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Post Info TOPIC: (Medscape) Food-Induced Anaphylaxis: Keeping Kids Safe
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Always misinterpret when you can

Posts: 21677
Date: Jul 23, 2013
(Medscape) Food-Induced Anaphylaxis: Keeping Kids Safe
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Food-Induced Anaphylaxis: Keeping Kids Safe

Julie Wang, MD, Michael Young, MD, Anna Nowak-Wegrzyn, MD

Jul 18, 2013

Food Allergies: Not to Be Underestimated

A 7-year-old girl with known peanut allergy was given 1 peanut on the playground during a school recess break by another child who was unaware of her severe allergies. Shortly after eating the peanut, she felt unwell and asked the teacher for help.

We will use the tragic example of the fatal outcome of peanut anaphylaxis in a child to discuss several important issues, with special emphasis on managing food allergies at school.

Epidemiology of Food-Induced Anaphylaxis

Food allergies are an important public health concern, and their prevalence is increasing. Recent data indicate that 5.1% of children 0-17 years of age were affected by food allergies in 2009-2011, an increase from 3.4% in 1997-1999.[1]

Food allergies trigger allergic reactions that can range from mild to severe, including life-threatening anaphylaxis.[2] In fact, food was the most common trigger of anaphylaxis in a population-based incidence study.[3] In another study examining emergency department visits and admissions for food-induced anaphylaxis between 2001 and 2006, a significant increase in both was observed, demonstrating that food-induced anaphylaxis continues to be an important issue.[4]

Deaths as a result of anaphylaxis do occur, and approximately 500-1000 fatalities per year are reported in the United States.[5] Up to 30% of fatal anaphylaxis cases are triggered by food allergens. Although over 90% of these are associated with nut (peanut or tree nuts) exposures in the United States, it is important to note that allergic reactions to any foods have the potential to cause severe allergic reactions and anaphylaxis. Furthermore, the severity of allergic reactions to foods cannot be predicted by history or by either skin prick or allergen-specific IgE level testing.[6]

For some, the first presenting sign of an allergy is anaphylaxis. Nearly 25% children who received epinephrine to treat severe allergic reactions in schools had no history of life-threatening allergy,[7] and approximately 20% of reactions occurring in school settings are due to first exposure to the food allergen.[8]

For which of the following cases would you strongly consider anaphylaxis as the diagnosis? Check all that apply:
A 10-year-old reports acute onset of pruritic rash and complains that he can't catch his breath while at a school party
A 5-year-old has hives that started along with fever and cough 3 days ago; the family reports no new foods or exposures
A 7-year-old with peanut allergy ate a cookie from a friend and complained of feeling lightheaded; the nurse noted her blood pressure to be 80/60 mm Hg, with no other symptoms
A 6-year-old develops hives on his hands after playing with ice for a science experiment; he says that the same thing happened when he was playing in the snow this winter

Food Anaphylaxis: Diagnosis

Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death.[9] The signs and symptoms can be varied and can affect any organ system. Until 2006, there was no consensus definition for anaphylaxis, resulting in significant variations in and underrecognition of identification and treatment of anaphylaxis -- not only by medical professionals, but also by patients and their caretakers.[10,11] Because there can be significant variability in the presentation of anaphylaxis, an expert panel proposed criteria for diagnosing anaphylaxis.[9]

Table. Clinical Criteria for Diagnosing Anaphylaxis

Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled:
1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or flushing, swollen lips/tongue/uvula)
AND AT LEAST ONE OF THE FOLLOWING
    a. Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced PEF, hypoxemia)
    b. Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope, incontinence)
2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):
    a. Involvement of the skin/mucosal tissue (eg, generalized hives, itch/flush, swollen lips/tongue/uvula)
    b. Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced PEF, hypoxemia)
    c. Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence)
    d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)
3. Reduced BP after exposure to known allergen for that patient (minutes to several hours):
    a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in systolic BP*
    b. Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease from that person's baseline

BP = blood pressure; PEF = peak expiratory flow. Data from Sampson HA, et al. Ann Emerg Med. 2006;47:373-380.

