Allergy Group

Question 1

EPI BULLETS

Answer 1

• < 1 % of children has anaphylaxis to penicillin
• < 2 % of rashes with exposure to amoxcillin are 2/2 the drug
• 94 - 96 % of children with a history of beta-lactam allergy, do not when challenged
• There’s a 2 % risk of a cephalosporin-penicillin cross-reactivity in confirmed cases of allergy, < 1 % when the allergy is not confirmed.

Question 2

What historical red flags warrant evaluation by an allergist for a beta-lactam allergy ?

Answer 2

• Required hospitalization
• Anaphylaxis (required epipen)
• Serum sickness-like Syndrome
• TEN / DRESS / Stevens-Johnson Syndrome
• Drug induced hemolytic anemia

Question 3

What is the management for an anaphylactic bug bites or sting?

(After the emergent therapy)

Answer 3

1. ABCs and anaphylaxis managment*
2. Measure tryptase levels (mutation associated with allergic severity)
3. Refer to allergist for Venom Immune Therapy** candidacy
4. Educate on preventive measures
   
   • Dont walk in grass barefoot
   • Don’t garden with exposure arms/feet/legs
   • Search and remove nests in the area
   • Cover exposed food when eating outside
5. Provide an epipen

​*Check out the pathway at this LINK**VIT can reduce anaphylaxis risk to 20 - 5 % per sting, and magnitude of acute illness.

Question 4

Read the LEAP Study

Answer 4

Seriously, read it. I found it for you

LEAP STUDY

Isn’t that neat

(https://www.nejm.org/doi/full/10.1056/NEJMoa1414850)

Question 5

What maternal habits can impact atopy in children ?

(Besides smoking and poor hygiene)

Answer 5

Nothing really all that substantial

• Topping up with formula can*decrease CMPA development
• Avoidance during pregnancy doesn’t help
• Avoidance during breastfeeding might* help eczema (nothing else)
• Breastfeeding vs. formula is equivocal for asthma

*One study showed this

Question 6

What is the management for a child with

1. Delayed rash after amoxicillin exposure
2. Anaphylaxis with amoxicillin exposure
3. Clinical symptoms of Type 3* or 4** Hypersensitivity

**Type 3 is serum sickness-like syndrome (arthritis, cutaneous lesions, renal injury)

**Type 4 is auto-immunity exacerbation-like (i.e. enteritis, thyroiditis, cutaneous lesions)

Answer 6

1. Delayed rash after amoxicillin exposure
   
   1. Assess for systemic hypersensitivity
   2. Reassurance, no future restrictions on beta-lactam use*
2. Anaphylaxis with amoxicillin exposure
   
   1. Treat anaphylaxis
   2. Refer to allergist
   3. No amoxicillin/ampicillin, methicillins or cephalosporins until cleared by allergist
3. Clinical symptoms of Type 3 or 4* Hypersensitivity
   
   1. Stop drug - consider alternative for initial indication
   2. Supportive care for system involved
   3. Refer to allergist
   4. Restrict instigating drug (there’s no evidence for cross-reactivity)

​***You can observe for 1 h in the office after first dose if the parents are nervous

Question 7

What is the management for localised swelling from bug bites/stings ?

Answer 7

1. Assure there is no evidence of anaphylaxis
2. Symptomatic treatment (NSAIDs/paracetamol for pain, ice swelling)
3. OTC non-sedating anti-histamines and give some relief
4. Educate on avoidance hygiene and when to return
   
   • Return if secondary infection occurs (rare) or concerned for anaphylaxis
   • Cover well when playing in grass/forests
   • Have known nests dealt with by city / pest control
   • Cover food when eating outside
5. Consider systemic steroid course for sensistive areas (genitals, hands with impaired function, eye occlusion)

​Mild localised symptoms can take up to 10 days for resolution of swelling. Just make sure the symptoms don’t worsen or change.

Question 9

What makes an infant “at risk” for developing a food allergy?

Answer 9

First degree relative with atopy

Atopy = Allergies, Asthma, IgE oro/esophago/gastro/entero/colitis, eczema, rhinitis

Question 10

EPI BULLETS

Answer 10

• 0.4 - 0.8 % of kids will get a bug bite/sting
• Having isolated urticaria after a sting, has a 90 % chance that future stings will yield a less intense presentation

Question 11

What are the nesting and aggresion patterns for the following hymenoptera (bee-like stingers) ?

• Yellow Jackets
• Wasp
• Hornet
• Honey/Bumble Bee

Answer 11

• Yellow Jackets (#1 Stinging culprit)
  
  • Dirt/Underground nests
  • Very aggresive
• Wasp
  
  • Ground, play structures, decks/fences or furniture
  • Aggresive when threatened (usually by accident)
  • LOVE outdoor food/sweet beverages
• Hornet
  
  • Shrubs and tree nests (issue when gardening)
  • Aggresive when threatened (usually by accident)
• Honey/Bumble Bee (only ones to leave stinger in)
  
  • Hives in trees and rarely structures
  • Not aggresive unless hive is threatened
  • Adorable

Question 12

What are the 4 types of hypersensitivity ?

(Give a clinical example for each)

Answer 12

1. IgE mediated (anaphylaxis, atopy - 0 - 2 h onset)
2. Antibody mediated (ABO incompatibility 10 h - weeks onset)
3. Immune complex mediated (Serum sickness 1 - 3 week onset)
4. T-cell mediated (autoimmunity 2 - 14 day onset)

Question 13

What is the proper procedure to introduce possible allergens in infants that are “at risk” for having an allergy ?

Answer 13

1. Introduce solids as early as possible*
   
   1. Suggests at 4 months+** for at risk
   2. 6 months+** for those not at risk is ok
2. Introduce 1 allergen per week
3. Sustain exposures to allergens after the first week trial

*The baby has to be interested in trying new things and capable of processing the solid. Don’t rush for allergy prevention as this is a choking risk. **Corrected gestational age!