TREATING ALLERGIES THROUGH EDUCATION

World allergy week: Allergies and Anaphylaxis Dr Mike Levin Paediatric Asthma and Allergy Division University of Cape Town Red 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

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 Drug reactions Allergy Eczema Urticaria Angioedema Food hypersensitivity Rhinitis

Symptom ISAAC I 2002 ISAAC III 2002 OR Wheeze 6,4 % 11,2 % 1.75 Exercise induced wheeze Nocturnal wheeze Nocturnal cough Severe wheeze 11,5 % 13,9 % 1.24 3,9 % 5,3 % 1.39 11,6 % 19,2 % 1.8 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

Atopic Eczema

Urticaria

The Treatment of Allergy Allergen avoidance Anti-allergic medicines Desensitisation injections

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!

Food allergy is under-recognised BUT also over diagnosed! Prevalance of food allergy & sensitisation - SAFFA study of unselected kids aged 1-3 years - 13 % sensitised: egg, peanut, soy, wheat - 1,7 % food allergy: egg, peanut Anaphylaxis South African data - 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 attendees

RXH anaphylaxis attendees

South African data Pharma Dynamics school survey: Would you like to know what to do if your friend or students suddenly have an allergy attack? No student or teacher was able to answer!

Issues brought 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 attack at 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 Gut Upper 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 Airway Upper Respiratory Tract Hoarseness Dry staccato cough Swelling of the larynx Stridor Blocked nose Itchy, runny, sneezy nose

Reactions in the Airway Lower Respiratory Tract 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

Clinical criterion 2 Known allergic patient exposed to likely allergen

Clinical criterion 3 Reduced BP occurring rapidly after exposure to known allergen for that patient

Clinical diagnosis Skin PLUS resp or CVS or Likely allergen with TWO of Skin Resp CVS GIT or Known allergen with reduced 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

NAME D.O.B. Emergency contact (name): (Relation to patient): Work: Home: Cell: I am allergic to: My medic alert number is:

Paste photo here Municipal: 10177 ER24: 084 124 Netcare 911: 082 911 Ambulances: Plan prepared by Dr: Signed: Hospital/Clinic: Date: Tel. No.:

Minor reaction Face and Skin Itching, redness, hives ( bommels ) Swelling of face, eyes, hands, and feet Stomach Stomach pain, vomiting, diarrhoea In INSECT allergy these are signs of a SEVERE reaction

MINOR REACTION (Face / Stomach / Skin) GIVE ANTIHISTAMINE... DOSE... If asthmatic give Reliever pump 6-10 puffs via spacer. Locate adrenaline in case of progression. Observe closely for signs of severe reaction. Contact family / emergency contact Consult your doctor as soon as possible.

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

Major reaction Airway Difficulty breathing, coughing Wheezy, noisy breathing Voice change Choking Total body Change of colour Floppy, sense of impending doom Loss of conciousness, sleepy

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)

MAJOR REACTION (Airway / Total body) BREATHING DIFFICULTY OR CHANGE OF CONCIOUSNESS GIVE IMMEDIATELY ADRENALINE DOSE... OR EPIPEN /EPIPEN JNR AND ANTIHISTAMINE DOSE... If asthmatic give Reliever pump 6-10 puffs via spacer. CALL AMBULANCE & say ANAPHYLAXIS Get to closest doctor/clinic/hospital immediately If no improvement in 5 minutes, give a second dose of adrenaline

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

This treatment plan has been recommended by me / my child s allergy doctor and explained to the patient / parent. Adrenaline given in the appropriate dose is safe. I give permission for nominated caregivers, teachers, and laypersons to administer adrenaline to myself / my child and absolve them against wrongdoing should theydo so in the case of a suspected anaphylactic reaction. (Patient/Parent/Guardian Name and Signature) Date

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 Junior If the child s weight is between 8 and 25 kg EpiPen When the child s weight reaches 25 to 30 kg

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 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

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

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 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

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 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?

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: Allergies in general Food allergies and anaphylaxis Emergency treatment Practical adrenaline use Risk reduction at home and at school More resources

Allergy Society of South Africa www.allergysa.org Allergy Epicentre www.facebook.com/allergyepicentre Allergy Expert www.allergyexpert.co.za

Allergy advisor Some interesting facts about allergies... Allergic conditions can have an impact on quality of life, daily activities & work performance Dr. Mike, our allergy advisor, answers all your allergy related questions.

Sever allergies and Anaphylaxis Register Tell your patients about the Anaphylaxis register: A resource aimed at gathering information on people with severe allergies and anaphylaxis, assessing their current care and providing information to decrease their future risk. They should sign themselves up at www.allergysa.org for the opportunity to learn more about anaphylaxis, recieve information and be linked in with other people with anaphylaxis.

Thank you Head of Department Assoc Prof. Michael Levin Email: michael.levin@uct.co.za Room 516 ICH building Red Cross Children s Hospital Klipfontein Road, Rondebosch