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

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