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Paediatric allergy Dr Jenny Hughes Consultant Paediatrician, NHSCT QUB GP Society Monday 15 November, 2021 Phonecall from Mum: Sarah, her 3 year old daughter, has developed an itchy rash after contact with peanut butter and she is concerned its an allergy. Next steps?Return call • Mum needs to take some photos of the rash • Is this urticarial? • Is this eczema? • Is this something else – scabies?? • HistoryHistory is the most important aspect of allergy diagnosis Allergy test support this diagnosisEATERS history • E Exposure • A Allergen • T Timing • E Environment • R Reproducible • S SymptomsExposure Allergen • A food triggered allergic reaction usually occurs when the food has actually been eaten • Parent eating and kissing on cheek • Handling and then touching face / eyes • Reaction as a result of aerosolisation is rare. • Rare food allergies are usually associated with other more common food allergies • Raw fruits • Can cause irritation around the mouth • Oral Allergy Syndrome • Sensitisation to birch pollen • Symptoms with raw fruit • Tolerance to cooked fruitTiming Environment • Most IgE mediated allergic • Infants: typical history of reaction reactions occur immediately after during introduction of new food eating the food when weaning • Some are delayed for up to an hour • Onset must be within 2 hours • Older children: more likely to occur outside the home • Parties / social gatherings • ResturantsReproducible Symptoms • Food allergy is very reproducible • Reactions should have occurred at each and every subsequent exposure • The patient may have eaten the food before but not since the allergic reaction • May contain labels! • Food induced allergy: rapid onset and then regression over several hours • Symptoms don’t come and go over a few days • Tend to start where first contact • Eaten - around the mouth and face (not the trunk first) • Airborne - eyes and nose before the skinEATERS history • E Exposure • A Allergen • T Timing • E Environment • R Reproducible • S Symptoms Sarah, 3 year old girl, has developed an itchy rash after contact with peanut butter and her mum is concerned its an allergy. History A History B • Brother was eating peanut butter on • Tried some peanut butter on toast toast at breakfast when on holiday • Sarah’s rash was first noted after •developed puffy lips and eyes and a lunch nettle sting rash on face, then on her trunk • Sarah had previously eaten peanut butter •been given some may containut had products • Not tried since • Not tried since • Itchy nettle sting type rash persisted • Gave some chlorphenamine and for several days symptoms resolved. No, they didn’t • Also had a temperature and runny come back the next day noseHistory A: Not a food allergy • E Exposure • Didn’t eat the food • Peanut – a common allergen • A Allergen • T Timing • Onset of symptoms over 2 hours later • In the home environment • E Environment • Previously eaten but not since this episode • R Reproducible • Persistence of symptoms for the next few days • S Symptoms • Associated temperature and runny noseHistory A: Viral triggered Urticaria & Angioedema • Common condition • Not an allergy; it’s a skin condition • Treatment • Regular Non sedating antihistamines Ie not chlorphenamine – short acting, sedating e.g. Cetirizine – longer acting and non sedatingChronic Urticaria and angioedema in children • DAILY Symptoms for at least 6 weeks • Children often have episodic symptoms lasting for shorter periods • Classic history: I just can’t seem to identify the trigger • Its not the washing powder! • • Confirm the skin rash – pictures • Is there urticaria and / or angioedema • Commonest causes in children: • Viral triggered urticaria • Spontaneous • Cold induced • Stress • Heat • PressureChronic Urticaria and angioedema in children • In the vast majority of cases investigations are not required • No indication for allergy testing – its not an allergy • Treat with regular non sedating antihistamines (NOT CHLORPHENAMINE) • Up to x4 standard doses my be required • Tolerated well • Angioedema with no urticaria: consider hereditary angioedema • C4 levels • C1 inhibitor levels and activityHistory B: Possible peanut allergy • E Exposure • Ate the food • Peanut – a common allergen • A Allergen • T Timing • Onset of symptoms within minutes • In an hotel • E Environment • Not previously eaten • R Reproducible • Typical allergy symptoms that had a quick onset, • S Symptoms responded to treatment – and didn’t recurHistory B: Possible peanut allergy • Refer to allergy OPC • Advice? • Avoid peanuts • Only 50% individuals allergic to peanuts are also allergic to treenuts • • Could send Specific IgE to peanut to confirm the diagnosis • BUT this will not help to predict the severity of a future reaction • Don’t need to avoid other ‘allergenic’ foods • If Mum breastfeeding and eating peanuts – don’t need to stop • Reactions don’t get worse with future reactions CAN WE PREDICT THE SEVERITY OF A FUTURE REACTION? NO! • Number of hospital admissions for Anaphylaxis anaphylaxis has increased 1998 – 2018 • Especially in children - x3 increase • WHY? • Has there been a true increase in the prevalence of anaphylaxis? • There is no evidence to suggest that the prevalence of food allergy has increased over this time period • Possibly seeking medical help more often? Fatal Anaphylaxis So whilst there has been x3 increase in presentation to hospital with anaphylaxis, the case fatality rate has halved over the Milk is now one of the commonest triggers same time period for fatal anaphylaxis in children Why: Improvement in recognition and Peanuts & treenuts remain a common management of anaphylaxis? triggerFatal food anaphylaxis is rare DOES MY CHILD NEED TO CARRY AN ADRENALINE PEN?Who should be prescribed an adrenaline pen? • Previous anaphylaxis •anaphylactic reactionesent with anaphylaxis are unlikely to have a second •anaphylaxisen with initial anaphylaxis – 25% further reaction but only 1 had • High risk allergens • Milk and peanut are commonest cause of fatal anaphylaxis in children in UK • Allergens that are difficult to avoid • Teenagers / young adults • Limited access to emergency careThe prescription of an AAI in isolation is not lifesaving • • Dietary advicee food • Variable apps available – Food Maestro • AAI must be carried at all times • Lack of timely epinephrine is an important factor in some anaphylactic deaths • Family must know how to use • If you prescribe it you must show the family how to use it • Family must know when to use • Position: potential for decompensation when moving from sitting to standing • 2 AAI should be available at all times • 2 for school and 2 for outside schoolAdvice to parents • Food allergy reactions do not get worse with time • You will refer their child to an allergy OPC for further assessment • In the meantime, avoid the food • Allergy UK and The Anaphylaxis Campaign have lots of great information leaflets • You don’t have to prescribe an AAI – but if you do, you must show how and when to use and it must be carried at all times • Any parental concerns about a further reaction - don’t be scared to call an ambulance • Fatal anaphylaxis is rareCOVID Vaccines and allergyThank-you for listening