world allergy week: allergies and anaphylaxis dr mike levin paediatric asthma and allergy division...
TRANSCRIPT
World allergy week: Allergies and Anaphylaxis
Dr Mike LevinPaediatric Asthma and Allergy Division
University of Cape TownRed Cross Hospital
Agenda
• Introduction: Allergies in general• Food allergies and anaphylaxis• Emergency treatment• Practical adrenaline use• Risk reduction at home and at school• More resources
www.allergyexpert.co.za
Agenda
• Introduction: Allergies in general• Food allergies and anaphylaxis• Emergency treatment• Practical adrenaline use• Risk reduction at home and at school• More resources
What is an allergy?• Hypersensitivity: Reproducible symptoms
or signs caused by exposure to a stimulus at a dose tolerated by normal persons
• Allergy: hypersensitivity reaction initiated by an immunological mechanism
Hypersensitivity(exaggerated response)
Immunological(“Allergy”)
Non-immunological(“Intolerance” )
Allergy
• Allergy is not a disease!• It is a mechanism that is important in
some diseases all the time, and in others for some of the time.
Asthma
Drugreactions
ALLERGY
Foodhypersensitivity Rhinitis
EczemaUrticaria
Angioedema
SymptomISAAC I
1995ISAAC III
2002 OR
Wheeze 6.4% 11.2% 1.75
Exercise induced wheeze
11.5% 13.9% 1.24
Nocturnal wheeze 3.9% 5.3% 1.39
Nocturnal cough 11.6% 19.2% 1.8
Severe wheeze 5.0% 7.0% 1.4
Zar HJ, Ehrlich RI, Workman L, Weinberg EG. The changing prevalence of asthma, allergic rhinitis and atopic eczema in African adolescents from 1995 to 2002. Pediatric Allergy Immunol. 2007; 18(7): 560-5.
Allergic Rhinitis
Stages : Acute Vesicular
Subacute ErythemaScalingCrusting
Chronic CrustingLichenification
Atopic Eczema
Urticaria
Allergen avoidance
Anti-allergic medicines
Desensitisation injections
The Treatment of Allergy
Allergen avoidance
Anti-allergic medicines
Desensitisation injections
The Treatment of Allergy
Anti-allergic Medicines
Agenda
• Introduction: Allergies in general• Food allergies and anaphylaxis• Emergency treatment• Practical adrenaline use• Risk reduction at home and at school• More resources
Food allergy
Food allergies are increasing– Peanut allergy in UK doubled in 1-2
decades: 1.8%– Hospital admission rates increased 5 fold
1990s to 2000s in UK– Australia: 10% of children!
South African data
• Food allergy is under-recognised ……But also over diagnosed!
• Prevalence of food allergy and sensitisation– SAFFA study of unselected kids aged 1-3 years – 13% sensitised: egg, peanut, soy, wheat– 1.7% food allergy: egg, peanut
• Anaphylaxis– Case reports (Elliot Moses) and anecdotes
South African data
• Pharma Dynamics school survey:– Long duration of problems– Low healthcare diagnosis (20 to 80%)– Only 40% know medication names– Limitation of activities through shame or fear!– Less limitation due to physical problems
RXH food allergy attendances
RXH anaphylaxis attendances
South African data
Pharma Dynamics school survey:“Would you know what to do
if your friend or students suddenly had an allergy attack?”
No student or teacher was able to answer!
Issues bought up• Identification bracelets for life threatening
allergies e.g. Asthma and food allergies.• Need for proper diagnosis done in the form
of a blood test.• Teachers concerned that parents do not submit
relevant information pertaining to their child’s allergies and the type of medication that should and could be administered should they experience an attackat school.
Anaphylaxis
• A sudden, severe, potentially fatal, systemic allergic reaction.
• Skin, respiratory tract, gastrointestinal tract, and cardiovascular system.
• Symptoms occur within minutes to two hours after contact with the allergy-causing substance.
Anaphylaxis
• Many systems can be involved: skin, gut, airways, circulatory system.
• Must recognise “mild” versus “severe” reactions.
