude possible coexisting IgE-mediated food allergies if no clear
history of exposure
Existing IgE-mediated food allergy
Egg and peanut allergy
Peanut and tree nut
Cross-reactivity
Legumes, Seafood
To determine the timing of a challengeMisconceptions about Specific IgE testing
• Positive is diagnostic of food allergy
– PPV variable
• Negative excludes a food allergy
– Exclude IgE-mediated but not non-IgE mediated/Intoler
• Correlates with the severity of a reaction
– Cannot predict anaphylaxis
• Cant be done in infants ( 6 monthsUnproven food testing
• Cytotoxicity testing
– In vitro addition of allergen
to blood will reduce the
WBC
– Controlled studies - no effect
or correlation with IgE
mediated food allergy
• Vega testing
– In vivo - use of a
galvanometer and vials of
food
– No physiological basis - no
trials
• IgG food antibodys9. Know the current ASCIA infant feeding
guidelinesAllergic Sensitisation
Modified infant feeding guidelines (draft) • Promote breast feeding • When your infant is ready, at around 6 months, but not before 4 months, start to introduce a variety of solid foods, starting with iron rich foods while continuing to breast feed • All infants should be given allergenic solid foods including peanut butter, cooked egg, and wheat products in the first year of life. This includes those at high risk of allergy. • Hydrolysed (partially or extensively) infant formulae are not recommended for prevention of allergic disease.
Infants with allergic disease
Peanut
If your child already has an egg allergy or other food
allergies or severe eczema, you should discuss how to
do this with your doctor.
– Graded home introduction
– Serology (specific IgE peanut)
• Introduction - < 0.35 KU/L
• Refer > 0.35 KU/L10. Know how to contact our service to
discuss patients
T: 08 8161 8638
F: 08 8161 9295 (Referrals – Named)
– Gold, Quinn, Chan
E: michael.gold@adelaide.edu.au
Telephone advice (24/7) : 08 8161 7000, Allergist on callCase presentation – Dear Dr...... Please review AG a 6 year old who presented to the WCH ED with generalised urticaria, persistent cough and wheeze after her first apparent exposure to cashew nuts. Diagnosis of anaphylaxis She was treated with an anti-histamine and ventolin Rx Adrenaline
Case presentation – Dear Dr......
She has troublesome eczema and asthma and I
performed some blood tests – she was positive to
peanut, wheat and cheese so I have advised that she
no longer have these foods in the diet.
Sensitisation does not equal allergy
Don't remove foods that are tolerated
The school have asked for a plan but I have indicated I
cant do this until she has been reviewed by you.
Should have an Adrenaline Autoinjector
Guidelines for prescription, PBS authority, Education and
action plans – www.allergy.org.auYou can also read