Symptoms affecting the skin are commonly seen in allergic reactions (up to 80% of cases). Cutaneous symptoms appearing in conjunction with respiratory or cardiovascular symptoms fulfill the criteria for anaphylaxis.

As seen in the diagnostic criteria, the clinical spectrum of anaphylaxis is wide. Although skin symptoms are seen in the majority of allergic reactions, up to 20% of cases of anaphylaxis can present without skin findings. Thus, the absence of dermatologic symptoms does not rule out anaphylaxis.[2,12] In these cases, a history of allergy and likely exposure to a food allergen, along with symptoms affecting at least 2 organ systems (gastrointestinal, respiratory, or cardiovascular), establishes the diagnosis of anaphylaxis.

In rare cases, isolated hypotension has been reported to be the primary symptom of anaphylaxis. Therefore, if hypotension is found in a patient who has known exposure to a food allergen, treatment for anaphylaxis should be initiated.

Although the onset of anaphylaxis can be variable, ranging from within seconds to a few hours after exposure to the causal food allergen, the majority of reactions manifest within 1 hour of exposure. The time course for anaphylaxis can be uniphasic, biphasic, or protracted. Most reactions are uniphasic, with symptoms resolving quickly after treatment. Up to 20% are biphasic, in which recurrence of symptoms is seen after resolution of the initial symptoms without reexposure to the allergen.[13] The biphasic response is often variable in terms of severity and most often occurs within 8 hours of the initial symptoms.[14] Protracted anaphylaxis from food allergy is less commonly seen.

Risk factors for severe or fatal allergic reactions to foods include (select all that apply):
Severe asthma
Asthma of any severity
History of previous severe reactions
Allergy to peanuts or nuts
Age younger than 10 years

Risk Factors

Several risk factors have been identified for food-induced anaphylaxis. Approximately one third of persons who have had anaphylaxis have comorbid asthma,[15] and the majority of those with fatal or near-fatal anaphylaxis to foods had underlying asthma.[16,17] Patients with asthma of any severity are at increased risk for severe food allergic reactions.

Although any food allergen can trigger anaphylaxis, the majority of severe food reactions are triggered by peanuts and tree nuts. In a report of fatal anaphylaxis cases, over one half were triggered by nuts.[17] In a recent study of children with food allergy in the United States, anaphylaxis was most often associated with multiple food allergies or having allergies to peanuts, tree nuts, or shellfish.[18]

Adolescents and young adults are particularly at risk owing to their increased risk-taking behaviors, which can include ingestion of unsafe foods and not carrying emergency medications. In a survey of college students, only 39.7% reported always avoiding the foods to which they were allergic; 21% reported that they had self-injectable epinephrine, but only 6.6% reported always carrying the device.[19] Additional risk-taking behaviors include alcohol and drug consumption, which can compromise an individual's ability to evaluate the safety of foods and impair self-recognition of signs and symptoms of allergic reaction, leading to delays in initiating appropriate treatment.

Exercise and alcohol, as well as such medications as aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, monoamine oxidase inhibitors, tricyclic antidepressants, and antacids, may independently increase the severity of anaphylactic reactions or diminish the efficacy of epinephrine.[6,20]

Diagnosing Food Anaphylaxis

The diagnosis of food-induced anaphylaxis relies on the clinical picture and recognition of signs and symptoms, because there is currently no rapid, reliable test to establish the diagnosis. A detailed history should include the time of onset of symptoms after the allergen exposure, evolution of signs and symptoms, presence of augmenting factors (eg, medications, alcohol, exercise), and treatments given before presenting for medical attention. Additional questions should include comorbid medical problems, prior experiences with the triggering food, and history of anaphylaxis.

Laboratory tests, such as serum histamine and serum tryptase, have poor diagnostic value for food-induced anaphylaxis because they have low sensitivity and specificity. Elevations of histamine can be seen in food-induced anaphylaxis; however, samples require special handling and increases in histamine level are transient (15-60 minutes) and therefore are often missed.[21] Elevations in serum tryptase are often not seen in food-induced anaphylaxis.[16] Novel biomarkers, including platelet-activating factor acetylhydrolase, are currently being investigated.[22]

Back to the Case

The teacher walked the child to the nurse's office. By the time they arrived, the child was struggling to breathe.

