Allergy

Please remember there is a Paediatric Clinical Mailbox that can be used for any non-urgent queries: clinical_paediatrics_crosshousehospital@aapct.scot.nhs.uk

• An allergic reaction is an exaggerated immune response to a non-harmful substance.
• Reactions can range from mild discomfort to life-threatening changes.
• Reactions can be IgE mediated and non-IgE mediated.

History

• Is it likely to be an IgE-mediated allergy, or non IgE-mediated reaction?
• If IgE-mediated, advise to completely avoid allergen, complete Allergy Action Plan (see ‘Resources’ below) and consider referral to Allergy clinic.
• If not, advise to keep a symptom/dietary diary and review.
• If suggestion of non-IgE mediated reaction from a food substance, test is with complete exclusion from the diet for around 6 weeks followed by reintroduction.
• If exclusion diet has a positive impact, consider onward referral to dietetic team to ensure no nutritional detriment to exclusion diet.

Exposure e.g. by touching or consuming a food allergen.

Allergen a common, known food allergen.

Timing between exposure and onset of symptoms.

Environment where reaction occurred, and may occur again in the future.

Reproducible symptoms - all exposures will cause a reaction, and knowledge of previous and future exposures to the same allergen can guide towards diagnosis and onward avoidance management.

Symptoms typical for an allergic reaction, and are other symptoms involved?

When to refer to allergy clinic

• Suspicion of IgE-mediated allergy.
• Need identified for adrenaline autoinjector.
• Unclear allergen – testing may be indicated and can be discussed in clinic.
• Cases of suspected chronic urticaria, which may require a combination of antihistamines.

How to refer

Referrals to Paediatrics should be made via the SCI Gateway.

Please note, these are vetted in a timely manner so the priority status of a referral may change upon review.

• In the event of an acute (not life-threatening) reaction, prescribe antihistamine (as per table below) which can be repeated after 10 minutes if the reaction continues to progress.
• Asthma, eczema and rhinitis management should be optimised at all times to reduce the risk of a more significant reactions.
• MMR is safe to be administered even in the case of egg allergy, as per the Green Book.

Adrenaline autoinjectors

• Indications for an adrenaline auto injector (e.g. EpiPen) include:
  • Airway or breathing compromise during an acute reaction.
  • Concern regarding level of consciousness during an acute reaction.
  • Children prescribed regular inhaled corticosteroids due to increased chance of severe reaction.
  • Generalised urticaria with minimal exposure to an allergen.
  • Geographically remote children.
  • Generalised urticaria to bee or wasp sting.
• Children who will need assistance with administering autoinjectors (roughly up to end of primary school age) should have four pens prescribed – two to carry in a ‘Grab Bag’ and two for school. When young people are able to self-administer pens, only two need to be prescribed for the young person to carry themselves
• Guidance regarding adrenaline auto injectors for Primary Care can be found in ‘Resources’ below.

Medication Dosing Suggestions for acute reactions

Note - doses of cetirizine for acute reactions are higher than those suggested for allergy as per Resus Council guidance.

• Children and Young People Allergy Network Scotland – info for Health Professionals at the time of diagnosis including milk, egg and nut allergies NSD610-014-CYANS-Management-of-food-allerg.pdf (scot.nhs.uk)
• Paediatric Allergy Action Plans from BSACI site Paediatric Allergy Action Plans - BSACI
• Primary Care Guidance for adrenaline auto injectors BSACI-AAI-Guidance-June-2023.pdf
• Allergy UK - useful patient/carer information about allergy and avoiding triggers https://www.allergyuk.org/
• Epipen demonstration https://www.epipen.co.uk/en-gb/patients/your-epipen/how-to-use-your-epipen
• NHS Ayrshire and Arran App – Anaphylaxis section – for parental education including EpiPen demonstration
• Immunisation against infectious disease - GOV.UK (www.gov.uk) The Green Book
• BNFc https://bnfc.nice.org.uk/
• Emergency Treatment of Anaphylaxis May 2021_0.pdf