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Anaphylaxis in children - help them reduce their fear and gain control

By Edward Holloway and Neelam Sharma

A six-year-old boy (NS) was at a local restaurant with his family. He had Paul rapson/SPLbeen diagnosed with a severe allergy to certain foods in the past year and the restaurant was made aware of these. However, he suddenly complained of feeling sick and knew he had eaten something that he was allergic to. His parents quickly administered 10ml of chlorphenamine as per their emergency plan (see later) but over the next five minutes NS’s condition worsened and he complained of a feeling of being strangled and asked for help. He also became pale and increasingly distressed. His parents also started to panic at how quickly his condition was deteriorating. They administered his Epipen and called 999, requesting urgent help for anaphylaxis. The paramedics arrived promptly and NS was admitted to hospital for observation. He made a full recovery.

No one knows how many lives are saved each year by the emergency administration of adrenaline but there are now around 20 deaths each year in the UK from anaphylaxis (although this may be a substantial underestimate) and the National Institute for Health and Clinical Excellence suggests that around one in 1,300 of the population of England has experienced anaphylaxis at some point in their lives.1 This article aims to address two key issues:

  • How to recognise when a child is having an anaphylactic reaction
  • How anaphylaxis should be treated in the community


Knowing the answers will empower both practitioners and parents to

Key points

  • Mucocutaneous changes are indicative of onset of IgE mediated allergic reaction and require prompt treatment with an antihistamine.
  • Respiratory or systemic symptoms with a history suggestive of allergic reaction or with mucocutaneous signs should be taken as indicating anaphylaxis is occurring, requiring immediate adrenaline and emergency services to be alerted.
  • Three types of adrenaline auto-injector device are available. Thereare important differences between their triggering mechanisms so repeatprescriptions should specify the brand (Anapen, EpiPen or Jext) to be supplied.
  • When supplying auto-injectors pharmacists should check that patients (and carers) are confident that they can use the device correctly and that the dose is suitable for the child’s current weight.

allow even children at high risk of anaphylaxis to lead safe and normal lives.

Anaphylactic reactions in children evoke considerable fear among patients, their parents or carers and also healthcare professionals. Despite national and international guidelines on recognition and management of anaphylaxis2,3 it remains a medical emergency that continues to be commonly misdiagnosed and mismanaged, even by trained medical personnel.4-6 Cases of death from anaphylaxis are often highlighted in the press, fuelling fear among the general population and those called to treat and prevent such reactions. Anaphylactic reactions have increased sevenfold since the 1980s with a UK incidence of 36 per 1,000,000 per year.7

 

IgE mediated response

The World Allergy Organisation defines anaphylaxis as a severe life-threatening generalised or systemic hypersensitivity reaction.8 In children this is almost entirely limited to an overwhelming IgE mediated response leading to massive histamine release. If not controlled quickly, this can lead to respiratory compromise, systemic shock and, ultimately, death.

Common causes of anaphylactic reaction, especially in children, include foods such as nuts, eggs, shellfish, milk, fish and some seeds, such as sesame. Non-food causes are less common in children but include wasp or bee stings, natural latex (rubber) and medicines (eg, penicillin). A significant proportion of anaphylaxis is classified as idiopathic.

The speed of onset of IgE mediated allergic reaction varies considerably but typically symptoms will develop within two hours9 and in cases of anaphylaxis most patients have symptoms within minutes. The speed of onset and deterioration necessitates immediate recognition and treatment.

 

Is it anaphylaxis?

It has been found that as little as a third of parents with children known to be at risk of anaphylaxis used their adrenaline auto-injector at the time of a recurrence of anaphylaxis.10 A large part of the problem is uncertainty in identifying when a child is experiencing true anaphylaxis.

The clinical features of anaphylaxis can be divided into three affected systems: mucocutaneous, respiratory and systemic. Anaphylaxis represents the severe end of a progression of symptoms and signs during an IgE mediated allergic response and herein lies the key to helping patients and parents to recognise when to administer adrenaline.

Mucocutaneous symptoms

Mucocutaneous symptoms of an IgE mediated allergic reaction include itch, flushing, sneezing and swelling. All areas of skin and mucosal surfaces can be affected. When internal mucosal surfaces are affected this can cause vomiting and abdominal pain. Visual clues, such as rash, are important for parents because small children often misdescribe what they feel, for example, an itch is often vocalised as “it hurts”. “Hives”, “nettle rash” and “swelling up” are more useful terms for parents than “urticaria” and “angioedema”.