What is the most appropriate treatment at this time?
Observation
Administer albuterol
Administer diphenhydramine
Administer epinephrine autoinjector and call 911
Call the child's parents
Call the child's primary care provider to determine the best treatment
In what situations would epinephrine use be discouraged in a child with symptoms of anaphylaxis?
The child has had no prior anaphylaxis
The child has a history of congenital heart disease
The child is taking antidepressant medications
The child has an arrhythmia
None; there are no absolute contraindications to epinephrine use for anaphylaxis

Treating Anaphylaxis

Epinephrine is the treatment of choice for anaphylaxis. The reversal of anaphylaxis results from the pharmacologic effects of epinephrine:

  • Alpha-1-adrenergic effects that lead to vasoconstriction, increased vascular resistance, and decreased mucosal edema;

  • Beta-1-adrenergic effects that increase inotropy and chronotropy; and

  • Beta-2 adrenergic effects mediating bronchodilation.

Stimulation of the beta-2-adrenergic receptor may also downregulate mast cell activation and inhibit further release of the mast cell mediators.

There are no absolute contraindications to the use of epinephrine in the setting of anaphylaxis. The recommended dose is 0.01 mg/kg, up to 0.3 mg for children and 0.5 mg for adults, administered intramuscularly in the thigh.[2] The preferred location for injection is the thigh (vastus lateralis muscle) because compared with subcutaneous or intramuscular injection into the deltoid muscle of the arm, the time to peak concentration of epinephrine in serum is shorter and the peak concentration is higher.[23] Epinephrine should not be administered intravenously for the treatment of anaphylaxis except in severe hypotension, in which case it should be administered as a titrated vasopressor drip.

Any patient with a history of anaphylaxis or allergy to peanut, tree nuts, fish, or shellfish or with both food allergy and asthma should be prescribed an epinephrine autoinjector for emergencies.[2] Epinephrine autoinjectors are available in the community setting, with prefilled doses of 0.15 mg for persons weighing < 55 lb and 0.3 mL for those weighing 55 lb or more. Several autoinjectors are currently on the market (Adrenaclick®, Auvi-Q™, EpiPen®). Although instructions appear on the autoinjectors themselves, it is important to ensure that patients and caregivers are familiar with the use of these autoinjectors to minimize delay in administration or incorrect use (eg, accidental injection in the finger or self-injection when a caregiver is administering the medication).

Up to 20% of children with food-induced anaphylaxis require 2 doses of epinephrine to adequately treat symptoms.[24,25] It is therefore advisable that patients have 2 doses available at all times. The second dose of epinephrine is indicated when there is no improvement or symptoms recur or increase in the 5-10 minutes after the first dose.

Epinephrine administration should be immediately followed by a 911 call to activate the emergency medical system for transport to the nearest hospital for further medical treatment and to observe for biphasic anaphylaxis, which can occur in up to 20% of anaphylaxis cases.[26] Epinephrine administration should not be delayed while help is being sought.

Back to the Case

The health aide did not have an epinephrine autoinjector with the child's name on it and was unable to administer the drug. Although 911 was called immediately, by the time the ambulance arrived, the child was in cardiac arrest. Despite cardiopulmonary resuscitation by school and ambulance staff and rapid transport to the hospital by the ambulance crew, the child was pronounced dead on arrival.

What should be done after administering epinephrine and calling 911? (select all that apply):
Lay the child down with feet raised
Have the child walk around to ensure that she does not lose consciousness
Have the child drink some water to help the throat symptoms
Give diphenhydramine even if there are no skin symptoms

What Else Should be Done?