Skin Reactions• Urticaria • Angioedema• Itching, redness and flushing• Immediate worsening of eczema
Reactions in the GutUPPER GIT• Angioedema of the lips, tongue, or
palate• Oral itching
Reactions in the Gut
LOWER GIT• Nausea• Colicky abdominal pain• Vomiting• Diarrhoea
Reactions in the Airways
UPPER RESPIRATORY TRACT• Hoarseness• Dry staccato cough• Swelling of the larynx• Stridor• Blocked nose• Itchy, runny, sneezy nose
Reactions in the Airways
LOWER RESPIRATORYTRACT
• Cough• Chest tightness• Shortness of breath• Wheezing
Reactions in the Eyes
• Itching • Redness• Tearing• Swelling around the eyes
Neurological Signs
• Change in activity level• Anxiety• Feeling of impending
doom• Dizziness• Loss of Consciousness
Circulatory System
• Tachycardia• Hypotension• End-organ dysfunction:• Dizziness• Fainting• Loss of consciousness
Manifestations• Urticaria, angioedema 88 %• Upper airway oedema 56 %• Wheeze, dyspnoea 47 %• Flush 46 %• Many others ……………… far lower %• Shock ………………………… very rare
Variation in manifestations
• Skin involvement progressing to additional systems
• Multiple systems involvement without skin / mucous membranes
• Hypotension only shock, seizures, syncope
• Bradycardia• Myocardial infarction• Venticular tachycardia
Clinical criterion 1
Known allergic patient exposed to likely allergen
Clinical criterion 2
Reduced BP occurring rapidly after exposure to known allergen for that patient
Clinical criterion 3
Clinical diagnosis
• Skin PLUS resp or CVSor
• Likely allergen with TWO of• Skin• Resp• CVS• GIT
or
• Known allergen withreduced BP
Agenda
• Introduction: Allergies in general• Food allergies and anaphylaxis• Emergency treatment• Practical adrenaline use• Risk reduction at home and at school• More resources
Emergency treatment
1. Recognise that the child may be reacting
2. Recognise how bad the reaction is 3. Treat accordingly
Action Plan for anaphylaxis
MILD TO MODERATE ALLERGIC REACTION
– Swelling of lips, face, eyes– Hives or welts– Tingling of the mouth– Itchy feet or palms of hands– Abdominal pain, vomiting
Action• Remove allergen or sting • Give Anti-histamine• Stay with the person and call for
assistance• Locate the EpiPen or Adrenaline• Contact parents or ambulance
Watch for signs of anaphylaxis:
• Difficult / noisy breathing• Swelling of tongue• Swelling, tightness of throat, throat
clearing• Difficulty in talking and/or hoarse voice• Wheeze or persistent cough• Persistent dizziness or collapse• Very anxious • Pale and floppy (young children)
Action• Lay person flat - they should not stand
or walk, if breathing is difficult allow to sit up
• Administer Adrenaline• Start going to an emergency room by
Ambulance or car• Contact parent/emergency contact• Further adrenaline doses may be given
if no response after 5 min
Agenda
• Introduction: Allergies in general• Food allergies and anaphylaxis• Emergency treatment• Practical adrenaline use• Risk reduction at home and at school• More resources
Adrenaline ampoule with syringe and needle
Vial & Syringe
Parents slower than doctors / nurses
Parents doses varied 40 fold !!
Parents times 140 secs +- 42 secs
Simons FER, Chan ES, Gu X, Simons KJ. Epinephrine for the out-of-hospital (first aid) treatment of anaphylaxis in infants: is the ampule/syringe/needle method practical?
J Allergy Clin Immunol 2001;108:1040-4
EpiPen ‘Junior’ - 0,15mg or EpiPen - 0,3mg ?
EpiPen JuniorIf the child’s weight is between 8 and 25kg
EpiPenWhen the child’s weight reaches 25 to 30kg
Storage and care of Adrenaline
• Always make sure you have your adrenaline or EpiPen with you
• Keep your adrenaline at room temperature
• Adrenaline should not be refrigerated or exposed to extreme light
• Check expiry dates • Not re-usable
How to use EpiPen auto-injector
• Remove EpiPen from its storage case.• Pull off the blue safety release cap at the
end.• Hold the pen firmly, with orange tip
facing your child’s thigh, and swing your arm from about 10cm away, pushing the orange tip against outer thigh.
• This may be done through clothing if it is not too thick.
How to use EpiPen auto-injector
• Hold it firmly in place while the Adrenaline is being released automatically into your thigh muscle.
• Hold the pen in place for 10 seconds.• As soon as you release the pressure, a
protective cover will extend over the needle tip.