Mucocutaneous changes alone do not signify anaphylaxis — these changes may be absent or subtle in up to 20 per cent of reactions. However, their importance lies in marking the beginning of an IgE mediated reaction and therefore alerting the patient and others to the potential risk of anaphylaxis.

Where mucocutaneous signs of allergic reaction are present without signs of anaphylaxis immediate administration of an oral antihistamine will usually successfully treat such milder allergic reactions.8

 

Respiratory symptoms

Respiratory changes indicate onset of anaphylaxis. They can be subdivided into upper and lower airway symptoms and signs. Upper airway signs are due to angioedema of the oropharynx and vocal cords. They can be recognised as inspiratory noise (stridor), loss of or change in tone of voice or protusion of the tongue. Lower airway signs are primarily due to bronchospasm and can be recognised by audible wheeze and the child struggling to breathe. These respiratory signs may all indicate anaphylaxis and require immediate administration of intramuscular adrenaline.

Useful pointers to an IgE mediated cause of breathing difficulties (ie, anaphylaxis as opposed to other causes of respiratory difficulty) are associated cutaneous signs as described above or a history that suggests allergen contact. For example, onset of wheeze and difficulty in breathing after walking into a smoky room is less likely to be due to anaphylaxis than the same respiratory signs with swollen lips and hives shortly after ingestion of a peanut butter sandwich.

Systemic symptoms

Systemic changes can also lead to some confusion. In the context of anaphylaxis, these changes occur with the onset of vasodilation causing a drop in blood pressure and features of shock (eg, pallor, fast weak pulse). Patients may faint or feel an “impending sense of doom”. Patients prone to syncope from other causes (most typically vasovagal faints) may find it hard to differentiate their symptoms from anaphylaxis and adrenaline is commonly misused in these cases. However, it is again useful to look for possibilities of exposure to allergen and other features of the IgE mediated allergic reaction. As with the respiratory signs above, in the context of an IgE mediated allergic reaction, systemic signs are indicative of anaphylaxis and require emergency services and immediate administration of intramuscular adrenaline. My [Edward Holloway] message is if the child seems about to collapse, give them the adrenaline. The worst that will happen if they get it wrong is that the child gets a bruised leg but if they wait too long they might miss a window of opportunity to treat anaphylaxis early.


These principles form the basis of the emergency plan for children with known allergies. Click here for an example emergency plan. Such plans can be useful in primary care and also for schools and nurseries. They should be reviewed at each visit to the allergy clinic.

 

Auto-injectors and emergency kits

The European Academy of Allergy and Clinical Immunology (EAACI) consensus8 is that children thought to be at significant risk of anaphylaxis should have two adrenaline auto-injectors available at all times (ie, two at school as well as at home). They should also have a written emergency plan with them. These make up the basis of an emergency allergy kit, which children carry with them. Kits for children with asthma and at risk of anaphylaxis also contain a bronchodilator.

There are currently three brands of adrenaline auto-injector available to prescribe: EpiPen, Anapen and Jext. The Panel below summarises some key features. All three devices are designed to be used through clothing (including jeans) and each is administered slightly differently. [Click here to see how.] Some of these differences may be subtle but important. For example, it is recommended that the EpiPen device is “swung” (with some force) onto the outer thigh in order to administer the adrenaline whereas the Jext device just needs to be placed against the thigh and pushed.

 

 Types of aut0-injector*

   
  Anapen EpiPen Jext
CompanyAllergy Therapeutics (UK) LtdMeda Pharmaceuticals LimitedALK-Abelló Ltd
Doses available
150µg, 300µg, 500µg**150µg, 300µg 150µg, 300µg
 Cost (BNF 62)
 £30.67£26.45
£28.77
 Shelf life
 24 months
18 months 24 months
 CommentsHigher dose of 500µg** available Been around the longest so prescribers and staff in schools are likely to be most familiar with this device
 Contains a needle sheath to allow for safe disposal

* Repeat prescriptions should specify the brand of auto-injector because there are important differences between the triggering mechanisms.

** The 500µg dose is licensed for use by patients witha body weight over 60kg or those at risk of severe anaphylaxis.

 

It is essential for patients, carers and health care professionals to have adequate and regular training to ensure effective use in an emergency. Those who are likely to need to administer the injections should be able to do so when panicking and without the need to read the instructions — it should be second nature. Administration with a dummy device should be practised regularly. (My [Neelam Sharma] son and I practise at least every three months.)

In addition, children must be reassessed and weighed each year to ensure that the dose is appropriate for them.

