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

2. 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

3. 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

4. Anaphylaxis-Avoidance Avoid known allergic triggers Foods Insect stings Latex Other or Unknown Anaphylaxis Action Plan Epinephrine available

5. 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

6. 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#

7. 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

8. Food Allergy Common foods include: peanuts, tree nuts, fish, shellfish, egg, wheat, milk, soy Young children may have difficulty describing symptoms

9. Food Allergy-Treatment Avoidance And Preparedness!! Classroom-treats Sharing food in cafeteria Cross contamination in food preparation Field trips

10. 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

12. 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

13. 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

14. 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

15. 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

16. Asthma Leading cause of missed school days due to chronic illness Severity highly variable Symptoms include: Cough Wheeze Chest tightness Shortness of breath

17. Asthma Triggers Allergens-pollen, mold, animal dander, dust mites Exercise Irritants Weather conditions Respiratory viruses

18. 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

19. 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

20. 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

21. 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

22. 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

23. Allergic Rhinitis-Symptoms Nose-itchy, sneezy, stuffy, runny Eyes-itch, tear, dark circles under eyes Ears-feel plugged Throat-itch, post nasal drip Cough

24. 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

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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.