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Year 5 - Paediatrics > Allergic reactions in a child - anaphylaxis, allergic rhinitis, CMPA, food allergy > Flashcards

Allergic reactions in a child - anaphylaxis, allergic rhinitis, CMPA, food allergy Flashcards

1
Q

How does the adrenline dose for anaphylaxis vary in children with known anaphylaxis for self-administration?

A

Children with known anaphylaxis are issued with self-administration injections containing the correct dose appropriate to body weight

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2
Q

What is the 1g in 10,000ml concentration of adrenaline used in ?

A

Cardiac arrest

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3
Q

How much adrenaline should be given in anaphylaxis in different age groups?

A

<6 yrs - 150mcg

>6 yrs - 300 mcg

NB: the higher dose of 500mcg has been removed from the EpiPen market

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4
Q

Define anaphylaxis.

A

RCPCH

Severe generalised or systemic, life-threatening, hypersensitivity reaction, in which both of the following criteria are met:

  1. Sudden onset and rapid progression of symptoms
  2. Life-threatening airway and/or breahing and/or circulation problems.

​Skin and/or mucosal changes (flushing/urticaria/angioedema) can also occur, but are absent in a significant proportion of cases.

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5
Q

How common is anaphylaxis?

A

1 episode every 20,000 person years

1 in 1000 cases are fatal

Fatal cases usually in adolescents with a nut allergy but most cases in children <5 years as this is when food allergy is most common.

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6
Q

What are the most common triggers for anaphylaxis in children?

A

85% of cases due to food

Other allergens include: insect stings, drugs, latex, exercise, inhalant allergens and idiopathic.

NB: in adults the most common trigger is medicinal products.

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7
Q

What are the risk factors for fatal outcome in anaphylaxis?

A

Adolescent age group

Coexistent asthma

Nut allergy

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8
Q

What are the risk factors for severe allergic reactions in children?

A
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9
Q

What is the aetiology of anaphylaxis?

A

Usually IgE-mediated reactions to the allergen

Non-IgE mediated reactions can also occur, most commonly with drugs.

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10
Q

What is the pathophysiology/signs and symptoms of anaphylaxis?

A

Airway narrowing - laryngeal or pharyngeal oedema

Breathing difficulties - bronchospasm with tachypnoea

Cardiovascular compromise - hypotension and/or tachycardia

Mucosal and skin changes

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11
Q

What % of anaphylactic reactions do not present with skin signs?

A

10-20% - this may delay diagnosis

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12
Q

What are the ABCDE findings in anaphylaxis?

A

Airway: swelling, hoarseness, stridor

Breathing: tachypnoea, wheeze, SpO2 <92%,

Circulation: cyanosis, pale, clammy, hypotension,

Disability: drowsy, coma

Exposure: skin can show urticaria, angioedema (not always present)

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13
Q

Where should adrenaline be injected during anaphylaxis?

A

Anterolateral aspect of the middle third of the thigh

0.15ml or 0.30ml of 1:1000 adrenaline (i.e. 1mg/ml or 1g per 1000ml)

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14
Q

What is the management of anaphylaxis after the ABCDE assessment?

A
  1. Call for help
  2. Reposition - sit up if breathing difficulties, supine and elevate legs if hypotensive, recovery position if unconscious, BLS/ALS if necessary
  3. Adrenaline 1:1000 IM (150mcg <6 years, 300mcg 6-12 years, 500mcg >12 years)
  4. Other:
    • Establish airway
    • High-flow oxygen
    • IV fluid challenge (20ml/kg crystalloids in children)
    • Chlorpheniramine (IM or slow IV)
    • Hydrocortisone (IM or slow IV)
    • Consider salbutamol if wheeze
  5. Admit and monitor for 6-12 hours
    • Pulse oximetry
    • ECG
    • BP
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15
Q

What is the long-term management of anaphylaxis?

A
  1. Allergen avoidance
  2. Adrenaline auto-injector provision and education about use. Two should be prescribed, ensure each is in date.

+/- allergen immunotherapy may be given in cases of insect sting anaphylaxis

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16
Q

Why is monitoring for at least 6-12 hours important?

