Ailléirge Péidiatraiceach. Pediatric Allergy 3/9/2018. Disclosures & Conflicts Of Interest

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Felicity Janice Newman
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Allergy/Immunology Disclosures & Conflicts Of Interest Green Bay

1 Ailléirge Péidiatraiceach Michael Zacharisen, M.D. Allergy/Immunology Pediatric Allergy Michael Zacharisen, M.D. Allergy/Immunology Disclosures & Conflicts Of Interest Green Bay Packer fan I drive a Jeep I m Irish (today only!) I don t speak Gaelic (Irish) 1

with colds twice FH: Mother--allergies and father--asthma Does he have allergies or asthma?

2 Outline: Allergic March Eczema Food Allergy Rhinitis Asthma Anaphylaxis Latex, stinging insect Case Mrs O Riley brings in Sean Ryan: 3 yrs old Concern about his frequent runny nose and cough PMH: eczema and wheezed with colds twice FH: Mother--allergies and father--asthma Does he have allergies or asthma? When do allergies develop? In 80% of cases, symptoms develop before age 20 40% of cases prior to age 6 20% of cases prior to age 3 2

What is the Allergic March? A. Bagpipers marching in a parade on St.

Atopic Dermatitis (Allergic Eczema) 40% of children with AD (before 3 yr

3 What is the Allergic March? A. Bagpipers marching in a parade on St. Pat s Day. B. The name for tree pollen allergies that start in the month of March. C. Progression of atopic/allergic disorders through childhood. Atopic Dermatitis (Allergic Eczema) 40% of children with AD (before 3 yr old)have allergies Food: Milk Egg Soy Wheat Environmental: Dust mite Pet dander Pollen More severe the eczema, more likely an allergic triggers exists! 3

Atopic Dermatitis (Allergic Eczema) Diagnosis: Pruritus Chronic/relapsing

Sparing of the groin and axillary regions Treatment: Avoid triggers Skin care

potencies Topical non-steroids (Protopic, Elidel, Eucrisa) Pediatric Rhinitis

unilateral Anatomical: adenoiditis, teeth Irritant Allergic Rhinitis Symptoms

4 Atopic Dermatitis (Allergic Eczema) Diagnosis: Pruritus Chronic/relapsing Distribution pattern 1. Current/previous flexural lesions at any age 2. Sparing of the groin and axillary regions Treatment: Avoid triggers Skin care (bathing), bleach bathes and emollients Antihistamines Topical steroids: various potencies Topical non-steroids (Protopic, Elidel, Eucrisa) Pediatric Rhinitis Allergies: up to 40% of children Infection: viral, bacterial Foreign body: unilateral Anatomical: adenoiditis, teeth Irritant Allergic Rhinitis Symptoms Itching: Nose/Eyes Sneezing Rhinorrhea Fatigue Signs Conjunctivitis Pale, nasal mucosa Transverse crease Adenoid facies Allergic salute 4

Identify these Allergic Triggers Allergens Seasonal Tree:

fall Perennial Dust mite Pet dander Feathers Fungal spores

Skin Testing Requires an allergist Clinical correlation

allergist needed Clinical correlation Abnormal skin On any

5 Identify these Allergic Triggers Allergens Seasonal Tree: spring Grass: summer Weed: fall Fungal spores: Summer & fall Perennial Dust mite Pet dander Feathers Fungal spores Usually >3 yr old Usually > 6 months old Allergy Testing Skin Testing Requires an allergist Clinical correlation Normal skin Off antihistamines Serum IgE Testing No allergist needed Clinical correlation Abnormal skin On any medication including antihistamine Avoid IgG testing: controversial and unproven 5

6 Allergy Skin Testing: With what? Prick = puncture = percutaneous scratch For venom and penicillin Allergy Skin Testing: where? Results in 20 minutes NO minimum age! Pediatric Allergic Rhinitis: Treatment Avoidance Medications New generation antihistamines (skin Benadryl) Nasal steroids (>2 yr old) Singulair (>6 mo old) Allergy Immunotherapy Injections (>5 yr old) Grass SLIT (Grastek 5 yr old or Oralair 10 yr old) 6

Food Allergies Perception of public: 20-25% Children: 3.9% <5 y/o: 4.7% 5-17 y/o: 3.

