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Pediatrics > Pediatric Allergies > Flashcards

Pediatric Allergies Flashcards

1
Q

IgE Mediated reactions

  1. What kind of onset?
  2. Can affect what areas? 4
A
  1. Typically rapid in onset
    • Skin
    • GI tract
    • Respiratory tract
    • Anaphylaxis
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2
Q

90% of IgE mediated reactions in children are from these 8 sources
(which ones usually resolve by age?)
(which ones are usually lifelong?)

A
  1. Cow’s milk
  2. Eggs
  3. Soybean
  4. Wheat
  5. Peanuts
  6. Tree nuts
  7. Fish
  8. Shellfish
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3
Q

Non-IgE mediated reactions

  1. Occurs when after exposure?
  2. Typically presents in what age?
  3. Can present how? 2
A
  1. Occur hours to days after exposure
  2. Typically presents in infants
  3. Can present as
    - chronic skin conditions or
    - most commonly manifests as GI symptoms
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4
Q

Non-IgE mediated reactions
1. WHat kind of GI manifestations?
3

A
  1. Proctitis/Proctocolitis
  2. Enteropathy
  3. Enterocolitis
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5
Q

Symptoms of food induced allergic reaction (IgE and non-IgE mediated)
7 areas

A
  1. Cutaneous
  2. Ocular
  3. Upper respiratory
  4. Lower respiratory
  5. GI oral
  6. Lower GI
  7. CV
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6
Q

Name the symptoms in the following areas:
1. Cutaneous 4

  1. Ocular 4
  2. Upper respiratory 7
  3. Lower respiratory 5
  4. GI oral 4
  5. Lower GI 5
  6. CV 5
A
    • Erythema,
    • pruritus,
    • urticaria,
    • angioedema
    • Pruritus,
    • conjunctival erythema,
    • tearing,
    • periorbital edema
    • Nasal congestion,
    • pruritus,
    • rhinorrhea,
    • sneezing,
    • laryngeal edema,
    • hoarseness,
    • dry cough
    • Cough,
    • chest tightness,
    • dyspnea,
    • wheezing,
    • intercostal retractions
    • Angioedema of the lips,
    • tongue or palate,
    • oral pruritus,
    • tongue swelling
    • Nausea,
    • colicky abd pain,
    • reflux,
    • vomiting,
    • diarrhea
    • Tachycardia (occasionally bradycardia in anaphylaxis),
    • hypotension,
    • dizziness,
    • fainting,
    • LOC
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7
Q

Diagnosis of allergy?

5

A
  1. History
  2. Physical exam
  3. Skin prick test (SPT),
  4. allergen specific serum IgE,
  5. oral food challenge

Parent and patient reports of food allergy should be confirmed with testing as multiple studies demonstrate 50-90% of presumed food allergies are not allergies.

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8
Q

Treatment of allergies?

2

A
  1. Avoidance

2. Epi-pen for treatment for anaphylaxis

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9
Q 
Which of the following symptoms can be associated with food allergies?
A. Atopic dermatitis
B. Chronic nasal congestion
C. Acute Urticaria
D. Both A and C
A

D

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10
Q

Skin symptoms

3

A
  1. atopic dermatitis,
  2. acute
  3. chronic urticaria
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11
Q

Consider evaluation in infants and children with what kind of dermatitis?
2

A
  1. moderate to severe atopic dermatitis or

2. if there is a history of exacerbation when eating specific foods.

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12
Q

If food allergy is diagnosed, the atopic dermatitis often improves after what?

A

after dietary elimination of that particular food.

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13
Q
  1. The causes of acute urticaria vary and include what? 3
  2. ______ urticaria is a common symptom present with food allergy.
  3. In contrast, _____ urticaria is very rarely related to food allergy.
  4. Food allergy testing is rarely indicated for _____ urticaria since most cases are ________?
A
    • infection,
    • drug reaction
    • food allergy.
  2. Acute
  3. chronic
  4. chronic, idiopathic.
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14
Q

Nasopharyngeal symptoms: Multiple nasopharyngeal symptoms occur with food allergy
such as?
2

A
  1. acute rhinitis (typically associated with other oropharyngeal symptoms such as pruritus of the throat and angioedema)
  2. Chronic rhinitis is not a manifestation of food allergy.
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15
Q

Jack is referred to an allergist for further evaluation. What is the most appropriate testing at this time?
A: Atopy patch testing
B: Serum specific IgE testing or skin prick testing
C: Oral food challenge

A

B

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16
Q

Skin prick testing introduces allergen extracts into the skin:

  1. Positive reaction is defined as what?
  2. The negative predictive value is > ___% while the positive predictive value is less than ___%;
  3. therefore, there are many _________ results.
  4. _________ should be discontinued prior to testing.
  5. Testing cannot be performed on skin what? 2
A
  1. A positive reaction is defined as a wheal at least 3mm greater than the negative control.
  2. 95, 50
  3. false positive
  4. Antihistamines
    • with extensive eczema/rash or
    • in patients with dermatographia.
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17
Q

Serum specific IgE testing:

  1. Detection of serum IgE to what?
  2. All positive and negative tests (skin and serum tests) need to be correlated with what?
  3. A _______________does not make the diagnosis of clinical food allergy.
    - what is this evidence of?
A
  1. specific allergens.
  2. the patient’s clinical history.
  3. positive test alone
    - Evidence of sensitization, i.e., an immunological response.
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18
Q

Gold standard for diagnosis of food allergy?

whats usually used?