Adjunctive treatments include placing the patient supine with legs elevated, if tolerable. This enhances cardiac preload in cases of anaphylactic shock.[27] To prevent orthostatic hypotension, rapidly standing or sitting the hypotensive patient up is contraindicated. In younger children with significant respiratory distress or patients with ongoing emesis, the recumbent position may increase their distress, and the position of comfort would be preferable.

Additional treatments include oxygen and intravenous fluids. In patients with significant bronchoconstriction and wheezing, a nebulized bronchodilator (eg, albuterol) may be administered, after intramuscular epinephrine.

Antihistamines are considered second-line treatment for anaphylaxis because these medications only treat cutaneous symptoms[2] and do not have a significant effect on cardiovascular symptoms.[28,29] A few studies have examined the role of corticosteroids in anaphylaxis treatment with mixed results. Whereas one study suggested that corticosteroids may minimize or prevent a late-phase response,[30] another found no beneficial effects.[31]

Back to the Case

It is unclear why an epinephrine autoinjector was not provided to the school by the child's family. It was illegal for the health aide to use another child's epinephrine autoinjector for the treatment of this child's peanut anaphylaxis.

What precautions can the school take to minimize the chance of future reactions?
Become a nut-free school
Instruct students to use hand sanitizers frequently
Implement an individual healthcare plan (IHP), formulated by the primary care provider and family in collaboration with the school nurse and school staff
Provide funding for home schooling

Management in the School Setting

Successful management of food-allergic children in the school setting requires collaboration among the child's family, primary care provider, school nurse, and school staff. The family is responsible for alerting the school to the child's food allergies; providing emergency medications, such as epinephrine autoinjectors; and submitting a written IHP that addresses prevention of unintentional exposures of food allergen, as well as an emergency action plan (EAP) for the treatment of acute allergic reactions and management of anaphylaxis.[8,32,33] The IHP is formulated by the family, healthcare provider, and school nurse with input from school staff, including administrators, teachers, transportation, and food services.

The family may elect to provide safe snacks for the child. The child is taught the principles of safe practices for food allergies, such as eating only designated foods, hand-washing before and after meals, and no food sharing. Food allergen avoidance strategies are age-dependent and relate to the child's emotional and cognitive maturity, attention span, communication and social interaction skills, and knowledge base.[8] As the child ages and matures, more responsibility can be transitioned from the school to the student, including carrying and administering epinephrine autoinjectors.[34]

The school is responsible for implementing the IHP and EAP and educating teachers and school staff in the recognition of the signs and symptoms of allergic reactions and anaphylaxis, usually under the supervision of the school nurse. The school nurse is also responsible for instructing designated school staff, needed in the absence of the nurse, in the administration of epinephrine autoinjectors. The school is responsible for providing safe foods for the child and a safe environment in which food is consumed; educating students and staff in the principles of label reading and issues of cross-contact; and decreasing the use of foods in classroom settings, such as parties and celebrations, arts and crafts projects, and counting exercises.[8]

In a Massachusetts study, 46% of anaphylaxis incidents occurred in the classroom, compared with 9% in the cafeteria.[7] In students registered in the US Peanut and Tree Nut Allergy Registry, 79% of food allergic reactions occurred in the classroom compared with just 12% in the cafeteria.[35]

A 2004 study demonstrated the effectiveness of soap and water and routine cleaning agents in the removal of the major peanut allergen, Ara h 1, from hands and table surfaces, concluding that it was relatively easily cleaned with common agents and did not appear to be widely distributed in schools.[36] Using these principles, schools can maximize the safety of food-allergic children by requiring hand-washing before and after meals and instituting the option of allergen-safe tables or areas that have received more careful cleaning and monitoring. To avoid creating an atmosphere of social isolation, friends with safe lunches should be allowed seating in these allergen-safe areas.

Finally, schools need to recognize that food-allergic children are often the victims of bullying. A recent study found 45.4% of food-allergic children reported being bullied, and 31.5% reported being bullied specifically because of their food allergy.[37] Furthermore, only 52% of parents knew that their child was being bullied, so schools need to be especially vigilant in efforts to identify and promptly address any instances of bullying.

