The first presentation of Asthma & Allergy

1. Allergy
April 2020
Rebecca Batt
Paediatric Allergy Advanced Nurse Practitioner
Evelina, London

2. Aim of Presentation
• Allergies and triggers
• Medical Management of allergic reactions
• Rhinoconjunctivitis
• Guidelines for treatment

3. Why are
allergies on
the rise?
Food allergy affects 7% children in UK
Five fold increase in peanut allergies in UK between 1995-2016
2.5% of three year olds now have peanut allergy (EAT Study)
Environmental – more likely in Western lifestyle and urban areas
Pollution and dietary changes
Less exposure to microbes which change how our immune systems respond
Migrants have higher prevalence of asthma and food allergy in their adopted
country
Children are not getting as many infections
Vitamin D deficiency leading to immune compromise
“Dual allergen exposure” balance of timing, dose and form of exposure

4. Natural history of allergy
Age (years)
Prevalence
Eczema
Asthma
Hay fever
1 2 3 4 5 10
Peanut allergy
Egg and milk allergy Tree nut allergy

5. The Atopic March
• Prevalence of food allergy increases with increasing severity of eczema in infants 0-2yrs
• 40% of children with eczema develop asthma
• Cow’s milk and egg sensitisation predicts AD, GI symptoms & recurrent wheeze
• Infants sensitised to egg, HDM, grass pollen or cat 60-80% risk of developing asthma within
the next 3 years
• Children with at least one confirmed food allergy at 12 months predicts allergic airways
disease by school age
• Food allergens e.g. milk and egg sensitisation leads to sensitisation to inhalants by 7-10yrs

6. IgE versus Non-IgE mediated
IgE
– Quick onset (0-2hrs)
– Urticaria, Angioedema,
Anaphylaxis
– Well defined mechanism
– Easier to diagnose
– Validated tests
– Reproducible
Non IgE
– Delayed onset (2-72 hrs)
– Eczema, reflux, dysphagia,
constipation, diarrhoea
– Mechanism unclear
– Harder to diagnose
– No validated tests
– Reproducible but threshold
effect

7. Is it allergy?
• Reaction within 0-2 hours of eating
• Reaction to food is reproducible
• Reaction is mostly to a common food allergen
• Reaction resolves within 24-48 hours
• Watch out for viral, spontaneous, pressure,
cold/warm urticaria – can last 1-4 weeks and can
persist into chronic urticaria

8. Skin Prick and Prick-
Prick tests
• Sensitive
• Results in 10-15 minutes
• Good patient education opportunity
• Safe, but….
• Reactions do happen
• Blocked by antihistamines
• Validated allergens
• Dermatographism

9. In vitro IgE testing
• Total IgE indicating atopic status
• Specific IgE (RAST)
• - >450 allergens
• - indicate sensitisation
• Multiple allergy screening assays
• Recombinant testing (CRD)

10. Interpretation
of IgE
ImmunoCAP Classes IgE
levels (kU/l)
Level of Allergen
6 – strong positive 100+ Very high. Refer to
patient history
5 – strong positive 52.5+ Very high. Refer to
history.
4 – strong positive 17.5+ Very high. Refer to
history.
3 - positive 3.5+ High. Grade 1-3 vary
in significance
depending on
allergen. Consider
history and risk of
anaphylaxis
2 - positive 0.7+ moderate
1 – low, weak
positive
0.35+ Low. Grade 1 to
inhaled allergens of
doubtful significance.
Foods or moulds
more significant
0-
undetectable,negati
ve
<0.3 Absent or
undetectable

11. Tryptase
Urticaria
Rhinitis
Asthma
Anaphylaxis
Eotaxin
RANTES
Chemokines
Capillary infiltration
Tissue oedema
Tissue damage
Mucous
Late phase
response
IL5
Leukotrines
Eotaxin
TNF-α
Adhesion molecules
ICAM
VCAM
Selectins

