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Ho HE, Arditi Z, Radigan L, Grishina G, Zhang L, Chun Y, Lo T, Wang J, Sicherer S, Bunyavanich S. Saliva antibody profiles are associated with reaction threshold and severity of peanut allergic reactions. J Allergy Clin Immunol 2024; 154:690-697.e4. [PMID: 38821318 PMCID: PMC11380589 DOI: 10.1016/j.jaci.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/18/2024] [Accepted: 05/02/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Reaction threshold and severity in food allergy are difficult to predict, and noninvasive predictors are lacking. OBJECTIVE We sought to determine the relationships between pre-challenge levels of peanut (PN)-specific antibodies in saliva and reaction threshold, severity, and organ-specific symptoms during PN allergic reactions. METHODS We measured PN-specific antibody levels in saliva collected from 127 children with suspected PN allergy before double-blind, placebo-controlled PN challenges in which reaction threshold, severity, and symptoms were rigorously characterized. Low threshold (LT) PN allergy was defined as reaction to <300 mg of PN protein cumulatively consumed. A consensus severity grading system was used to grade severity. We analyzed associations between antibody levels and reaction threshold, severity, and organ-specific symptoms. RESULTS Among the 127 children, those with high pre-challenge saliva PN IgE had higher odds of LT PN allergy (odds ratio [OR] 3.9, 95% CI 1.6-9.5), while those with high saliva PN IgA:PN IgE ratio or PN IgG4:PN IgE ratio had lower odds of LT PN allergy (OR 0.3, 95% CI 0.1-0.8; OR 0.4, 95% CI 0.2-0.9). Children with high pre-challenge saliva PN IgG4 had lower odds of severe PN reactions (OR 0.4, 95% CI 0.2-0.9). Children with high saliva PN IgE had higher odds of respiratory symptoms (OR 8.0, 95% CI 2.2-26.8). Saliva PN IgE modestly correlated with serum PN IgE levels (Pearson r = 0.31, P = .0004). High and low saliva PN IgE levels further distinguished reaction threshold and severity in participants stratified by serum PN IgE, suggesting endotypes. CONCLUSIONS Saliva PN antibodies could aid in noninvasive risk stratification of PN allergy threshold, severity, and organ-specific symptoms.
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Affiliation(s)
- Hsi-En Ho
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zoe Arditi
- Department of Genetics & Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lin Radigan
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Galina Grishina
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lingdi Zhang
- Department of Genetics & Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yoojin Chun
- Department of Genetics & Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Tracy Lo
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Scott Sicherer
- Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Supinda Bunyavanich
- Department of Genetics & Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY.
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Stanislo KJ, Neumann LS. Introducing NASN's School Nursing Evidence-Based Clinical Practice Guideline: Allergy and Anaphylaxis CPG and Implementation Toolkit. NASN Sch Nurse 2024; 39:247-253. [PMID: 39215595 DOI: 10.1177/1942602x241271276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Clinical Practice Guidelines (CPGs) are statements informed by a systematic review of research/evidence and provide recommendations for clinical practice to improve healthcare quality and patient outcomes. The National Association of School Nurses (NASN) released School Nursing Evidence-Based Clinical Practice Guideline: Students with Allergies and Risk for Anaphylaxis, in 2023, to provide evidence-based recommendations specific to school nursing practice and support the role of the school nurse in providing high-quality care for school-age children with allergies and risk for anaphylaxis. This article will provide an overview of the CPG and Implementation Toolkit. The implementation toolkit is designed to provide school nurses with tools and resources to implement the recommendations into practice. These tools and resources include school policies; nursing assessments and intake; planning, training, implementing, and evaluating care; and data collection. Examples are discussed, including how to customize the toolkit resources to your current practice needs.
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Affiliation(s)
- Kimberly J Stanislo
- Research Education Practice Director National Association of School Nurses Silver Spring, MD
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3
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Alcocer Alkureishi L, Hageman JR, Brown Z. Food Allergies: What We Know, and What We Are Learning. Pediatr Ann 2024; 53:e272-e274. [PMID: 39120460 DOI: 10.3928/19382359-20240715-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
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4
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Wang J. Epinephrine autoinjectors for individuals with food allergy: Who, how many, and when to use. JOURNAL OF FOOD ALLERGY 2024; 6:32-36. [PMID: 39257596 PMCID: PMC11382762 DOI: 10.2500/jfa.2024.6.240004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
Background Anaphylaxis is a serious allergic reaction that is effectively treated with epinephrine. Epinephrine autoinjectors are devices that contain fixed doses of medication that can be carried by patients at risk for anaphylaxis so that ready access to first line medication is available outside the medical setting. Methods This review will discuss recent studies evaluating patient characteristics to consider when prescribing epinephrine autoinjectors. Results Decisions regarding who should be prescribed epinephrine autoinjectors will depend on the type of allergy, as well as co-morbidities and other risk factors that can increase a patient's risk for poor outcomes. Conclusion Shared decision-making is essential when developing guidance regarding post-epinephrine management. Regular education during routine follow-up visits can reinforce knowledge and skills for managing food allergy reactions.
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Affiliation(s)
- Julie Wang
- From the Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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5
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Gupta RS, Epstein E, Wood RA. The role of pediatricians in the diagnosis and management of IgE-mediated food allergy: a review. Front Pediatr 2024; 12:1373373. [PMID: 38873581 PMCID: PMC11169649 DOI: 10.3389/fped.2024.1373373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
Importance Food allergy can often cause a significant burden on patients, families, and healthcare systems. The complexity of food allergy management requires a multidisciplinary approach involving different types of healthcare providers, including allergists, dieticians, psychologists, nurses, family practitioners and, of particular relevance for this article, pediatric primary caretakers. Pediatricians may be the first-line healthcare providers for food allergy: strategies for management and guideline adherence have been highlighted. Observations This review article summarizes the up-to-date recommendations on the role of pediatricians in the diagnosis, management, and prevention of IgE-mediated food allergy. Early introduction of allergenic foods like peanut is known to be of importance to reduce the development of peanut allergy in infants, and pediatricians are essential for educating and supporting parents in this decision. In scenarios of limited allergist availability, as is often the case among rural, Medicaid and minority populations, pediatricians can assist in the evaluation and management of food allergy, and provide action plans, education and counselling for patients and families. Conclusions and relevance Pediatric primary caretakers play a key role in the diagnosis, management, and prevention of IgE-mediated food allergy. As more diagnostic tools and therapies in food allergy become available, the need for a multidisciplinary team is paramount to optimize patient care.