A
  • A double-blind, placebo controlled food challenge is the gold standard for diagnosis of food allergy.
  • -open (unblinded) challenges are generally used in most clinical settings
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19
Q

Patients may benefit from an oral food challenge if they have what? 2

A
  1. borderline test results or

2. if a false positive or false negative is suspected based on clinical history.

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20
Q
  1. Describe the Oral food challenge?

- The process requires what?

A
  1. The patient is given gradually increasing amounts of the suspected food allergen over a time period of hours to a day.
    - -The process requires close medical supervision.
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21
Q

Atopy patch tests are currently used to diagnose what?

Atopy patch testing for IgE-mediated food allergy is what?

A

delayed hypersensitivity T-cell mediated reactions such as contact dermatitis.

not recommended.

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22
Q

Jack’s skin prick testing reveals the following:

Histamine (positive control): 3 mm wheal
Saline (negative control): 0 mm wheal
Peanut: 7 mm wheal
Walnut: 2 mm wheal
Cashew: 3 mm wheal
Almond: 3 mm wheal
Pecan: 2 mm wheal
Hazelnut: 1mm wheal
Fish: 2 mm wheal

Serum specific IgE testing reveals:

Peanut: 15 kU/L
Walnut: less than 0.35 kU/L
Cashew: less than 0.35 kU/L
Almond: less than 0.35 kU/L
Pecan: less than 0.35 kU/L
Hazelnut: less than 0.35 kU/L
Fish: less than 0.35 kU/L

What should you advise the family regarding food avoidance?

A: Avoid peanuts
B: Avoid tree nuts
C: Avoid fish
D: A and B
E: A, B, and C
A

Jack is therefore likely to be truly allergic to peanut since his IgE value is over the 14 kU/L cutoff value.

While there is no cross reaction between peanuts and tree nuts, children allergic to one have an increased risk of allergy to the other. Since peanuts and tree nuts are often processed together, it is often advisable to strictly avoid both peanuts and tree nuts to avoid exposure through cross-contamination.

The correct answer is D, Jack should continue to avoid peanuts and tree nuts.

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23
Q

Diagnosis of food allergy
4

Patients with what are likely to have a food allergy? 2

A
  1. Clinical history
  2. oral challenge
  3. Skin tests and
  4. serum specific IgE provide evidence of sensitization and help determine when a challenge is appropriate.

Patients with

  1. large wheals from skin prick testing (SPT) or
  2. with high serum specific IgE are likely to have food allergy.
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24
Q

Each allergen may have a different what? 4

A
  1. normal IgE level and
  2. wheal diameter
  3. Age of child
25
Q
  1. The cutoff value is the concentration of specific IgE for a particular food allergen that is ___% predictive of a clinical reaction to the food.
  2. Increasing levels of specific IgE and wheal response to SPT correlate with allergy but do not predict what?
A
  1. 90

2. severity of reaction.

26
Q

Established cutoff values for serum specific IgE testing include:

  1. Egg (child 3-17 yrs): __ kU/L
  2. Egg (child less than 2 yrs): __ kU/L
  3. Cow’s milk (child 3-17 yrs):__ kU/L
  4. Cow’s milk (child less than 2 yrs): __kU/L
  5. Peanut (child less than 18 yrs): ___ kU/L
  6. Fish (child less than 18 yrs): ___ kU/L
A
  1. 7
  2. 2
  3. 15
  4. 5
  5. 14
  6. 20
27
Q
  1. If consuming a food without experiencing a clinical reaction, SPT and IgE testing is what?
  2. If for whatever reason testing is conducted and positive results are observed, it is important to stress to the caregiver that the food continue to be consumed on a regular basis. Why?
A
  1. not warranted.
  2. Because testing indicates that the child is sensitized to the allergen, a prolonged absence of the food from the diet could lead to clinical symptoms upon re-exposure.
28
Q

Treatment for food allergies?

2

A
  1. Children should be instructed not to share or trade food with others and to notify adults if they eat something that may contain the food to which they are allergic.
  2. Epi-pen autoinjector
29
Q

Recommended dosage for epic-pen is what?
2

Administered how and when?