15. Mild
Reactions
• Facial swelling
• Rash
• Hives
• Swollen eyes and lips
• Swollen hands/feet/ears
• Burning, tingling or itchy
mouth and/or throat
• Nausea and/or vomiting
• Diarrhoea
• Light-headedness

16. Severe reactions
• Difficulty in breathing
• Wheeze, stridor, cough
• Swollen tongue
• Difficulty in swallowing
• Tachycardia
• Pale
• Drowsy
• Cyanosed lips
• Impending sense of doom
(children often extremely quiet)
• Collapse

17. Anaphylaxis
Severe, life-threatening, generalised or systemic
hypersensitivity reaction
Rapidly developing, life-threatening problems
involving
Airway (pharyngeal or laryngeal oedema) and/or
Breathing (bronchospasm with tachypnoea) and/or
Circulation (hypotension and/or tachycardia)
Associated skin and mucosal changes but can be
absent in a significant proportion of cases

18. What can cause Anaphylaxis?
Common: Foods
Insect Stings
Natural latex (rubber)
Drugs
Exercise - either on its own or in combination with other factors such as food or drugs (e.g.
aspirin)

19. Common
Food
Allergens
Beware of
Haribo’s!

20. Uni-phasic Reactions
QUICK ONSET OF
SYMPTOMS
RAPID WORSENING OF
SYMPTOMS
SETTLES WITH
ADRENALINE
PATIENT IMPROVES
WITH NO FURTHER
NEED FOR ADRENALINE

21. Bi-phasic reactions
Most occur within hours of
the initial reaction but
rarely more delayed
Very rare : Biphasic reaction
known to occur 72 hours
after the initial reaction
More likely in patients with
asthma
Hence observation period
vital

22. Treatment for mild/moderate reactions
Short Acting/ 1st Generation Long Acting/2nd Generation
Chlorphenamine Maleate
Syrup licenced from 1 year
Doses in BNF from 1 month
Injection not licenced in neonates
Tablets licenced from 6 years
Cetirizine
Licenced from 2 years
Prescribed ‘off licence’ in
under 2’s
Doses from 2 years in BNF

23. Treating Anaphylaxis
Actions of Adrenaline Side effects
Increases HR
Increases Contractility
Increases BP
Reduces oedema
Anxiety
Arrhythmias
Confusion
Dizziness
Dry mouth
Headache
Increased risk of cerebral bleed
Insomnia
Nausea

24. Observation Period Post Anaphylaxis
DECISION TO BE MADE BY
CLINICIAN
USUALLY 4 HOURS NICE 2011 RECOMMENDS 6-
12 HOURS AND OVERNIGHT

25. Asthma and Anaphylaxis
The major adverse feature in food allergy is respiratory compromise rather than
hypotension
Mild asthma is associated with an increased incidence of anaphylaxis
Risk is higher with severe asthma
Asthma is not a risk factor for recurrence of anaphylaxis but is a risk factor for
severity of reactions

26. Ongoing management
Avoidance of trigger
Signs and symptoms
Information about the risk of a biphasic reaction
Actions to take in case of anaphylaxis
When and how to use an adrenaline injector
Management plans
Referral process
Support Groups

27. How to use AAI’s
Don’t hold it like a pen!
Keep thumb firmly around pen
Take off safety cap (Epipen and Jext)
Take off end (Emerade)
Swing or hold pen into upper outer third of
thigh
Hold and count for 3, 5 or 10 seconds
Phone 999
If symptoms return or do not improve
administer another device after 5 minutes
Lie or sit down – do not stand up

28. Dosage
Recommendation
Resus Council
2016
Children < 6
years: 150
microgram
(0.15mg)
Epipen or Jext
For children
age 6-12 years:
300 microgram
(0.3mg) Epipen
or Jext
For teenagers
and adults
0.3mg
Ensure two
pens

29. How Many?
MHRA
RECOMMENDATION
2 TO BE CARRIED WITH
PATIENTS AT ALL TIMES

30. Storage of
devices
Carry all the time
Have a medication bag with
management plan
Away from sunlight/direct sources of
heat
Do not refrigerate
Ensure in date

