Common Allergic Conditions in School Children: Anaphylaxis to Wheezing 3 rd Annual School Health Skills Day Mark Huftel, MD Marshfield Clinic-Wausau Center.

Common Allergic Conditions in School Children:

Anaphylaxis to Wheezing

3rd Annual School Health Skills DayMark Huftel, MD

Marshfield Clinic-Wausau Center

Objectives

• Review the symptoms of common allergic conditions

• Understand the general treatment strategy of common allergic disorders

• Be able to initiate emergency treatment of acute allergic reactions

Anaphylaxis• Anaphylaxis = life threatening allergic reaction

• Many different causes

• Symptoms: Itching, hives, flushing, difficulty breathing, vomiting, diarrhea, dizziness, shock

• Individuals with asthma at greater risk of severe reactions

Anaphylaxis-Avoidance

• Avoid known allergic triggers• Foods• Insect stings• Latex• Other or Unknown• Anaphylaxis Action Plan• Epinephrine available

Anaphylaxis Treatment

• The treatment of anaphylaxis is epinephrine, oxygen, and intravenous fluids

• Delayed epinephrine a leading cause of bad outcomes-some individuals will require more than one dose

• Lay the patient down with their feet elevated, on their side if nausea/vomiting

• Call 911

Epinephrine auto injectors

• EpiPen (0.3 mg) and Epipen Jr (0.15 mg)• Auvi-Q 0.15 mg and 0.3 mg• Adrenaclick 0.15 mg and 0.3 mg

• Dosed by weight not age-0.01 mg/kg• 30# child = 0.15 mg. 60# child = 0.3 mg• Will often change dose at 50#

Food Allergy

• Common and increasing in frequency• May affect the skin, GI tract, upper

and lower respiratory tract, heart/blood vessels• Symptoms mild and localized to

anaphylaxis

Food Allergy

• Common foods include: peanuts, tree nuts, fish, shellfish, egg, wheat, milk, soy• Young children may have difficulty

describing symptoms

Food Allergy-Treatment

• Avoidance And Preparedness!!• Classroom-treats• Sharing food in cafeteria• Cross contamination in food

preparation• Field trips

Food Allergy Treatment

• Food Allergy Action Plan• Medical alert ID• Epinephrine• Antihistamine use for very limited

reactions• Asthma quick relief inhaler for asthmatics

AFTER epinephrine

Food Allergy-Important Notes

• If a person with food allergy and asthma develops sudden asthma while eating-assume food allergy and use epinephrine NOT an inhaler first• 15-20% of food induced anaphylaxis will

require more than one dose of epinephrine-may repeat in 5-15 minutes

Oral Allergy Syndrome

• Also called Food Pollen Syndrome• Represents a cross reaction between

ones pollen allergy and some fresh fruits and vegetables-occasionally nuts

• Heating the food breaks down the cross reacting allergen

• Reactions are local-not systemic

Bee Sting Allergy

• Most bee stings result in small local reactions which hurt, burn, itch, and swell. Apply ice, antihistamine if available, something for pain if needed

• Large local reactions-same approach but may need physician visit for short course of oral steroids

• Stings on the head or neck=greater swelling

Bee Sting Allergy

• “Systemic reactions” cause symptoms distant from the sting site(s)

• Reactions limited to the skin in children usually have a benign course

• Skin plus any other symptoms means ANAPYLAXIS!

• If in doubt-use epinephrine

Asthma

• Leading cause of missed school days due to chronic illness

• Severity highly variable• Symptoms include:• Cough• Wheeze• Chest tightness• Shortness of breath

Asthma Triggers

• Allergens-pollen, mold, animal dander, dust mites

• Exercise• Irritants• Weather conditions• Respiratory viruses

Asthma Severity

• Intermittent-do not need daily medication• Persistent-do need daily preventative

medication• Mild• Moderate• Severe• Severity may change over time and with

seasons

Asthma Treatment

• Children should have a “quick relief” or “rescue” medication at school such as Proair, Proventil, Ventolin, Xopenex. “Albuterol”