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Affiliation(s)
- Ruchi S. Gupta
- Institute for Public Health and Medicine, Center for Food Allergy & Asthma, Northwestern University, Chicago, IL, United States
| | - Ellen Epstein
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, United States
| | - Robert A. Wood
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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6
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Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Abrams EM, Bernstein JA, Chu DK, Horner CC, Rank MA, Stukus DR, Burrows AG, Cruickshank H, Golden DBK, Wang J, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Waserman S, Abrams EM, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt M, Horner CC, Ledford DK, Lieberman J, Rank MA, Shaker MS, Stukus DR, Wang J. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol 2024; 132:124-176. [PMID: 38108678 DOI: 10.1016/j.anai.2023.09.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 12/19/2023]
Abstract
This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.
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Affiliation(s)
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Alyssa G Burrows
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Heather Cruickshank
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | | | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | | | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
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7
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Gorham NP. Anaphylaxis:: After the Emergency Department. Immunol Allergy Clin North Am 2023; 43:467-471. [PMID: 37394253 DOI: 10.1016/j.iac.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
After treating the acute anaphylactic reaction, the clinician's next task is to prevent a recurrence. The patient should be observed in the ED. How long this observation period should last depends on their clinical course, risk factors, and social support. All patients should be discharged with a prescription for 2 epinephrine autoinjectors and counseled on appropriate use. The patient should also receive education on the signs and symptoms of anaphylaxis and avoiding triggers. The patient should follow-up with an allergy specialist who can confirm triggers and provide immunotherapy as indicated.
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Affiliation(s)
- Nicholas P Gorham
- Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121, USA.
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Lloyd M, Loke P, Mack DP, Sicherer SH, Perkin MR, Boyle R, Yin Leung AS, Lee BW, Levin M, Blumchen K, Fiocchi A, Ebisawa M, Oliveira LCLD, Tang MLK. Varying Approaches to Management of IgE-Mediated Food Allergy in Children Around the World. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1010-1027.e6. [PMID: 36805346 DOI: 10.1016/j.jaip.2023.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/17/2023]
Abstract
Food allergy is a chronic disease that affects individuals of all ages and is a significant public health problem globally. This narrative overview examines clinical management strategies for IgE-mediated food allergy in children around the world to understand variations in practice. Information was drawn from clinical practice guidelines, recent research, the websites of professional and governmental bodies with expertise in food allergy, and clinical experts from a broad cross-section of geographical regions. The structure and delivery of clinical services, allergen avoidance and food labeling, and resources to support the management of allergic reactions in the community are discussed in detail. The adoption of emerging food immunotherapies is also explored. Wide variations in clinical management of food allergy were apparent across the different countries. Common themes were continuing issues with access to specialist care and recognition of the need to balance risk reduction with dietary and social restrictions to avoid unnecessary detrimental impacts on the quality of life of food allergy sufferers. Findings highlight the need for standardized presentation of practice and priorities, and may assist clinicians and researchers when engaging with government and funding agencies to address gaps.
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Affiliation(s)
- Melanie Lloyd
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Paxton Loke
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, Monash University, Clayton, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael R Perkin
- Population Health Research Institute, St. George's, University of London, London, United Kingdom
| | - Robert Boyle
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Agnes Sze Yin Leung
- Department of Paediatrics, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong; Hong Kong Hub of Paediatric Excellence, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Michael Levin
- Division of Paediatric Allergology, University of Cape Town, Cape Town, South Africa
| | - Katharina Blumchen
- Department of Children and Adolescent Medicine, Division of Pneumology, Allergology and Cystic Fibrosis, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Alessandro Fiocchi
- Translational Research in Paediatric Specialities Area, Allergy Division, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Sagamihara, Japan
| | - Lucila Camargo Lopes de Oliveira
- Department of Paediatrics, Division of Allergy, Clinical Immunology and Rheumatology, Federal University of São Paulo, São Paulo, Brazil
| | - Mimi L K Tang
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, VIC, Australia.
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9
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Keller A, Morse B, Conroy M. Food Allergies and Anaphylaxis in the Community: The School Nurse's Role. NASN Sch Nurse 2023; 38:41-46. [PMID: 35848517 DOI: 10.1177/1942602x221110083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Food allergy prevalence in the United States has been increasing among school-aged children. Many community-based pediatric caregivers (e.g., camp staff, sports coaches) are not trained to prevent, recognize, or manage allergic reactions due to a lack of available training and standard policies on this topic. Epinephrine is the first-line of treatment for severe allergic reactions and delayed administration of this medication can result in poor health outcomes and death. School nurses may use their knowledge and expertise to educate community-based pediatric caregivers on allergy topics. Professional practice projects can be utilized by school nurses to help improve allergy and anaphylaxis confidence and knowledge among community-based pediatric caregivers. By educating community members on anaphylaxis management, it can improve health outcomes for children of the school community and result in saved lives.
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10
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Gereige RS, Gross T, Jastaniah E. Individual Medical Emergencies Occurring at School. Pediatrics 2022; 150:188345. [PMID: 35757966 DOI: 10.1542/peds.2022-057987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/24/2022] Open
Abstract
Children and adults may face emergency medical situations because of injuries, complications of chronic health conditions, or unexpected major illnesses that occur in schools. The American Academy of Pediatrics published a policy statement in 2001 titled "Guidelines for Emergency Medical Care in Schools," and in 2008, published its revision, "Medical Emergencies Occurring at School." Those statements focused on the preparedness of schools to address individual student emergencies. The increase in the number of children with special health care needs and chronic medical conditions attending schools, together with the added challenges faced by school districts to ensure that schools have access to on-site, licensed health care professionals on an ongoing basis, have contributed to added risks that medical and nonmedical personnel face in dealing with medical emergencies in schools. This newly revised policy statement serves as an update of the statement published in 2008 and reaffirmed in 2017, and intends to increase pediatricians' awareness of schools' roles in preparing for individual student emergencies and provide recommendations for the medical home and school physicians on how to assist and support school personnel. This statement does not address schoolwide or communitywide emergencies that might occur as a result of natural or man-made disasters.