32. All food businesses will be required by law to clearly label all pre-packaged foods by Summer 2021

35. Rhinoconjunctivitis
• Chronic, mostly eosinophilic, inflammation
of the nasal mucosa and conjunctiva
• Affects up to 25% of population
• Symptoms include itching, sneezing,
watery nasal discharge, and nasal
congestion
• Associated ocular symptoms (watery, red
and/or itchy eyes)
• Seasonal and/or perennial
• Intermittent or persistent
• Mild, moderate or severe according to the
impact on the quality of life

36. • Associated with considerable loss of
productivity and quality of life
• Leads to impaired performance, sleep
disturbance, learning ability, drop in grades
• Exacerbates asthma and is a major factor in
asthma development (Scadding, 2015)
• Rhinitis is present in up to 95% of patients
with asthma (Small 2018)
• Can occur in children as young as 1.4 years of
age (Ludman, 2016)
• History, examination and testing cornerstone
of diagnosis
• OTC medicines often first line

37. Common triggers
• House Dust Mite
• Grass
• Tree
• Weeds
• Mould and fungal spores
• Animal dander
• Occupational e.g. flour
• Latex
• Nonspecific triggers such as smoke, dust, viral
infections, strong odours, and cold air

38. Management
The aims of management are to control symptoms and reduce
inflammation
Despite medication, a significant number of patients continue to
experience symptoms that impair their quality of life
Avoidance is recommended in all guidelines

39. Guidelines
BSACI updated 2017
Allergic Rhinitis and its Impact on Asthma updated 2016
Aims to educate and implement evidence-based management of allergic rhinitis in conjunction with
asthma worldwide
Most patients with rhinitis and asthma consult their GP and are therefore encouraged to use current
guidelines

40. Step 1
Mild Rhinitis
• Non-sedating oral or topical H1
antihistamine for mild symptoms
consisting of nasal pruritus and
sneezing
• Mild symptoms can be defined as all of
the following:
• Normal sleep
• No impairment of daily activities, sport
or leisure
• No impairment at school/work
• Symptoms present but not troublesome
• Intermittent SAR can be classified as
symptoms less than 4 days per week or
for less than 4 consecutive weeks

41. Step 2
Moderate/Severe
Rhinitis
• Oral H1 non-sedating antihistamine,
intranasal corticosteroids (licensed for
>4 years spray or drops) for nasal
pruritus, sneezing and nasal congestion
• Moderate-severe symptoms can be
defined as the following:
• Sleep disturbance
• Impairment of daily activities, sport
and leisure
• Impairment at school/work
• Troublesome symptoms
• Persistent symptoms can be defined as
more than 4 days per week and for
more than 4 consecutive weeks

42. Step 3
Severe Rhinitis
• Oral H1 non-sedating antihistamine,
intranasal corticosteroids and
leukotriene modifying agent if
asthmatic
• Severe symptoms persist
• Nasal pruritus
• Sneezing
• Nasal congestion
• Conjunctivitis that failed to respond to
a step 2
• Specific immunotherapy for severe
persistent symptoms

43. Sublingual
immunotherapy
(SLIT)
Available for grass, tree, house dust mite,
dog, cat, horse allergies
First dose in hospital
Continue at home for 3 years continuous,
pre or co-seasonal
Safe and effective in studies up to 10 years

44. Websites for allergy
• Allergy UK https://www.allergyuk.org/Whole school allergy and awareness management (Allergy
UK)https://www.allergyuk.org/schools/whole-school-allergy-awareness-and-management
• Anaphylaxis Campaignhttps://www.anaphylaxis.org.ukAllergyWise training for
schoolshttps://www.anaphylaxis.org.uk/information-training/allergywise-training/for-schools/
• Anaphylaxis: assessment and referral after emergency treatment (The National Institute for
Health and Care Excellence,
2011)https://www.nice.org.uk/guidance/cg134?unlid=22904150420167115834
• Spare Pens in Schools http://www.sparepensinschools.uk