Atopic Dermatitis Respiratory Asthma: infants Heiner s Syndrome Rhinitis: children Gastrointestinal

Food-associated, exercise-induced Food Allergies 90% of food allergies Milk (casein/whey) Eggs

7 Food Allergies Perception of public: 20-25% Children: 3.9% <5 y/o: 4.7% 5-17 y/o: 3.7% Adults: 1-2% Immunopathology of Specific Food Disorders IgE-Mediated Non-IgE-Mediated Skin Hives Atopic Dermatitis Respiratory Asthma: infants Heiner s Syndrome Rhinitis: children Gastrointestinal GI Anaphylaxis Eosinophilic Enterocolitis Oral allergy disorders Celiac Systemic: Anaphylaxis, Food-associated, exercise-induced Food Allergies 90% of food allergies Milk (casein/whey) Eggs (ovalbumin/ovomucoid) Wheat Soy Peanut (Ara h1, 2, 3, 8, 9) Tree nuts Fish (parvalbumin) Crustacean shellfish (tropomyosin) 7

8 Food Allergy Treatment Prevention LEAP trial: introduce peanuts at 6 to 11 mo old Avoidance: Read labels Epinephrine IM Desensitization (coming soon!) Peanut oral immunotherapy Peanut patch (EPIT, Viaskin) Pediatric Asthma: Differential Diagnosis Upper Airway issues Tracheomalacia Lower Airway Issues Bronchiolitis Cystic Fibrosis: screened at birth Foreign body Aspiration Swyer-James Modified API (Asthma Predictive Index) API developed after following almost 1,000 children through 13 yr of age. A wheezy child with a positive API at 2 to 3 years old means an 80% chance that child would have a definite diagnosis of asthma when entering 1 st grade. 8

9 Modified API History: >4 episodes of wheezing ( 1 confirmed by MD) in a child with at least 1 major or 2 minor criteria MAJOR CRITERIA 1. Parent with physician-diagnosed asthma 2. Physician-diagnosed eczema 3. Allergic sensitization to 1 or more aeroallergen MINOR CRITERIA 1. Wheezing apart from colds 2. Eosinophilia ( 4%) 3. Allergic sensitization to milk, egg or peanut Wheezing in Children From Medscape Only 30% of infants who wheeze go on to develop asthma! Pediatric Asthma: Diagnosis Frequently starts before ability to perform spirometry! History: Symptoms, Timing Examination: may be normal CBC: for eosinophilia IgE testing: serum or skin test 9

10 Pediatric Asthma: Treatment Quick Relief Albuterol Lev-albuterol Prednisone Daily Controller Leukotriene modifier Montelukast Inhaled Steroid Budesonide Fluticasone Beclomethasone ICS/LABA (Symbicort >6 yr) Omalizumab: >6 yr Anti-IL-5: Nucala >12 yr Pediatric Anaphylaxis Food: Peanut, milk, egg, nuts Stinging insect: Increased risk >16 yrs old Generalized hives: Does NOT constitute high risk for anaphylaxis in children Latex: Spina bifida and/or recurrent surgery Anaphylaxis Treatment Avoidance Identification: medical ID Epinephrine IM 0.3 mg, 0.15 mg and now 0.1 mg Desensitization Venom? Peanut 10

diagnosis Effective age-appropriate treatment

11 Conclusion Allergies frequently start in childhood Progression: Allergic March Early and accurate diagnosis Effective age-appropriate treatment Allergies Affect Quality of Life Go raibh maith agat! (Thank you!) 11

Eczema: also called atopic dermatitis; a chronic, itchy, scaly rash not due to a particular substance exposure

Eczema: also called atopic dermatitis; a chronic, itchy, scaly rash not due to a particular substance exposure Allergy is a condition in which the immune system causes sneezing, itching, rashes, and wheezing, or sometimes even life-threatening allergic reactions. The more you know about allergies, the better prepared