A

Biphasic reactions may occur i.e. the recurrence of symptoms requiring treatment following complete resolution, and usually occur within 6-12 hours

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17
Q

What should the initial history include for anaphylaxis?

A

Exposures immediately prior to the episode of anaphylaxis.]

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18
Q

What is the role of mast cell tryptase levels in childre?

A

Little evidence for its use in children - in adults it may be indicative of a true episode of anaphylaxis and should be measured immediately after the episode and additionally 1-2 hours after (but not later than 4 hours after anaphylaxis).

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19
Q

How are mild/moderate allergic reactions managed?

A

Usually at home with oral antihistamines:

Under 2 years of age: Chlorphenamine 1mg (2.5mls)
2 - 6 years of age - Cetirizine 5mg (5mls)
Over 6 years of age - Cetirizine 10mg (10 mls)

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20
Q

What is the difference between chlorphenamine and citrizine in terms of side-effects?

A

Chlorpenamine = sedating antihistamine

Cetirizine = non-sedating antihistamine

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21
Q

What are the differential diagnoses for anaphylaxis?

A
  • Acute exacerbation of asthma
  • Panic attack
  • Vocal cord dysfunction
  • Generalised acute urticaria
  • Non-allergic angioedema
  • Systemic mast cell disorders
  • Foreign body aspiration
  • Acute poisoning
  • Hypoglycaemia
  • Vasovagal reactions
22
Q

What is allergic rhinitis?

A

Type 1 hypersensitivity reaction to allergens such as hay, pollen, dust, animal hair and mould spores. Causes nasal inflammation.

23
Q

How common is allergic rhinitis?

A

Affects 1 in 5

80% develop symptoms before age 20

24
Q

What is the aetiology of allergic rhinitis?

A

Type 1 hypersensitivity reaction i.e. immediate type, IgE-mediated. IgE is bound to mast cells via its Fc portion. When specific allergen binds to the IgE bound to mast cells, it causes cross-linking and degranulation leading to histamine release.

Usually occurs when the child has not been exposure to the allergen from a young age.

25
Q

What are the symptoms of allergic rhinitis?

A
  • Nasal obstruction, congestion - related to excess fluid in facial tissues and begins minutes after exposure to allergen.
  • Sneezing
  • Red/itchy swollen eyes
26
Q

What are the problems associated with episodes of allergic rhinitis in children?

A

Can affect concentration, sleep and work/school attendance.

27
Q

What conditions is allergic rhinitis associated with?

A

Asthma

FH of atopy

First born children

28
Q

How is allergic rhinitis diagnosed?

A

Skin prick test

Specific serum IgE levels

29
Q

What is the management of allergic rhinitis?

A
  • Allergen avoidance
  • Antihistamines e.g. cetirizine
  • Nasal washes
  • If severe, desensitisation with gradual slow exposure to allergen (e.g. Grasax for pollen immunotherapy)
30
Q

How is a food intolerance different from food allergy?

A

Food intolerance - non-immunological hypersensitivity reaction to a specific food

Food allergy - pathological immune response, usually IgE mediated, mounted against a specific food protein.

31
Q

How common is CMPA/CMPI?

A

Affects 3-6% of infants and typically occurs in first 3 months of life in formula-fed infants, although rarely seen in exclusively breastfed infants too.

32
Q

What is the aetiology of CMPA/CMPI?

A

Immediate (IgE-mediated, <2 hours after ingestion) and delayed (non-IgE mediated, usually 2-72 hours after ingestion) reactions seen.

CMPA = usually immediate

CMPI = mild-moderate delayed reactions

33
Q

What should the examination of a child with suspected CMPA involve?

A
  1. Ask about symptoms and relevant timing
  2. Examine for nutritional status and comorbid atopy
  3. Arrange skin-prick testing and/or serum-specific IgE allergy testing if there is suspected IgE-mediated allergy
34
Q

What are the clinical features of CMPA/CMPI?

A
  • Regurgitation and vomiting
  • Diarrhoea
  • Urticaria, atopic eczema
  • ‘Colic’ symptoms, irritability, crying
  • Wheeze, chornic cough

Rarely angioedema and anaphylaxis may occur.