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Affiliation(s)
- Rani S Gereige
- Director of Medical Education, Department of Medical Education, Nicklaus Children's Hospital, Miami, Florida
| | - Toni Gross
- Emergency Medicine, Children's Hospital New Orleans, New Orleans, Louisiana
| | - Ebaa Jastaniah
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Arkansas Children's Hospital/UAMS, Little Rock, Arkansas.,Department of Emergency Medicine, Section of Pediatric Emergency Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia
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11
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Wang J, He Z, Raghavan V. Soybean allergy: characteristics, mechanisms, detection and its reduction through novel food processing techniques. Crit Rev Food Sci Nutr 2022; 63:6182-6195. [PMID: 35075969 DOI: 10.1080/10408398.2022.2029345] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Human beings have consumed soybean as an excellent food source for thousand years due to its rich protein, fatty acids, minerals, and fibers. However, soybeans were recognized as one of the big eight allergens resulting in allergic symptoms and even could lead to death. With the increasing demand for soybean products, the challenges caused by soybean allergy need to be solved urgently. This review detailly described the pathogenesis and clinical characteristics of soybean allergy, and also the advantages and disadvantages of four different diagnostic methods were summarized. The major soybean allergens and their structures were summarized. Three types of soybean allergy including Type I, III, and IV, which could trigger allergic reactions were reported in this review. Summary in four different diagnostic methods showed that double-blind, placebo-controlled food challenge is recognized as a gold standard for diagnosing soybean allergy. Three types of processing techniques in reducing soybean allergy were discussed, and the results concluded that some novel food processing techniques such as ultrasound, cold-plasma treatment, showed potential application in the reduction of soybean allergenicity. Further, some suggestions regarding the management and treatment of food allergies were addressed in this review.
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Affiliation(s)
- Jin Wang
- Key Laboratory of Environmental Medicine and Engineering, Ministry of Education, and Department of Nutrition and Food Hygiene, School of Public Health, Southeast University, Nanjing, China
- Department of Bioresource Engineering, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Quebec, Canada
| | - Zhaoyi He
- Department of Bioresource Engineering, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Quebec, Canada
| | - Vijaya Raghavan
- Department of Bioresource Engineering, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Quebec, Canada
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12
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Motomura C, Okabe K, Matsuzaki H, Kawano T, Akamine Y, Yasunari D, Wakatsuki M, Taba N, Honjo S, Odajima H. Changes in clinical features of food-related anaphylaxis in children during 5 years. Asia Pac Allergy 2022; 12:e14. [PMID: 35571556 PMCID: PMC9066084 DOI: 10.5415/apallergy.2022.12.e14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Despite being frequently recommended, adrenaline auto-injectors (AAIs) are insufficiently prescribed and used for the prehospital management of anaphylaxis. Objective This study aimed to investigate recent changes in the clinical features and prehospital management of food-related anaphylaxis in children. Methods We retrospectively compared the clinical features of children who were hospitalized for food-related anaphylaxis in 2013 and 2018. The patients’ medical records were reviewed for causative foods, triggers, location, AAI prescription, and/or use, wheezing on admission, and treatment. Results Overall, 62 consecutive patients (43 males; median age, 5.6 years) hospitalized in 2018 were compared with 57 patients (37 males; median age, 4.3 years) hospitalized in 2013. There were no significant differences between the cohorts in age, gender, causative foods, or wheezing on admission. Cow’s milk, wheat, and egg represented over half of the causative foods in both groups. Compared with 2013, the incidence of anaphylaxis decreased at home but increased at nurseries and schools in 2018. Exercise was a significantly more common trigger for anaphylaxis in 2018. Furthermore, a significant increase was observed in AAI administration by lay helpers or the patients themselves and in ambulance transportation. After admission, intramuscular adrenaline was administered to 26 patients in 2013 and 12 patients in 2018. Patients receiving prehospital adrenaline were significantly less likely to require in-hospital adrenaline injections. Conclusion Food-related anaphylaxis triggered by exercise and AAI use have increased. Hence, raising awareness and educating caregivers, patients, teachers, and medical professionals are essential for the optimal management of this disorder.
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Affiliation(s)
- Chikako Motomura
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Koki Okabe
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Hiroshi Matsuzaki
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Toshiaki Kawano
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Yuko Akamine
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Daisuke Yasunari
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Masatoshi Wakatsuki
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Naohiko Taba
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Satoshi Honjo
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
| | - Hiroshi Odajima
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, Fukuoka, Japan
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13
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Ramsey N, Wang J. Management of Anaphylaxis in Infants and Toddlers. Immunol Allergy Clin North Am 2021; 42:77-90. [PMID: 34823752 DOI: 10.1016/j.iac.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anaphylaxis is a systemic allergic reaction that can be caused by food, drugs, insect bites, or unknown triggers in infants and toddlers. Anaphylaxis rates are increasing. Infants and toddlers may have increased exposure to known and unknown allergens, decreased ability to describe their symptoms, and an expanded differential diagnosis for consideration on presentation. The most common symptoms in these age groups are cutaneous and gastrointestinal. Age-specific language may be helpful for caregivers to identify and describe the symptoms of anaphylaxis in infants and toddlers. Long-term management of anaphylaxis includes allergy evaluation to guide avoidance and assess prognosis and education on allergic reaction management; this incorporates the prescription of epinephrine autoinjector and provision of an allergy emergency plan.
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Affiliation(s)
- Nicole Ramsey
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA
| | - Julie Wang
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA.
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14
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Gorham NP. Anaphylaxis:: After the Emergency Department. Emerg Med Clin North Am 2021; 40:33-37. [PMID: 34782089 DOI: 10.1016/j.emc.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
After treating the acute anaphylactic reaction, the clinician's next task is to prevent a recurrence. The patient should be observed in the ED. How long this observation period should last depends on their clinical course, risk factors, and social support. All patients should be discharged with a prescription for 2 epinephrine autoinjectors and counseled on appropriate use. The patient should also receive education on the signs and symptoms of anaphylaxis and avoiding triggers. The patient should follow-up with an allergy specialist who can confirm triggers and provide immunotherapy as indicated.
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Affiliation(s)
- Nicholas P Gorham
- Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121, USA.