A
  1. 0.15 mg of 1:1000 epinephrine for 15 to 30 kg (33 to 66 lbs)
  2. 0.3 mg of 1:1000 epinephrine for anyone over 30 kg (66 lbs).

Epinephrine should be given intra-muscularly in the thigh

30
Q

A 17 year old male comes to your office in August because he is concerned that he has a food allergy. After eating bananas, he develops pruritus of his lips and tongue without edema. He has no systemic symptoms after eating bananas. The symptoms resolve with no treatment. He has no history of eczema or asthma. He does have seasonal allergic rhinitis in the late summer for which he takes loratadine with good response.

What further testing is needed? 
A. Skin prick testing for banana
B. Skin prick testing for pollens
C. Skin prick testing for banana and pollens
D. No further testing is needed
A

C

31
Q

Pollen-food allergy syndrome (PFAS), also known as oral allergy syndrome (OAS),

  1. What kind of reaction and what does it affect?
  2. PP?
  3. Symptoms?
  4. When do symptoms usually not occur?
  5. This syndrome affects up to 50% of adults with what?
A
  1. IgE-mediated reaction that affects the oropharynx
  2. It is thought to occur from the cross-reactivity between proteins present in pollens and those expressed by fruits and vegetables.
  3. Patients develop tingling and itching of the lips, tongue and palate when eating certain raw fruits and vegetables.
    - -Systemic signs are very rare.
  4. Symptoms do not occur when the fruit or vegetable is cooked
  5. This syndrome affects up to 50% of adults with allergic rhinitis secondary to pollens.
32
Q

Specific fruits and vegetables are associated with certain types of pollen:
1. Birch pollen allergy cross reactivity? 6

  1. Ragweed pollen cross reactivity? 3
  2. Grass pollen cross reactivity? 2
A
    • apples,
    • plums,
    • peaches,
    • nectarines,
    • cherries
    • almonds
    • melons,
    • bananas
    • tomatoes
    • melons
    • kiwi fruit
33
Q

Diagnosis of PFAS

A

Confirmed through skin prick testing to the fresh foods and pollen, and also with oral food challenges
–oral challenges are rarely necessary

34
Q

Treatment of PFAS
1. Symtpoms can be controlled sometimes with?

  1. Patients should avoid consumption of the raw food product that produced symptoms. What can they eat?
  2. Any patient who has a history of systemic symptoms should do what? 2
A
  1. Symptoms can sometimes be controlled with antihistamines
  2. may continue to eat the specific food if it is cooked
  3. Any patient who has a history of systemic symptoms should
    - - strictly avoid the food in all forms and
    - - carry an epinephrine auto-injector.
35
Q

A 16 year old female presents to your office for a well-child exam. She has a history of peanut allergy but admits that she does not carry her epinephrine autoinjector. She feels that she is always careful in avoiding food with peanuts.

What advice would you give this patient regarding her risk of fatal anaphylaxis?

A. Adolescents are at a lower risk for fatal anaphylaxis than younger children, but she should still carry her epinephrine autoinjector with her at all times to be safe

B. Foods may be unknowingly contaminated with peanuts and therefore having an epinephrine auto-injector is critical at all times

C. Because she is careful in screening for peanut products in food, her risk of anaphylaxis is low

A

B

36
Q

Teenagers are at higher risk for fatal food-induced anaphylaxis than younger children. Why?

A
  1. Dose provoking symptoms in peanut-allergic patients decreases with age, which may in part contribute to the observed difference in risk.
  2. Studies have also shown that adolescents have poor understanding of when food allergy reactions are severe and when epinephrine is indicated.
37
Q

Which of the following food allergies are more common in adults than children?

A. Shellfish
B. Egg
C. Peanut

A

A

38
Q

Most common allergies varies among age groups:
1. The most common food allergies in children are what? 3

  1. The most common food allergies in adults are what? 3
  2. _______ allergy is the second most common food allergy in adults it is still more common in children, affecting 0.8% of young children (0-5 yrs).
  3. Only 0.1% of young children have _______ allergy while it affects 2% of adults.
  4. Allergies to what (2) are also more prevalent among adolescents and adults than children.
A
  1. milk, egg, and peanut.
  2. shellfish, peanut, and tree nut.
  3. Peanut
  4. shellfish
  5. tree nuts and fruits
39
Q

Peak prevalence in allergic rhinitis?