• Massage the area for 10 seconds.• Make sure you tell the paramedics that
you have used an adrenaline pen.
Using an EpiPen auto-injector
To use adrenaline from an ampoule• Remove the needle and syringe from their
packaging• Attach needle firmly to the syringe• Hold the ampoule up-right and flick air out of
the top• Face little blue dot away from you and firmly
break the top of the ampoule off.• Remove cap of the needle• Place the needle into the ampoule and draw up
prescribed amount• Hold syringe upright and flick to remove air• Inject into upper outer thigh
If in doubt...
Give The EpiPen or Adrenaline!
Agenda
• Introduction: Allergies in general• Food allergies and anaphylaxis• Emergency treatment• Practical adrenaline use• Risk reduction at home and at school• More resources
www.allergyexpert.co.za
Risk reduction
Death from anaphylaxis is rare, but completely preventable• Avoid foods: dietician, ensure nutrition• Carry emergency medication: epipen or
vial / syringe• Communication: Medic alert, action
plans
www.allergyexpert.co.za
Risk reduction
Death from anaphylaxis is rare, but completely preventable• Avoid foods: dietician, ensure nutrition• Carry emergency medication: epipen or
vial / syringe• Communication: Medic alert, action
plans
www.allergyexpert.co.za
Avoid foods
• Dietician, ensure nutrition• Age appropriate education of children
regarding sharing food, avoiding food• Develop an individualised health care
plan for each environment regarding sharing food, identified safe areas or completely food (peanuts usually) free school.
Food consumption in schools
• Options used in different places internationally– Specified allergen free schools (usually
peanuts)?– Specified class / grade as allergen free?– Specified area within the school as allergen
free (don’t isolate kid)?– ± no food sharing (cultural and allergy issues)?– Anything goes?
Food consumption in schools
• In canteens or during lunch or snack times• During classroom activities, including
elective classes• Before and after school, in the school yard
and during breaks• For special events, such as sports days,
class parties and extra-curricular activities• For excursions and camps
Risk reduction
Death from anaphylaxis is rare, but completely preventable• Avoid foods: dietician, ensure nutrition• Carry emergency medication: epipen or
vial / syringe• Communication: Medic alert, action
plans
www.allergyexpert.co.za
Risk factors for fatal anaphylaxis
• Previous anaphylactic reaction• History of asthma• Current poor asthma control• Reactions with trace exposure• Peanut > age 5• Adolescents• Remote from medical help
www.allergyexpert.co.za
Carry emergency medication
• Training about when to give medication• Training about how to give medication• Medication available at all times• Store adrenaline appropriately: safely,
accessible, out of direct heat/light• If carried by child preferably be in
specified location: pocket, bag, belt bag, pouch.
Medication in schools• Options used in different places
internationally– Adrenaline in communal locations?– Adrenaline in schools for any patient? – Medications (including adrenaline) in schools
for individual “named patients” with prior approval?
• Provided by parent or by school?
– Limited selection of medications with prior parental approval?
– No medication allowed to be given at schools?
Medication in schools• Options used in different places
internationally– Adrenaline in communal locations?– Adrenaline in schools for any patient? – Medications (including adrenaline) in schools
for individual “named patients” with prior approval?
• Provided by parent or by school?
– Limited selection of medications with prior parental approval?
– No medication allowed to be given at schools?
Medication in schools
• Who will give it?• How will they be trained?• How will they be supported on an
ongoing basis?• Absolution from responsibility for side
effects if administered for suspected anaphylaxis?
• How long does it take to find and administer adrenaline?
Risk reduction
Death from anaphylaxis is rare, but completely preventable• Avoid foods: dietician, ensure nutrition• Carry emergency medication: epipen or
vial / syringe• Communication: Medic alert, action
plans
Communication
• Individualised (signed) action plan, including photo
• Medic alert• Notify school principal or preschool
supervisor and teacher• Individualised health care plan for
environment• Training of alternative caregivers, school
staff
Agenda
• Introduction• Food allergies and anaphylaxis• Emergency treatment• Practical adrenaline use• Risk reduction at home and at school• More resources
Allergy Society of South Africawww.allergysa.org
Allergy Expertwww.allergyexpert.co.za
Allergy Epicentrewww.facebook.com/Allergyepicentre
Allergy advisor
Thank You