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15
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Higgs J, Styles K, Bowyer S, Warner A, Dunn Galvin A. Dissemination of EAACI food allergy guidelines using a flexible, practical, whole school allergy awareness toolkit. Allergy 2021; 76:3479-3488. [PMID: 33894060 PMCID: PMC8596703 DOI: 10.1111/all.14871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/28/2021] [Accepted: 02/22/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Essential training for emergency adrenaline auto-injector administration alone provides an inadequate safeguard in school environments. Recent UK deaths have reinforced the urgency for embedding whole school (WS) allergy awareness to minimise risk. We documented the development of a practical, flexible WS Food Allergy Awareness Toolkit for UK secondary schools. METHODS We used a multidisciplinary participatory action research methodology, involving successive modification and retesting of a pragmatic toolkit in 3 case study schools. A School Allergy Action Group drives WS risk assessment, helping schools gradually implement best practice policy in line with their particular needs. Additional schools self-piloted the resulting toolkit with only remote monitoring. School surveys, based on EAACI guidelines were developed to identify priorities and assess change. RESULTS Effectiveness of the resulting process toolkit, now available online, was independently demonstrated via pre/post-intervention questionnaires from 24/10 pupils with food allergy (FA) and 97/6 pupils without FA, respectively. Pearson correlational analysis showed strong negative relationships between Food Allergy Quality of Life Questionnaire (FAQLQ) at T0 and School Support (SS) at T0 (r = -0.8, P<0.01), and between SS and Self-Efficacy (SE) (r = 0.73, P<0.05). Mean FAQLQ scores improved between T0 (3.3) and T1 (2.5). SE improved for those with FA (mean difference = 1.0). In those without FA, SE (mean difference = 0.9) and Attitudes and Knowledge (mean difference = 0.7) also improved. CONCLUSIONS Full stakeholder involvement in toolkit development encourages usage and, therefore, improves WS community awareness; reduces risk of reactions; fosters a more accepting societal attitude and empowers pupils with/without allergies to self-manage effectively.
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Abstract
Food allergy is an immune-mediated disease and must be differentiated from other adverse effects related to food that are non-immune mediated. Symptoms of immunoglobulin (Ig) E-mediated allergy can range from mild to severe, and life-threatening anaphylaxis may occur. Current recommended strategies for diagnosis include the use of skin prick tests, allergen-specific serum IgE, and/or oral food challenges. Management entails allergen avoidance and appropriate treatment of allergic reactions should accidental ingestions occur. Treatment approaches under investigation include immunotherapy as well as biologics and novel vaccines. Attention has also recently focused on implementing strategies for prevention of food allergy.
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Affiliation(s)
- Roxanne Carbonell Oriel
- Department of Pediatrics, Division of Allergy & Immunology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA
| | - Julie Wang
- Department of Pediatrics, Division of Allergy & Immunology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA.
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17
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Abstract
PURPOSE OF REVIEW Epinephrine is the agreed-upon first line treatment for anaphylaxis, yet it continues to be underused by patients/caregivers and providers alike. RECENT FINDINGS There are unfortunately limited data on how epinephrine can best be utilized in anaphylaxis, which hinders how best to inform patients and providers. Studies reporting underuse suggest various barriers and themes on why this may happen. SUMMARY Continued education of patients, caregivers, and providers is needed; however, is not likely to be enough to close the gap. Thus, novel studies on how to increase use; increase availability in a cost-effective manner; and newer, effective delivery routes are still needed.
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A severity grading system of food-induced acute allergic reactions to avoid the delay of epinephrine administration. Ann Allergy Asthma Immunol 2021; 127:462-470.e2. [PMID: 33895419 DOI: 10.1016/j.anai.2021.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/11/2021] [Accepted: 04/16/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Substantial discrepancies among anaphylaxis severity scores may delay epinephrine administration. OBJECTIVE The study aims to develop a transparent severity grading system of food-induced acute allergic reactions with a decision model for epinephrine use. METHODS The natural course of 315 acute food-induced allergic reactions in children hospitalized at the Allergology department between May 2016 and July 2019 owing to follow-up treatment and allergy diagnostics was evaluated. The severity of episodes was classified according to the 5 most accepted grading systems. The interrater reliability of classification between anaphylaxis severity scores was assessed. All symptoms were grouped into a heat map according to their real-life incidence and clinical relevance. Based on the heat map analysis, a severity grading system of food-induced acute allergic reactions in children with the epinephrine administration decision model was created. RESULTS Data from 259 food-induced anaphylaxis episodes in 157 children were included in the analysis. Comparing the grading systems, we observed a 24.7% to 70.2% disagreement between severity scores. The heat map illustrated a strong association between 29 symptoms and their categorization. A new severity grading system was developed and a 2-stage decision model was proposed: "epinephrine yes" (any rapidly progressing symptoms, even mild ones or from 1 organ system; any symptoms from more than 1 organ system; or every grade of anaphylaxis), and "epinephrine available and prepared to use" (nonprogressing mild systemic allergic reaction from 1 system area only; no anaphylaxis). CONCLUSION A new severity grading system of food-induced acute allergic reactions in children could serve as a clinical tool for health care professionals to avoid epinephrine administration delay.
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Passanisi S, Caminiti L, Zirilli G, Lombardo F, Crisafulli G, Aversa T, Pajno GB. Biologics in food allergy: up-to-date. Expert Opin Biol Ther 2021; 21:1227-1235. [PMID: 33733975 DOI: 10.1080/14712598.2021.1904888] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: In recent years, the advent of immunotherapy has remarkably improved the management of IgE-mediated food allergy. However, some barriers still exist. Therefore, the effort of researchers aims to investigate new perspectives in the field of non-allergen specific therapy, also based on the current knowledge of the pathogenesis of this disease.Areas covered: This review aims to focus on the role of biologics as a treatment option in patients with IgE-mediated food allergy. These agents are characterized by their ability to inactivate the Th2 pro-inflammatory pathways. Biologics can be used both alone and in association with immunotherapy. Monoclonal antibodies targeting IgE, the IL-4/IL-13 axis, IL-5, and alarmins have been proposed and investigated for treating food allergy.Expert opinion: The clinical efficacy and safety of biologics have been demonstrated in several preclinical studies and randomized controlled trials. Future studies are still required to address current unmet needs, including the identification of the optimal dose to be used by ensuring the effectiveness of therapy.