35
Q

How is CMPA diagnosed?

A
  • Clinically (e.g. improvement with cow’s milk protein elimination)
  • Investigations:
    • Skin prick/patch testing
    • Total IgE and specific IgE (RAST) for cow’s milk protein
36
Q

What is the management of CMPA?

A
  1. Refer to paediatrician if symptoms are severe (e.g. failure to thrive)
  2. Hypoallergenic formula replacement
    • If mild-moderate symptoms –> eHF (extensive hydrolysed formula)
    • If severe CMPA or no response to eHF –> amino acid-based formula

NB: around 10% also intolerant to soya, formula replacement should be undertaken for at least 2-4 weeks to see for improvement then continues in mother and infant until child is 9-12 months and for at least 6 months.

37
Q

What is the management of CMPA in exclusively breastfed infants?

A
  1. Continue breastfeeding
  2. Eliminate CMP from mother’s diet - consider calcium supplements for mother to prevent deficiency during exclusion of cow’s milk
  3. Use eHF when breastfeeding stops
38
Q

What is the prognosis of CMPA/CMPI? How do you check for tolerance at later stage?

A

IgE mediated = around 55% resolves by age 5 years

non-IgE mediated = resolves by age 3 years in most

Oral challenge is undertaken in hospital as anaphylaxis can occur.

39
Q

Is goat’s milk a replacement for cow’s milk in CMPA?

A

No - the proteins contained in both are very similar.

40
Q

Is food allergy usually primary or secondary?

A

Usually oocurs on primary exposure to the food

41
Q

What are the most common food allergies in infants and older children?

A

Infants - milk, egg, peanut

Older children - peanut, tree nut, fish, shellfish

42
Q

When can food allergies be secondary?

A

When they are due to cross-reactivity between proteins present in fresh fruits/ vegetables/ nuts and those present in pollens e.g. if a child becomes allergic to birch pollen they may also develop apple allergy because these share a similar protein.

This is pollen food allergy syndrome.

43
Q

What are the symptoms of pollen food allergy syndrome?

A

Mild such as itchy mouth, but no systemic symptoms.

44
Q

What are the clinical features of IgE mediated food allergy?

A

Allergic symptoms occurring 10-15 min (<2 hours) after ingestion of a food e.g. urticaria, facial swelling, anaphylaxis

45
Q

What are the clinical features of non-IgE mediated food allergy?

A
  • Diarrhoea
  • Abdominal pain
  • Faltering growth.
  • Colic
  • Eczema
  • Blood in stools in first few weeks of life from proctitis
  • Severe repetitive vomiting
46
Q

What is a complication of food allergy induced vomiting in infants?

A

Food protein-induced enterocolitis syndrome (FPIES) - non-IgE mediated (cell-mediated) immune reaction in the GI system to foods, characterized by profuse vomiting and diarrhoea

47
Q

How are food allergies diagnosed?

A
  • Skin prick tests
  • Measurement of specific IgE in blood - false positive results are common but negative skin-prick tests make IgE-mediated allergy unlikely.
  • Non-IgE mediated allergies are harder to diagnose and usually based on clinical history and examination. Endoscopy/intestinal biopsy may be used to check for eosinophilic infiltrates to support the diagnosis.
  • Food challenge - double-blind placebo-controlled trial of a small amount of the food done in hospital with full resuscitation facilities
48
Q

How do you confirm allergy with skin-prick testing?

A

4mm weal and flare reaction should be produced

49
Q

What is the management of food allergy?

A
  1. Avoidance
  2. Refer to dietician for advice about alternative foods and how to avoid nutritional deficiencies
  3. Written self-mangement plan and training about anaphylaxis management
  4. Non-sedating antihistamines for mild-reactions (without cardiorespiratory symptoms)
50
Q

What is the prognosis with food allergies in childhood?

A
  • Shellfish and nut allergies usually persist through to adulthood
  • Egg and cow’s milk protein allergies may resolve in early childhood and can be reintroduced

Year 5 - Paediatrics (91 decks)

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