In the United States, children with the diagnosis of anaphylaxis are protected by the Americans With Disabilities Act of 1990, which prohibits educational institutions from discriminating against children on the basis of their disability and guarantees food-allergic children a free, appropriate education.[8,38] When families are unable to resolve issues related to food allergy management plans with their schools, legal recourse is provided by Section 504 of the Rehabilitation Act of 1973.[8] For most situations, 504 plans are generally unnecessary.

For food-allergic children participating in free snack and lunch programs, federal regulations provide appropriate substitute foods if the school has received documentation of the specific food allergies and dietary recommendations from the child's healthcare provider.[8] In 2011, the United States enacted the Food Allergy and Anaphylaxis Management Act, which requires the Department of Health and Human Services to develop and make available to all schools a voluntary set of guidelines for the management of food allergies and anaphylaxis and to provide incentive grants to schools to implement these policies.[39]

An 8-year-old child with no documented history of allergies presents to the school nurse with diffuse hives, cough, and wheezing after having lunch in the cafeteria. What should be done for this child?
Call the parents and ask whether the child has allergies
Ask the child whether he has allergies
Administer diphenhydramine and albuterol
Call the child's pediatrician for advice
Administer stock epinephrine and call 911

What About the Child Without a History of Allergy?

The first episode of peanut allergy can occur in the school setting.[35] In Massachusetts, 25% of anaphylactic reactions occur in individuals (including students and school staff) with no history of allergic reactions or anaphylaxis.[7] Schools need to be prepared to diagnose and treat both students and staff with no previous history or known diagnosis of allergy and anaphylaxis.

Recognizing the potential for this scenario, many, but not all, schools have on hand unassigned "stock" epinephrine autoinjectors. There is some controversy related to liability issues of prescribing and administering unassigned epinephrine. The School Access to Emergency Epinephrine Act was introduced in Congress in 2011 to allow schools to have unassigned stock doses of epinephrine available to treat previously undiagnosed students or staff experiencing anaphylaxis, but this legislation is still pending.[40] Other initiatives are under way to pass similar legislation on the state level.

Key Messages

  • Foods are the most common cause of anaphylaxis outside of the hospital setting in children and adults.

  • Any food can trigger anaphylaxis, but the majority of severe anaphylaxis episodes are triggered by nuts and seafood.

  • Prior reaction severity does not predict future reaction severity.

  • Up to 20% of cases of severe food-induced anaphylaxis may manifest without cutaneous symptoms

  • Epinephrine is the treatment of choice for anaphylaxis. There are no absolute contraindications to the use of epinephrine in cases of anaphylaxis.

  • The major risk for near-fatal and fatal anaphylaxis is delayed or lack of timely administration of epinephrine.

  • 25% of anaphylaxis cases in school settings occur in individuals (students and staff) who have no previous diagnosis of allergy or anaphylaxis.

  • Any student with history of anaphylaxis or with allergy to peanut, tree nuts, fish, or shellfish or with food allergy and asthma should be prescribed an epinephrine autoinjector and given an individual emergency treatment plan for school.

 



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Jedi

Posts: 2718
Date: Jul 23, 2013
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Oh, Ed ~
How I wish I had seen this article several weeks ago. Not allergic to food, but Texas Fire Ants sent me to the hospital twice - ICU for 2 days, then a CCU step-down for one day, and just the ER the second time. The 2nd time, DH didn't wait for an ambulance - he drove me directly to the ER, for follow-up on my EpiPen. Man, that HURT! But its a life saver!

We now carry an EpiPen in both vehicles, my purse, our home, the boat, and our pier - anywhere Fire Ants might rear their ugly little heads!





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Sith Lord

Posts: 24870
Date: Jul 23, 2013
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It is NOT incumbent upon the rest of the world to adapt to the few. It is incumbent upon the few to adapt to the world.

It's ridiculous to have a "peanut free" school.

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Life goes by pretty fast.  If you don't stop to take a look around once in a while and do whatever you want all the time, you might miss it.

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Jedi

Posts: 1498
Date: Jul 23, 2013
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Good post ed.

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