• Rare use of nebulizer• May become capable of carrying and self

treating at the middle school level

Asthma Treatment

• Pre-medicate for triggers such as gym, recess if necessary

• May need extra doses with colds• Some may have peak flow meters• Daily controller medication used at

home. Exception-overnight school trips-school forest etc

Asthma Treatment

• Some districts have Asthma Action Plans• Frequent use of quick relief inhaler

unrelated to activity suggests suboptimal asthma control

• Some may have asthma “masqueraders”• Hyperventilation/panic attacks• Vocal cord/fold dysfunction

Allergic Rhinitis-”Hayfever”

• Affects approximately 20% of the population-most start in childhood

• Seasonal, year round, combination• Triggers-Like asthma, pollen, mold, dust

mite, animal dander• Non-allergic forms as well

Allergic Rhinitis-Symptoms

• Nose-itchy, sneezy, stuffy, runny• Eyes-itch, tear, dark circles under eyes• Ears-feel plugged• Throat-itch, post nasal drip• Cough

Allergic Rhinitis-Treatment

• Nasal steroid sprays-Flonase/fluticasone, Nasacort AQ, Nasonex, others

• Antihistamines-Claritin/loratidine, Zyrtec/cetirizine, Allegra/fexofenadine

• Decongestants-pseudoephredrine• Eye drops-Patanol/Pataday, Zaditor• Leukotriene blocker-montelukast

Skin Rashes

• Hives-may be the start of many different allergic reactions-foods, drugs, stings, but also viral illnesses

• Contact dermatitis-poison ivy, metal allergy

• Eczema-Chronic with flares, often present in skin folds

Case 1

• 8 yo boy with milk allergy and eczema eating lunch with friends. Feels sick, throws up and says he does not feel well.

• Mild facial flush. Throat feels funny.

Case 1 Treatment Options

• A. Observe• B. Give antihistamine and observe• C. Give antihistamine and dial 911• D. Give epinephrine and observe• E. Give epinephrine, antihistamine, and

observe• F. Give epinephrine and call 911

Case 2

• 14 yo girl with asthma and tree nut allergy presents to the office from the cafeteria with an “asthma attack”

• Complains inhaler “not working”• Chest tight• Short of breath

Case 2 Treatment Options

• A. Give 2 puffs inhaler-call 911 for severe asthma attack

• B. Suspect food allergic reaction-give antihistamine, call 911

• C. Suspect food allergy-give epinephrine and call 911

• D. Suspect food allergy-give epinephrine, call 911, give 4 puffs of inhaler

Case 3

• Called to the cafeteria for a 12 yo otherwise healthy youngster with hives and difficulty breathing

• Some swelling around eyes and lips• No known history of allergies

Case 3 Treatment Options

• A. Call parents with probable new allergy condition for direction

• B. Call 911 for EMTs/Paramedics to evaluate student

• C. Give school supplied epinephrine, lie student down, dial 911

Case 4

• 10 yo student with asthma comes in from playground stating it is hard to breath

• Coughs between sentences• Chest hurts• Does not feel well

Case 4 Treatment Options

• A. Have student sit down and rest• B. Give 2 puffs of quick relief inhaler,

send back outside to play• C. Give 2 puffs of quick relief inhaler,

assess in 15 minutes-repeat inhaler if needed

Case 5

• 16 yo playing soccer in gym class stung by unseen insect

• Breaks out in hives on trunk and extremities

• Some nausea, no vomiting• Feels a little lightheaded and needs to sit

down

Case 5 options

• A. Give antihistamine and observe• B. Give antihistamine and call 911• C. Call 911 to have paramedics/EMTs to

evaluate• D. Give school provided epinephrine and

call 911, position on their side

Case 6

• 10 yo student presents to the office with a red, lumpy, itchy rash

• A little coughing and runny nose• Recent respiratory illness currently on

antibiotics

Case 6 Options

• A. Give school supplied epinephrine and dial 911

• B. Contact parents, encourage them to contact primary care provider and provide antihistamine if possible

Summary

• Allergic conditions are common amongst school age children

• Severity ranges from mild to life threatening

• Avoidance of known triggers and preparedness to treat acute reactions is critical to improve outcomes.