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Affiliation(s)
- Stefano Passanisi
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi, University of Messin, Messina (Italy)
| | - Lucia Caminiti
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi, University of Messin, Messina (Italy)
| | - Giuseppina Zirilli
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi, University of Messin, Messina (Italy)
| | - Fortunato Lombardo
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi, University of Messin, Messina (Italy)
| | - Giuseppe Crisafulli
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi, University of Messin, Messina (Italy)
| | - Tommaso Aversa
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi, University of Messin, Messina (Italy)
| | - Giovanni B Pajno
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi, University of Messin, Messina (Italy)
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Passanisi S, Lombardo F, Crisafulli G, Salzano G, Aversa T, Pajno GB. Novel diagnostic techniques and therapeutic strategies for IgE-mediated food allergy. Allergy Asthma Proc 2021; 42:124-130. [PMID: 33685556 PMCID: PMC8133008 DOI: 10.2500/aap.2021.42.200129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background: Immunoglobulin E (IgE) mediated food allergy is a potentially life-threatening condition and represents a heavy burden for patients and their families. Identification of the most suitable way for management of each patient has currently become the primary goal for physicians. Methods: This study reviewed the current literature related to IgE-mediated food allergy. Results: The use of innovative diagnostic tools, such as allergen-specific IgG4 determination, basophil activation test, and component-resolved diagnostics, is currently available to facilitate a proper diagnosis of food allergy. After several decades of "passive clinical management" of the disease, which was based only on avoidance of the allergenic food and the use of epinephrine in the event of anaphylaxis, there has been a switch to active treatment. The most recent evidence-practice guidelines strongly recommend the use of immunotherapy as an effective therapeutic option, particularly in cases of allergy to cow's milk, egg, or peanut. The use of omalizumab, in association with immunotherapy or alone, has been tested in several studies, and results on its effectiveness seemed to be encouraging. Other biologics, such as dupilumab, reslizumab, mepolizumab, and other anticytokines therapies, are being investigated. Another interesting future treatment strategy could be the use of DNA vaccines. Conclusion: In recent years, the management of IgE-mediated food allergy has greatly improved. Knowledge of pathogenetic mechanisms, understanding of the disease course, and the introduction of novel biomarkers led to more accurate diagnoses along with the active treatment of patients.
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21
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Pistiner M, Mendez-Reyes JE, Eftekhari S, Carver M, Lieberman J, Wang J, Camargo CA. Caregiver-Reported Presentation of Severe Food-Induced Allergic Reactions in Infants and Toddlers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:311-320.e2. [PMID: 33217612 DOI: 10.1016/j.jaip.2020.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/15/2020] [Accepted: 11/02/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Recognizing anaphylaxis in infants and toddlers can be challenging for health care providers and caregivers, and current diagnostic criteria and anaphylaxis action plans do not specifically address this younger population. OBJECTIVE To describe symptoms and signs observed by primary caregivers of infants and toddlers during severe food-induced allergic reactions. METHODS We conducted a national online survey among primary caregivers of children who experienced a severe food-induced allergic reaction when less than 36 months of age. Respondents who were present during the child's most severe reaction were asked to report symptoms and signs observed. The survey asked about infant- and toddler-specific symptoms and signs in lay language for caregivers. Data were compared with patient-reported data from past studies to identify distinct patterns among the younger population. RESULTS The survey was completed for 374 children (193 infants, 181 toddlers). The most common symptoms and signs reported were skin reactions (90%), facial and extremity swelling (59%), gastrointestinal issues (51%), and coughing/wheezing (45%). Infants (aged <12 months) more frequently experienced skin reactions, skin mottling, and ear pulling/scratching or putting fingers in ears, as compared with toddlers (aged 12-35 months). Toddlers experienced throat itching and coughing/wheezing more frequently than infants. CONCLUSIONS Anaphylaxis presentation demonstrates similarities and differences in infants and toddlers. Modifying the terminology used in the current criteria allowed for reporting of symptoms and signs of anaphylaxis that are more common in infants and toddlers. Diagnostic criteria, clinical guidelines, and anaphylaxis action plans may be enhanced to address this young, often nonverbal, population.
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Affiliation(s)
- Michael Pistiner
- Mass General Hospital for Children, Harvard Medical School, Boston, Mass.
| | | | | | | | - Jay Lieberman
- The University of Tennessee Health Science Center, LeBonheur Children's Hospital, Memphis, Tenn
| | - Julie Wang
- Department of Pediatrics, Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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Venter C, Sicherer SH, Greenhawt M. Management of Peanut Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:345-355.e2. [PMID: 30717865 DOI: 10.1016/j.jaip.2018.10.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 01/14/2023]
Abstract
Peanut allergy is a growing public health concern in westernized countries. Peanut allergy is characterized as an often severe and lifelong allergy, which can have detrimental effects on quality of life and trigger anxiety. Although multiple therapeutic options are emerging, the focus of current management strategies is strict peanut avoidance and carriage of self-injectable epinephrine. The greatest risk of reacting to peanut comes from direct ingestion, whereas casual skin contact or airborne exposure is highly unlikely to provoke significant symptoms. Patients and families must be educated about how to best execute strict peanut avoidance through careful label reading as well as how to understand and address likely and unlikely risk with regard to peanut exposure in public, in particular when dining outside of the home and for children attending school or child care. This review discusses the risk of exposure in public such as at school or on an airplane and how such risk can be abated, situations and scenarios when dining out of the house that may pose more risks than others, the essentials of US and EU label reading laws with particular emphasis on precautionary labeling and the risk implied by such, quality of life and psychosocial issues that may affect the peanut allergic individual and family, and a discussion of how risk may differ and evolve based on the patient's age.
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Affiliation(s)
- Carina Venter
- Section of Allergy and Immunology, Children's Hospital Colorado, Food Challenge and Research Unit, University of Colorado School of Medicine, Aurora, Colo; The David Hide Asthma and Allergy Research Centre, Newport, Isle of Wight, United Kingdom.
| | - Scott H Sicherer
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai and the Jafee Food Allergy Institute, New York, NY
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Food Challenge and Research Unit, University of Colorado School of Medicine, Aurora, Colo
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McCaughey RA, McCarthy AM, Maughan E, Hein M, Perkhounkova Y, Kelly MW. Emergency Medication Access and Administration in Schools: A Focus on Epinephrine, Albuterol Inhalers, and Glucagon. J Sch Nurs 2020; 38:326-335. [DOI: 10.1177/1059840520934185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Access to emergency medications is a growing concern, particularly regarding the availability, safety, and use of these medications in schools. The purpose of this article is to report results not previously published from a national survey, specifically regarding the emergency use of epinephrine, albuterol inhalers, and glucagon. A nonexperimental, cross-sectional design was utilized for this descriptive study. An online survey was distributed to school nurses in 2015, and data from 6,298 school nurse respondents are presented in the analysis. Findings related to stock and student-specific emergency medication use and storage, epinephrine usage data, and delegation of emergency medication administration to unlicensed assistive personnel are presented in this article. Further development of policies and procedures regarding emergency medication administration in schools is needed. School nurses are a valuable resource for obtaining knowledge in this area and keeping students safe at school.
