Lifelong management: increased rates of dietary anaphylaxis
ANAPHYLAXIA is a serious systemic hypersensitivity reaction that usually develops quickly and can lead to death (REF Turner PJ, Worm M, Ansotegui IJ, et al. Time to revisit the definition and clinical parameters for anaphylaxis? World Allergy Organ J 2019; 12: 100066). Prompt identification and treatment with intramuscular epinephrine is essential, as late administration is associated with fatal anaphylaxis. In Australia, the recent introduction of a new epinephrine auto-injector (AAI) means clinicians now have the choice of prescribing either an EpiPen (available in 150 mcg or 300 mcg) or an Anapen (available in 150 mcg , 300 mcg or 500 mcg). Since the administration methods are different, patients and caregivers should receive specific anaphylaxis action plans and training.
As children grow older, the burden of managing anaphylaxis shifts from parents to self-management. This requires clinicians to evolve their approach to the management of dietary anaphylaxis at every stage of the patient’s life, taking into account age-specific management barriers and opportunities to provide optimal care to our patients.
Infants and young children
Australia has the highest rate of food allergies in children in the world, with one in 10 infants having a known food allergy, and anaphylaxis presented to a tertiary pediatric emergency department in children under 2 years increased 3.6 times over a 10-year period. In early childhood, the burden of managing dietary anaphylaxis falls solely on parents and caregivers. Toddlers should be constantly vigilant to avoid picking up allergenic foods or putting contaminated toys or hands in their mouths. Anaphylaxis in young children is often underestimated and can delay treatment. This may be due to limitations in verbal communication skills, and symptoms of an allergic reaction (eg vomiting, irritability) are also commonly seen in other common pediatric presentations (here and here). Parents who have previously only experienced milder allergic reactions, or are facing their first allergic reaction, may not have undergone a formal specialist assessment and therefore may be ill-equipped to recognize anaphylaxis. Unexpected allergic reactions can occur when children are given new foods at daycare. Therefore, anaphylaxis training programs for parents and caregivers in this vulnerable, nonverbal age group should focus on increased awareness and early recognition of anaphylaxis. Children weighing 7.5 kg to 20 kg may be prescribed an Anapen junior 150 or EpiPen junior 150.
In children attending kindergarten or preschool, signs of anaphylaxis are more defined and children may begin to verbalize their symptoms. However, children’s food intake at school is less monitored and contamination can occur through food sharing. Individual and general purpose AAIs should be kept in a secure but easily accessible location in each child care setting.
The constant vigilance required by parents to watch a young child with food allergies can have a negative impact on a child’s sense of autonomy and emotional health. Therefore, clinicians should support parents by helping them feel confident about managing anaphylaxis, allowing them to continue to encourage their child to safely explore the world around them.
School-aged children and adolescents
As children enter school age, they begin to share the ever-increasing responsibility for managing their own allergies. Parents are advised to meet with the school to discuss their child’s food allergies, implement risk minimization strategies, discuss the proper storage of their child’s IAA, and provide a copy of their child’s action plan. their child against anaphylaxis https://allergyfacts.org.au/ ressources / fiche-aide / starting-school-with-food-allergies. Children are educated not to share food at school and to quickly tell a teacher if they have an allergic reaction.
In children over 20 kg, the IAA should be upgraded from an EpiPen Junior 150 to EpiPen 300, or from the recently released Anapen Junior 150 to the Anapen 300. Doctors and caregivers have a wide range of perceptions about when a child should expect to recognize symptoms of anaphylaxis on their own (9-11 years) or start wearing and using their own AAI (12-14 years), which ultimately depends on the child’s level of development and the risk of severe anaphylaxis.
As children enter their teens, they experience rapid biological, emotional and social changes. Critically, adolescents and young adults with food allergies are at the highest risk of death from anaphylaxis. Barriers to successful self-management of anaphylaxis unique to adolescents include insufficient knowledge of the disease, suboptimal cognitive and coping skills, higher emotional intensity, and lack of surrounding social support. This leads to an increase in risky behavior, a lack of adherence to healthcare advice, and poor decision making during allergic reactions.