A newer version of Epipen is planned to be launched in the UK later this year and an updated Anapen device has just been launched.

 

What pharmacists can do

 

With clear guidance on how to recognise anaphylaxis and clear training on the use of adrenaline, these reactions can be well managed and effectively treated.

In addition to ensuring that they are able to administer adrenaline in an emergency (see Panel, right) pharmacists can play a part in giving guidance and education. For example, once diagnosed, many children and their parents will only receive training once from a nurse. Pharmacists can help reinforce that training. When supplying adrenaline auto-injectors, they can check whether the child and his or her parents are still confident about administering the treatment in a stressful situation. They could even obtain dummy pens (see Resources) to be used with children and parents and a medicines use review could, for instance, provide an opportunity to check technique.

When supplying adrenaline injections pharmacists could also check that the child has been weighed that year. Improved education for patients, their families and those called to manage anaphylaxis, empowers children with allergies to lead normal lives.

 

Resources

  • All three auto-injector companies have comprehensive websites offering free trainer pens and a number of useful leaflets for patients, carers and healthcare professionals (www.anapen.co.uk, www.epipen.co.uk, www.jext.co.uk).
  • Answers to questions frequently asked by healthcare professionals about treating anaphylaxis in an emergency are available on the Resuscitation Council (UK) website (www.resus.org.uk/pages/faqAna.htm).
  • The Anaphylaxis Campaign, a charity for people with severe allergies, offers resources for training and advice (www.anaphylaxis. org.uk), including useful information on types of allergy and resources for patients when they travel abroad. It also offers a distance learning course for healthcare professionals interested in advancing their knowledge in this area.
  • The Allergy Academy, part of King’s College London, offers a range of courses in paediatric allergy related matters for all healthcare professionals, including pharmacists (www.allergyacademy.org).

New NICE guidance 

Between 1990 and 2004 hospital admissions for anaphylaxis increased from 0.5 admissions per 100,000 to 3.6 per 100,000 — an increase of 700 per cent.

The National Institute for Health and Clinical Excellence published a new guideline in December 20111 on initial assessment and referral following emergency treatment for a suspected anaphylactic episode.

 

 

 

 

References

  1. NICE Clinical Guideline 134: Anaphylaxis. Published December 2011.
  2. Tse Y, Rylance G. Emergency management of anaphylaxis in children and young people: new guidance from the Resuscitation Council (UK). Arch Dis Child Educ Pract Ed 2009;94:97–101.
  3. Simons FER, Ardusso LRF, Bilo MB et al. World Allergy Organization Guidelines for the assessment and management of Anaphylaxis. WAO Journal 2011; 4:13–37.
  4. Batchelor M. Clinical lessons from an anaphylaxis management guideline audit. Int Med Journal, 2011; 41(2), 1444-0903.
  5. Esteso O, Sala Cunill A, Guilarte M et al. A review of anaphylaxis management in the emergency room. Eur J Allergy & Clinical Immunol, 2010, 65:589.
  6. Sampson HA, Munoz-Furlong A, Campbell RL et al. Second symposium on the definition management of anaphylaxis: summary report-Second National Institute of and Infectious Disease/Food Allergy Anaphylaxis Network symposium. Journal of Allergy and Clinical Immunology 2006;117:391-7.
  7. Gupta R, Sheikh A, Strachan DP, Anderson HR. Time trends in allergic disorders in the UK. Thorax 2007;62:91–96.
  8. Johansson SGO, Bieber T, Dahl R et al. A revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of World Allergy Organization. Journal of Allergy and Clinical Immunology 2004;113:832–6.
  9. Muraro A, Roberts G, Clark A et al. The management of anaphylaxis in childhood: position paper of the European Academy of Allergology and Clinical Immunology and Allergy 2007: 62: 857–71.
  10. Gold MS, Sainsbury R. First aid anaphylaxis management in children who were prescribed an epinephrine autoinjector device (EpiPen). Journal of Allergy and Clinical Immunology 2000;106:171–6. 
 

About the authors

Edward Holloway is specialist regstrar in paediatric allergy at the department of paediatric allergy, St Thomas’ Hospital, London, and Neelam Sharma is a pharmacist and mother of NS 

Acknowledgements

We would like to thank Adam Fox, consultant and honorary senior lecturer in paediatric allergy, Evelina Children’s Hospital, London, forhis advice and for allowing us to reproduce the emergency plan, and NS for allowing us to retell his story.

 

 

 

Citation: The Pharmaceutical Journal URI: 11093703

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