A
  1. Peak prevalence 14-25 years old
    80% develop symptoms before age 20
    20% by 2-3 yrs of age
    40% by 6 yrs of age
40
Q

Symptoms of Allergic rhinitis

7

A
  1. Sneezing
  2. Rhinorrhea
  3. Nasal congestion
  4. Itching of the eyes, nose, palate, ear canals
  5. Postnasal drip, cough
  6. Irritability
  7. Fatigue
41
Q

AR may have a significant impact on quality of life and cognitive function such as?
4

A
  1. Sleep disordered breathing
  2. Fatigue
  3. General malaise
  4. Cognitive and psychiatric issues in children
42
Q

What are some cognitive and psychiatric issues that AR could cause in children?
5

A
  1. ADHD,
  2. lower exam scores in peak pollen season,
  3. poor concentration,
  4. impaired athletic performance,
  5. low self esteem
43
Q

Diseases associated with allergic rhinitis

4

A
  1. Otitis media and eustachian tube dysfunction
  2. Sinusitis
  3. Asthma
  4. Sleep-related breathing disorders
44
Q

Differential diagnosis for AR?

11

A
  1. Viral URI
  2. Chronic sinusitis
  3. Adenoidal hypertrophy
  4. Septal deviation
  5. Turbinate hypertrophy
  6. Foreign bodies
  7. Choanal atresia
  8. Nasal polyps
  9. Immunodeficiencies
  10. CSF leak
  11. Tumors
45
Q

Physical findings for allergic rhinitis?

8

A
  1. Allergic salute = transverse crease across nasal bridge
  2. Allergic shiner = dark swollen, infra-orbital tissue
  3. DENNIE MORGAN LINES
  4. Pale, boggy nasal turbinates
  5. Clear nasal discharge
  6. postnasal drip
  7. Conjunctival chemosis
  8. Cobblestoning
46
Q
  1. What are allergic shiners?

2. What are dennie morgan lines?

A
  1. Sub-conjunctival sack venous congestion caused by blockage secondary to nasal edema
  2. Infra-orbital creases due to edema and thickening of the skin
47
Q

Diagnosis of allergic rhinitis?

3

A
  1. Suggestive history
  2. Supportive exam
  3. Identify specific-IgE
48
Q

Sensitization vs. Allergy
1. What tests detect sensitization? 2

  1. Define allergy?
A
  1. Both
    - skin testing and
    - serum IgE testing detect “sensitization”
    - -Presence of specific IgE to an allergen
  2. “Allergy” is a clinical syndrome with symptoms combined with evidence of sensitization (positive skin or serum test)
49
Q

Treatment of Allergic Rhinitis

3

A
  1. Environmental control
  2. Pharmacotherapy
  3. Immunotherapy
50
Q

What pharmacotherapy is there for allergic rhinitis?

7

A
  1. Antihistamines
  2. Decongestants
  3. Nasal steroids
  4. Anticholinergics
  5. Mast cell stabilizers
  6. Ocular meds
  7. Leukotriene modifiers
51
Q

Treatment Approach to children less than 2 years old with AR

A

Uncommon

In all patients avoidance therapy is the most effective first line treatment

52
Q

Meds for children less than 2 years old?
3

What can we not use?

A
  1. Cromolyn nasal spray
  2. 2nd generation antihistamine
    Ceterizine, fexofenadine (for kids ≥ 6 months)
  3. Intranasal glucocortocoids if severe symptoms and no response to above therapies
  4. NO first generation antihistamines (H-1 blockers)
53
Q

Treatment: In kids > 2 years old the approach is same as that with adults: Mild or episodic?
4

A

Mild or episodic symptoms

  1. Cetirizine, loratidine or fexofenidine
    - -2-5 hours prior to exposure
  2. Or intranasal topical antihistamine
  3. Or intranasal glucocorticoid
    - –More effective than antihistamines
  4. Or intranasal cromolyn 30 min prior to exposure
54
Q
  1. intranasal topical antihistamine examples? 2
A
  1. Azelastine (> 5 yr) or olopatidine (> 12 yr)
55
Q

Treatment: Kids > 2 yrs old with persistent or severe symptoms? 4

A
  1. Intranasal glucocorticoid
  2. Topical nasal antihistamines
  3. Oral antihistamine
  4. Decongestant

Start with first med and add on in this order if needed for persistent symptoms

56
Q

Intranasal glucorticoids for kids

3

A
  1. Mometasone (Nasonex) ≥ 2 years
  2. Fluticasone furoate (Veramyst) ≥ 2 years
  3. Fluticasone propionate (Flonase) ≥ 4 years
57
Q

Topical nasal antihistamines

3

A
  1. Azelastine (Astelin) > 5 years
  2. Olopatidine (Patanase) > 12 years
  3. Combo azelastine and fluticasone (Dymista) > 12 years
58
Q

AR with allergic conjunctivitis

treatment?

A
  1. Intranasal glucocorticoid + topical ophthalmic antihistamine drops
    - -This combo is less drying than oral antihistamines
59
Q

AR with asthma treatment?

A
  1. Leukotriene modifier
    –Monteleukast (Singulair)
    Approved for use in children as young as 6 months

Pediatrics (18 decks)

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