How is it treated and managed?
Care for children at risk of anaphylaxis should be provided as a comprehensive management package, containing the essential elements of avoidance advice, provision and training in the use of emergency medication and appropriate follow up. School and early years setting staff should receive avoidance advice and training in emergency medication. Evidence shows that provision of such a plan by an allergy specialist reduces the risk of accidental reactions.
Avoidance
The main treatment of allergy with a risk of anaphylaxis is avoidance. This means total avoidance of the allergen. All other treatments are secondary to this and are designed to treat the child only when avoidance has failed.
Children and parents will be trained how to practise avoidance and this will be the main action that they will take to preserve the health of their child. It is not easy to avoid common allergens completely. Allergens may be hidden in foods that are not clearly labelled or foods may be contaminated with allergens during manufacture or packaging, again this will not be labelled. Parents are likely to spend time contacting manufacturers about individual products to find out if they are safe. The amount of time and effort put into avoidance will depend on the perceived severity of each child’s allergy.
Children with peanut and nut allergies are most likely to be affected by this as many of them react to small traces of nut allergen. Up to 50% of children with peanut allergy may have reactions to 3mg (1/50th) of a peanut, although the majority of reactions to such small doses are mild. This is clearly a very small amount, and too small to see or smell in food to be able to avoid it. A smaller number of children will react to even smaller traces of nut allergen, and may not have to eat it to react. For example nut proteins in the air of a bakery may be enough to cause a reaction. Nut proteins on a door handle when touched by a severely allergic person may be enough to cause a reaction, although this degree of sensitivity is extremely rare. Reactions to tiny traces of allergen that have not been eaten are most likely to cause mild, but not immediately life threatening reactions.
Avoidance requires constant vigilance and means simple activities like eating lunch at school or going to a friend’s house require planning and may cause stress. The simplest solution is for the child to eat only safe food prepared at home in a nut free environment at all times. No matter how well educated and motivated parents and children are, reactions are likely to occur. Most accidental reactions to peanut occur at home or with the extended family, only 1 in 20 reactions happen at school. Children’s independent activities are likely to be restricted because of their allergy, these include sleepovers and playing at friends’ houses.
Social isolation can be a real problem for the child with allergies. This can range from ‘being different’ not being able to go on school trips without a parent, to eating lunch at a peanut free table. All of these issues are negative but necessary aspects of avoidance. They apply to children with any type of allergy where there is a risk of anaphylaxis. The problems are worse for children with more than two allergies. A proportion of children may be home schooled because of their allergy and more may feel very isolated despite attending school.
Treatment of asthma
The risk of death during anaphylaxis increases in children who have asthma that is not well controlled. In these children, it is vital that asthma medication is given regularly as prescribed in addition to any other measures but mainly allergen avoidance that are taken.
Treatment of allergic reactions
Each child at risk of anaphylaxis should have a written emergency treatment plan to follow when they have an allergic reaction. This should include provision of an intramuscular adrenaline autoinjector and oral antihistamines. School and Early Years Settings staff should also have a copy of the treatment plan and know how to avoid the appropriate trigger and be trained in treatment of the allergic reaction.
Emergency Treatment
The cornerstone of treatment of an episode of anaphylaxis is an injection of adrenaline given into a muscle. This is often given by a care-giver using an auto-injector device. Other medications such as antihistamines or corticosteroids may also be given by mouth, or injection. Less severe allergic reactions may be treated with oral antihistamines alone.
Once anaphylaxis has occurred then that child will remain at risk of further anaphylactic reactions for some considerable time, as the condition rarely resolves and some triggers are highly prevalent in the environment (e.g. children with milk induced anaphylaxis). Some children who have only ever had mild reactions may also be at risk of anaphylaxis because of the nature of the allergy and other co-factors (e.g. peanut allergy or a child with food allergy and poorly controlled asthma).
Prevention of further episodes of anaphylaxis is vital and is achieved by referral to a specialist allergy clinic. The triggers of anaphylaxis are ruled in or out using the clinical history, specialised testing and where relevant challenge testing. A risk assessment for future anaphylaxis is performed, detailed advice is given on allergen avoidance and treatment of further reactions. Training of carers and school staff in all these aspects is achieved by coordinating with trained community nurses, and other allergies (especially asthma) are treated. This approach has been shown to reduce the number and severity of further anaphylactic reactions.
Adrenaline autoinjector
An intramuscular injection of adrenaline, given early during a reaction is the cornerstone of treatment. It can be referred to sometimes by the brand name (e.g. EpiPen, AnaPen or Twinject). It should be carried at all times. In practice for children with food allergies, the rule is that the device should be available whenever food is eaten, i.e. both in the home and in School and Early Years Settings.
The autoinjector is a disposable spring-loaded needle device. Different devices are activated using specific techniques and training should be provided. An autoinjector with 0.3mg adrenaline is provided for children >30kg and 0.15 for children <30kg. A further dose of 0.5mg is available for some injector types.
Adrenaline reverses the symptoms of an allergic reaction because it has the opposite effect on the body to the chemical mediators produced during a severe allergic reaction. So it raises blood pressure, reduces leakiness of small blood vessels so reducing or reversing allergic swelling. It relaxes smooth muscles in the airways relieving asthma/ shortness of breath. Families should receive training on when to give adrenaline during a reaction, and how to do this.
Children with allergies should always go to hospital for further monitoring and possible treatment after they have been given adrenaline. A second injection of adrenaline may be given after 5 minutes, but this is rarely required. Other treatments that may be used include antihistamine or steroid tablets. Most children with anaphylaxis will not require admission to hospital but will be observed for 4-6 hours before being sent home.
Unusually, some children may have biphasic reactions. This means the reaction occurs in 2 phases, there is the initial reaction, which may resolve quite quickly and a further similar reaction within 24 hours, which may be more severe than the initial phase. Children who suffer anaphylaxis are also routinely given antihistamines and corticosteroid tablets, which may help to prevent a biphasic reaction.
Other treatments used in children at risk of anaphylaxis
- Corticosteroids - e.g. soluble prednisolone tablets – short course used after anaphylactic reactions. Sometimes children with asthma may have a worsening of their asthma symptoms several hours after the allergic reaction, known as a ‘late phase’ or ‘biphasic reaction’. Corticosteroids are given to prevent this from happening.
- Antihistamines – e.g. chlorpheniramine syrup, may be prescribed to use in the event of an allergic reaction. This medication helps to relieve mild symptoms such as itchiness hives and reduce flushing associated with an allergic reaction.