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Affiliation(s)
- Rebecca A. McCaughey
- College of Pharmacy, University of Iowa, IA, USA
- College of Public Health, University of Iowa, IA, USA
| | | | - Erin Maughan
- Department of Research, National Association of School Nurses, Silver Spring, MD, USA
| | - Maria Hein
- College of Nursing, University of Iowa, IA, USA
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Malipiero G, Heffler E, Pelaia C, Puggioni F, Racca F, Ferri S, Spinello L, Merigo M, Lamacchia D, Cataldo G, Sansonna M, Canonica GW, Paoletti G. Allergy clinics in times of the SARS-CoV-2 pandemic: an integrated model. Clin Transl Allergy 2020; 10:23. [PMID: 32566128 PMCID: PMC7299638 DOI: 10.1186/s13601-020-00333-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Almost the entire World is experiencing the Coronavirus-Disease-2019 (COVID-19) pandemic, responsible, at the end of May 2020, of more than five million people infected worldwide and about 350,000 deaths. In this context, a deep reorganization of allergy clinics, in order to ensure proper diagnosis and care despite of social distancing measures expose, is needed. MAIN TEXT The reorganization of allergy clinics should include programmed checks for severe and poorly controlled patients, application of digital medicine service for mild-to-moderate disease in well-controlled ones, postponement of non urgent diagnostic work-ups and domiciliation of therapies, whenever possible. As far as therapies, allergen immunotherapy (AIT) should not be stopped and sublingual immunotherapy (SLIT) fits perfectly for this purpose, since a drug home-delivery service can be activated for the entire pandemic duration. Moreover, biologic agents for severe asthma, chronic spontaneous urticaria and atopic dermatitis should be particularly encouraged to achieve best control possible of severe disease in times of COVID-19 and, whenever possible, home-delivery and self-administration should be the preferred choice. CONCLUSION During COVID-19 pandemic, allergists have the responsibility of balancing individual patients' needs with public health issues, and innovative tools, such as telemedicine and digital medicine services, can be helpful to reduce the risk of viral spreading while delivering up-to-date personalized care.
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Affiliation(s)
- Giacomo Malipiero
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI Italy
| | - Corrado Pelaia
- Department of Medical and Surgical Sciences, University “Magna Grecia” of Catanzaro, Catanzaro, Italy
| | - Francesca Puggioni
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI Italy
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
| | - Sebastian Ferri
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI Italy
| | - Lina Spinello
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
| | - Morena Merigo
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
| | - Donatella Lamacchia
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
| | - Giuseppe Cataldo
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
| | - Melissa Sansonna
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI Italy
| | - Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, Rozzano, MI Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI Italy
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Elliman MG, Sloman P, South M, Cheng DR. Action plans into action - An electronic action plan generation tool at a paediatric centre. Int J Med Inform 2020; 141:104219. [PMID: 32623329 DOI: 10.1016/j.ijmedinf.2020.104219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/24/2020] [Accepted: 06/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Individualised Action Plans (APs) are a key management tool for paediatric asthma, allergy, anaphylaxis and eczema. They provide salient care instructions for patients and caregivers and are thought to improve disease outcomes, albeit with minimal supporting evidence. Whilst the provision of an AP has become a widely measured healthcare quality marker, the content of the plans provided has been relatively neglected. The Royal Children's Hospital, Melbourne (RCH) implemented an AP generation tool integrated within its Electronic Medical Record (EMR) in 2017. This case study aims to exhibit the potential benefits of a hospital-wide integrated AP tool, assess its uptake and usage at our institution and demonstrate quality and user interface issues detected through audit of APs provided. METHODS A retrospective observational analysis of all APs created within the RCH EMR for patients aged 0-18 years between January 1 and December 31, 2018 was conducted. For each AP, automatically populated and clinician entered fields were extracted and analysed. RESULTS 2637 APs were completed during the study period. The most used AP was for asthma. Omission rates of critical information were low but could be improved. Depending on clinical condition, there was variation in both the location of completion (ED vs clinic/hospital visit) and role of clinician completing the AP (consultant vs junior medical staff). CONCLUSION There was considerable uptake of an EMR-integrated AP tool across our institution. An electronic AP allowed for qualitative evaluation of usage and audit of AP content and will guide further system and user interface improvements to improve AP quality.
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Affiliation(s)
- Mark G Elliman
- Department of General Medicine, Royal Children's Hospital, Parkville, Australia
| | - Peter Sloman
- EMR Project, Royal Children's Hospital, 50 Flemington Rd, Parkville, Australia
| | - Mike South
- Department of General Medicine, Royal Children's Hospital, Parkville, Australia; EMR Project, Royal Children's Hospital, 50 Flemington Rd, Parkville, Australia; Department of Paediatrics, University of Melbourne, Carlton, Australia; Murdoch Children's Research Institute, Parkville, Australia
| | - Daryl R Cheng
- Department of General Medicine, Royal Children's Hospital, Parkville, Australia; EMR Project, Royal Children's Hospital, 50 Flemington Rd, Parkville, Australia; Department of Paediatrics, University of Melbourne, Carlton, Australia; Murdoch Children's Research Institute, Parkville, Australia.
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Abstract
PURPOSE OF REVIEW Food allergy is increasing in prevalence, and management focuses on strict avoidance of known allergens and appropriately treating reactions. Any reaction has the potential to result in anaphylaxis, which can be fatal. Children spend a significant amount of time in the childcare or school setting, and interactions between families, school personnel, and clinicians are important to ensure the health and safety of children with allergies and asthma. RECENT FINDINGS This review examines current food allergy guidelines and legislation, an assessment of allergen-free schools, the importance of written anaphylaxis action plans, training and education of school personnel, emerging treatment options, and the social implications of having food allergies. As the clinical use and research into food allergen immunotherapy continues to expand, an additional level of education and management is required of school personnel and caregivers. Food allergy has both medical and social implications, which are magnified in the school setting.
