Does Hafiz need a referral for allergy testing?
Hafiz, a 13-month-old infant, who lives on a rural property 90 minutes from town was brought to the GP practice by his concerned parents. They reported that shortly after giving Hafiz peanut butter this morning, they developed a rash around their mouth and cheeks. The rash appeared red and raised, accompanied by mild swelling. The parents also noted that Hafiz seemed agitated and irritable following the ingestion of the peanut butter.
Your assessment is as follows;
A: Airway is patent with no evidence of stridor or airway swelling
B: RR is 20, regular and equal and clear breath sounds bilaterally
C: HR is 130, pink and well perfused, capillary refill 3 secs, Temperature 36.4
D: Settled and calm in mothers lap, playing with their toy. interacting appropriately
E: No evidence of rash now,, but Hafiz’s mother took a photo at the time of the reaction and she shows it to you.
Does this child require a referral for further investigations into this allergic reaction?
Hafiz is not demonstrating signs of an anaphylactic reaction, however mild to moderate allergic reaction is consistent with their history.
Referral to an allergy specialist should be considered in any child with a history of suspected IgE-mediated food allergy. Like Hafiz, this type of reaction typically occurs rapidly, within 30 minutes to 1 hour after ingestion of the triggering food. Symptoms may involve various systems, including the skin (urticaria, angioedema), gastrointestinal tract (vomiting, diarrhoea, abdominal pain), respiratory system (cough, wheeze, chest tightness, changes in voice, tongue swelling), or cardiovascular system (hypotension, collapse).
Non-IgE-mediated reactions usually have a delayed onset, with symptoms appearing several hours to days after consuming the allergenic food. These reactions primarily manifest with gastrointestinal symptoms such as diarrhoea, vomiting, and abdominal pain. However, approximately 10–15% of cases present with food protein-induced enterocolitis syndrome (FPIES), characterised by severe vomiting, pallor, and collapse. A referral to an allergy specialist should also be made for suspected non-IgE-mediated food allergies. Diagnosis relies on clinical history, including elimination of the suspected food and subsequent rechallenge when appropriate, as there is no specific diagnostic test available.
Allergic disease is one of Australia’s greatest public health challenges, with one in 10 children developing a proven food allergy in their first year of life. The most common in the first twelve months is egg, but generally it is outgrown by six years old.
Most mild to moderate food allergies will respond well to an oral antihistamine. The prescription of a non-drowsy antihistamine and education for when to administer it should also be provided to the parents in the meantime.
|
Oral antihistamine |
Age |
Dose |
|
Certrazine |
1-2 years |
2.5 mg BD |
|
Certrazine |
2-6 years |
5 mg Daily or 2.5mg BD |
|
Certrazine |
6-12 years |
10 mg Daily or 5mg BD |
|
Certrazine |
12+ years |
10 mg Daily |
They should also receive education on how to avoid the trigger and how to recognise the signs of a severe allergic reaction or anaphylaxis.
If a child presents with symptoms indicative of anaphylaxis (a life threatening allergic reaction) immediate administration of IM Adrenaline 10 mcg/kg of 1:1000 into the thigh is the first line treatment. This can be repeated every 5 minutes if signs and symptoms are still present.
Anaphylaxis will present as a rapidly evolving multisystem allergic reaction including one or more of these respiratory features;
-
Difficulty / noisy breathing
-
Swelling of tongue
-
Swelling / tightness in throat
-
Difficulty talking and/or hoarse voice
-
Wheeze or persistent cough
and/or one or more of the following cardiovascular features;
-
Loss of consciousness
-
Collapse
-
Pallor and floppiness (in young children)
-
Hypotension
It's also important to have the child lie down and not allow them to walk around as this will speed up the progression of the reaction in the body. Call an ambulance or a MET call if you are treating anaphylaxis so that help is on the way as soon as possible. Anaphylaxis can potentially progress to cardiac arrest, so clinicians should be prepared to commence CPR if the child stops breathing and becomes unresponsive.
Parent handouts
RCH Kids Info Fact Sheet: Allergies and Anaphylaxis
ASCIA Allergic reactions signs and symptoms
ASCIA Fast Facts Peanut allergy
ASCIA Dietary guide for peanut allergy
References
Allergy Testing and Referral in Children
Allergy and Anaphylaxis - Emergency Management in Children
Related Courses
Courts in Session: A Coronial Investigation To Anaphylaxis
Grace Larson, RN, BN, CertIV(TAE), GradDipClinNurs(PaedCritCare), MAdNursPrac(PaedCritCare), has extensive experience in paediatric nursing, with 13 years in Paediatric Intensive Care Units (PICU). She’s published journal articles in the specialty area of pain and sedation in PICU, and has presented at national and international conferences on the area of pain and sedation in paediatrics. Grace has previously worked with the ACCCN delivering Paediatric Advanced Life Support in Victoria, bringing a wealth of experience into her clinical teaching on paediatric resuscitation. She has also consulted with NSW Health on quality and safety delivering within PICU, and has been contracted with the ANMF to develop nursing programs for nurses who require additional education as part of their practice requirements.
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