The cornerstone of care therefore involves repeated education and training of young adults in the management of their allergic reactions. Points to emphasize include:
- discuss the reasons for wearing their AAI at all times, as the majority do not and the majority of reactions occur outside the home;
- help the adolescent recognize which specific symptoms (eg difficulty breathing, wheezing) should trigger the use of their AAI;
- emphasizing the importance of maintaining a supine position during an allergic reaction to avoid sudden cardiovascular collapse; and,
- ask the adolescent to show how he would administer his own AAI.
Teens should be given practical advice on how to avoid food allergic reactions in high-risk social situations, such as attending parties, dining out, ice cream parlors, kissing, and drinking alcohol. The importance of checking food labels cannot be overstated. A high proportion of fatal cases of food anaphylaxis have asthma and the clinician plays a critical role in ensuring that this and other co-morbidities are optimally controlled. Management should be underpinned by a respectful and supportive approach on the part of the clinician and parents, and the young adult should be encouraged to seek peer support by reaching out to friends and family support organizations. patients.
For many people, food allergy will be a lifelong illness that will require appropriate management throughout adulthood. As with children, food anaphylaxis admission rates among Australian adults are also increasing, and the median age of food anaphylaxis deaths in Australia is 28 years old.
Although many food allergies start in infancy, up to half of adults may have their first allergic reaction in adulthood. Adults with a suspected history of food allergy should be promptly referred to an allergist.
Adult complacency in self-management of anaphylaxis is common. The proportion of people at risk for anaphylaxis who have a current AAI prescription declines with age, with only about a third of college students reporting that they always wear their AAI, while less than 10% of adults with AAI. anaphylaxis receive prehospital treatment with epinephrine. . Although the absolute risk of fatal food anaphylaxis is low (estimated annual risk between 1 in 100,000 and 1 in a million), deaths do occur in adults, including those who previously had only mild to moderate reactions. . In addition, cofactors, such as sleep deprivation or exercise, can lower reaction thresholds. New challenges are presented for young adults with food allergies when they move into a shared apartment or residential college with a shared dining room and when they travel; useful resources are available at www.250k.org.au. In some cases, adults are prevented from pursuing a chosen career because people with food allergies are unlikely to be accepted into the Australian Defense Force.
Therefore, clinicians caring for adults must constantly strengthen measures to prevent (for example, always read food labels, declare your allergy every time you order from a food service provider), recognize and manage rapidly anaphylaxis.
Pregnant women can be reassured that they can receive intramuscular epinephrine safely, while recovery should be in the left lateral position or by performing manual left uterine displacement to improve venous return. While the association of food allergy with increased anxiety and poor mental health seen in children and adolescents may decrease in adulthood due to better coping strategies, clinicians should remain vigilant. significant impact that food allergies can have on an individual’s quality of life and mental health.
Prompt recognition and prompt treatment with epinephrine is essential to reduce the risk of fatal anaphylaxis. Barriers to effective management change as the child grows older and, therefore, clinicians play a critical role in the success of anaphylaxis education for parents and patients, tailoring health care advice to suit parents and patients. according to the changing needs of the patient at each stage of life development – from infancy to adulthood.
Associate Professor Kristina Rueter is a consultant in pediatric immunology, general pediatrician and emergency physician at Perth Children’s Hospital. Her academic post is in the Pediatrics Division of the University of Western Australia School of Medicine. She is vice-chair of the ASCIA Anaphylaxis Committee. She is a member of the Center for Food and Allergy Research at the Murdoch Children’s Research Institute and the Child Allergy and Immunology Research Group at the University of Western Australia.
Dr Michael O’Sullivan is a Consultant Clinical Immunologist at Perth Children’s Hospital and Fiona Stanley Hospital, and an Immunopathologist at PathWest. He is Honorary Research Associate at the Telethon Kids Institute, Senior Clinical Lecturer at UWA, Director of ASCIA, and a member of the Anaphylaxis, Education and Pediatrics Committees.
Dr Dean Tey is a pediatric allergist and immunologist in the Department of Allergy and Immunology at the Royal Children’s Hospital in Melbourne and an honorary member of the Murdoch Children’s Research Institute. He is the Chairman of the ASCIA Annual Scientific Conference in Melbourne, 2022.
The statements or opinions expressed in this article reflect the opinions of the authors and do not represent the official policy of WADA, the MJA Where InSight + unless otherwise stated.