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Abstract
Urticaria and, to a lesser extent, angioedema are common occurrences in the pediatric population. There are multiple causes of acute and chronic urticaria and angioedema. Most causes are benign, although they can be worrisome for patients and their parents. An allergist should evaluate acute urticaria and/or angioedema if there are concerns of an external cause, such as foods or medications. Chronic urticaria and angioedema can severely affect quality of life and should be managed aggressively with antihistamines and immunomodulators if poorly controlled. Chronic symptoms are unlikely to be due to an external cause. Anaphylaxis is a more serious allergic condition characterized by a systemic reaction involving at least 2 organ systems. Anaphylaxis should be initially managed with intramuscular epinephrine. Patients who experience anaphylaxis should be evaluated by an allergist for possible causes; if found, avoidance of the inciting antigen is the best management. All patients should also be given an epinephrine autoinjector and an action plan. Foods are a common cause of anaphylaxis in the pediatric population. New evidence suggests that the introduction of highly allergic foods is safe in infancy and should not be delayed. In addition, the early introduction of foods such as peanuts may help prevent the development of food allergies.
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Affiliation(s)
| | - Theresa A Bingemann
- University of Rochester, Rochester, NY.,Department of Allergy, Immunology, and Rheumatology, Rochester Regional Health, Rochester, NY
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28
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Physician instructions to inject epinephrine with mild or no symptoms on food allergy and anaphylaxis emergency plans. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1423-1425.e7. [DOI: 10.1016/j.jaip.2020.01.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/14/2020] [Accepted: 01/31/2020] [Indexed: 12/30/2022]
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Brown JC, Simons E, Rudders SA. Epinephrine in the Management of Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1186-1195. [DOI: 10.1016/j.jaip.2019.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/13/2019] [Accepted: 12/18/2019] [Indexed: 10/24/2022]
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30
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Abstract
Immediate administration of intramuscular epinephrine to a patient experiencing anaphylaxis is the first-line therapy for this life-threatening allergic reaction. Alhough anaphylaxis is generally a rare occurrence, it has dire consequences if left untreated. In infants, anaphylaxis is typically triggered by exposure to egg, cow's milk, or peanuts. The rapid onset of symptoms in multiple organ systems makes an accurate diagnosis in infants difficult because there are numerous ways in which anaphylaxis may present. The symptoms of infant anaphylaxis are often underrecognized or misdiagnosed for less serious illnesses or even normal findings, including drooling, loose stools, and irritability. Because infants are mostly nonverbal-and most pediatric emergency department visits for anaphylaxis cases are the first diagnosis-ascertaining potential exposure to common allergens is difficult; this further complicates diagnosis in these youngest patients for whom the clinical presentation of anaphylaxis varies widely. A key factor in diagnosing anaphylaxis is the temporal profile of symptom development following allergen exposure; however, some children with anaphylaxis develop symptoms that reoccur hours or days after an initial anaphylactic reaction, making diagnosis challenging. Advanced practice nurses are often the first health care provider to encounter a patient who may be experiencing anaphylaxis. Although diagnostic criteria exist for anaphylaxis, specific criteria for the diagnosis of anaphylaxis in infants have not been developed. As such, it is important to understand and recognize the variable presentation of anaphylaxis in infants and to rapidly diagnose and treat with epinephrine.
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Alqurashi W, Awadia A, Pouliot A, Cloutier M, Hotte S, Segal L, Barrowman N, Irwin D, Vaillancourt R. The Canadian anaphylaxis action plan for kids: development and validation. PATIENT EDUCATION AND COUNSELING 2020; 103:227-233. [PMID: 31383563 DOI: 10.1016/j.pec.2019.07.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/02/2019] [Accepted: 07/23/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES We designed a written Canadian Anaphylaxis Action Plan for Kids (Kids' CAP) which incorporates validated pictograms with written instructions. Using a patient-centered approach, we aimed to validate the Kids' CAP and assess its impact on anaphylaxis recognition and treatment, and to determine its' perceived usefulness. PATIENT INVOLVEMENT Children and their parents were involved in appraising the design and written contents of the Kids' CAP. METHODS The design process consisted of a development phase and clinical validation phase. First, we assessed the readability and understandability of the Kids' CAP using validated instruments. Then, patients (12-17 years of age) and parents of patients (<12 years of age) were given the Kids' CAP during the first consultation with allergy specialists or an Emergency Department visit for anaphylaxis. Subsequently, we conducted a phone interview 2-3 weeks later to assess their comprehension of anaphylaxis management. We also used the Consumer Information Rating Form to measure the participants' perception of the design quality and usefulness of the Kids' CAP. RESULTS Of the 230 participants enrolled, 205 (89%) completed the follow-up interview. The written contents of the Kid's CAP were modified to match grade 7 readability level. The total mean score of the Consumer Information Rating Form for comprehensibility was 23.1 (SD 2.4), and 25.1 (SD 2.3) for design quality. The mean comprehension score was 11.3 (SD 1.8) (reference range 0-12), with no significant difference between participants with and without previous experience with anaphylaxis, or high vs. low literacy level. CONCLUSION Engaging children and parents in the design and contents of written anaphylaxis action plan is an innovative approach to produce a useful document for the end-users. PRACTICE IMPLICATIONS The Kids' CAP is a valid tool that can be used in emergency departments and allergy clinics to improve patient's comprehension of anaphylaxis manifestations and treatment.
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Affiliation(s)
- Waleed Alqurashi
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Canada; Department of Pediatrics, University of Ottawa, Ottawa, Canada; Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Canada.
| | - Alisha Awadia
- Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Annie Pouliot
- Pharmacy, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Michel Cloutier
- Pharmacy, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Simon Hotte
- Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Lauren Segal
- Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Nick Barrowman
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Danica Irwin
- Pharmacy, Children's Hospital of Eastern Ontario, Ottawa, Canada
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Butler SM, Boucher EA, Tobison J, Phan H. Medication Use in Schools: Current Trends, Challenges, and Best Practices. J Pediatr Pharmacol Ther 2020; 25:7-24. [PMID: 31897071 PMCID: PMC6938291 DOI: 10.5863/1551-6776-25.1.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2019] [Indexed: 02/01/2023]
Abstract
There are a significant number of students on maintenance medications for chronic diseases or with diagnoses that may result in medical emergencies requiring administration of medications in school. With passing of legislation in all 50 states allowing self-administration of emergency medications for allergic reactions and asthma, the landscape of medication use in schools is changing. These changes have raised questions about the need for legislation or policy development relating to self-carrying and self-administration of medications for other disease states, undesignated stock of emergency medications, and administration of medications by non-medical personnel. Medication administration in the school setting has become a complex issue, and this review will discuss current legislation related to medication use in schools and provide best practices for administering medications to children and adolescents while at school.
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Abstract
Food allergy is an immune-mediated disease and must be differentiated from other adverse effects related to food that are non-immune mediated. Symptoms of immunoglobulin (Ig) E-mediated allergy can range from mild to severe, and life-threatening anaphylaxis may occur. Current recommended strategies for diagnosis include the use of skin prick tests, allergen-specific serum IgE, and/or oral food challenges. Management entails allergen avoidance and appropriate treatment of allergic reactions should accidental ingestions occur. Treatment approaches under investigation include immunotherapy as well as biologics and novel vaccines. Attention has also recently focused on implementing strategies for prevention of food allergy.
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Affiliation(s)
- Roxanne Carbonell Oriel
- Department of Pediatrics, Division of Allergy & Immunology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA
| | - Julie Wang
- Department of Pediatrics, Division of Allergy & Immunology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA.
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Shaker M, Greenhawt M. Providing cost-effective care for food allergy. Ann Allergy Asthma Immunol 2019; 123:240-248.e1. [PMID: 31128233 DOI: 10.1016/j.anai.2019.05.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/30/2019] [Accepted: 05/11/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To review the cost-effectiveness of food allergy management strategies. DATA SOURCES AND STUDY SELECTIONS A narrative review and synthesis of literature identified using a PubMed search of relevant articles describing cost-effectiveness evaluations of food allergy management. RESULTS Screening at-risk infants for peanut allergy carries risk of overdiagnosis and is not cost-effective. Evidence suggests that cost-effective care could be better optimized by minimizing delay in oral food challenges for eligible patients, clarifying the role of precautionary allergen labeling, incorporating patient-preference sensitive care in activation of emergency medical services for resolved allergic reactions, and considering value-based pricing and school-supply models for epinephrine. Finally, the annual value-based cost (willingness to pay [WTP] $100,000/quality-adjusted life years [QALY]) of peanut immunotherapy has been estimated to be between $1568 and $6568 for epicutaneous immunotherapy (EPIT) and between $1235 and $5235 for probiotic with peanut oil immunotherapy (POIT), with each therapy showing more favorable cost-effectiveness with greater improvements in health utility, particularly if sustained unresponsiveness can be achieved. CONCLUSION Many aspects of food allergy management are not cost-effective, and recent evaluations suggest a greater role for incorporating patient and family preferences into guideline-based and traditionally reflexive management decisions. Caregiver understanding of food allergy screening tradeoffs is critical, given that screening children before allergen exposure has significant costs and results in overdiagnosis, especially when oral food challenges are omitted from diagnostic algorithms. Cost-effectiveness analysis can help to identify important decision levers in patient management across a wide range of topics. Further research is needed to better understand health state utilities of specific patient populations.
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Affiliation(s)
- Marcus Shaker
- Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, New Hampshire; Dartmouth Geisel School of Medicine, Hanover, New Hampshire.
| | - Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado School of Medicine, Section of Allergy and Immunology, Food Challenge and Research Unit, Aurora, Colorado
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Pham MN, Wang J. Management of food allergies and asthma in schools. Ann Allergy Asthma Immunol 2019; 121:391-399. [PMID: 30290894 DOI: 10.1016/j.anai.2018.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 01/12/2023]
Affiliation(s)
- Michele N Pham
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, New York
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, New York.
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Abstract
PURPOSE OF REVIEW The aim of this review is to describe effective management strategies in nursery or school based upon research findings. RECENT FINDINGS The prevalence of food allergy and number of emergency department visits for food-related anaphylaxis are increasing in children and adolescents. As there is currently no cure, the most effective strategy to decrease allergic reactions is food allergen avoidance. However, allergic reactions are inevitable in both food allergic children as well as in first-time reactors. Misconceptions exist on the safety of products with advisory labels and questions remain on whether school-wide bans decrease the risk of allergic reactions in school. Recent legislation has prompted schools to consider requiring unassigned epinephrine autoinjectors to better manage those who have allergic reactions in nursery or school. SUMMARY A collective effort is required to keep children with food allergies safe at school. Families, healthcare providers, and school personnel should be informed on food allergen avoidance strategies, symptoms consistent with allergic reactions and anaphylaxis, how to respond to allergic reactions, and the impact the diagnosis of food allergy may have on quality of life for affected children and their families.
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Shaker MS, Greenhawt MJ. Analysis of Value-Based Costs of Undesignated School Stock Epinephrine Policies for Peanut Anaphylaxis. JAMA Pediatr 2019; 173:169-175. [PMID: 30575857 PMCID: PMC6439603 DOI: 10.1001/jamapediatrics.2018.4275] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Children experiencing anaphylaxis at school may lack access to a personal epinephrine device, prompting recent legislation permitting undesignated (eg, non-student specific) stock epinephrine autoinjector units at school. However, epinephrine device costs vary, and the cost-effectiveness of undesignated school stock epinephrine is uncharacterized to date. OBJECTIVE To define value-based strategies for undesignated school stock epinephrine programs. DESIGN, SETTING, AND PARTICIPANTS Markov simulations of the Chicago Public Schools system were used over extended time horizons to model 2 school stock epinephrine autoinjector policies to provide access for at-risk students. The dates of the data used in the analysis were September 2017 to June 2018 (the 2017-2018 school year). MAIN OUTCOMES AND MEASURES This study compared the following 3 strategies: no school undesignated epinephrine supply, school undesignated supplemental epinephrine supply (supplemental model), and school undesignated universal epinephrine supply (universal model). The base-case model assumed a 10-fold reduced fatality risk with having undesignated stock epinephrine units available vs not having undesignated stock epinephrine units available. Costs of school stock epinephrine units available for acquisition by schools were evaluated from a societal perspective. Quality-adjusted life-years (QALYs) and total epinephrine acquisition expenses were calculated. RESULTS Based on Markov simulations of the Chicago Public Schools system (371 382 students), the cost was $107 816 (95% CI, $107 382-$108 250) for no school undesignated epinephrine supply compared with $108 160 (95% CI, $107 725-$108 595) for the supplemental model and $100 397 (95% CI, $99 979-$100 815) for the universal model. Undesignated stock epinephrine improved outcomes, with 26.869 (95% CI, 26.841-26.897) QALYs accrued as the model concluded compared with 26.867 (95% CI, 26.839-26.896) QALYs for the strategy without undesignated stock epinephrine. When comparing supplemental model stock epinephrine to the strategy without undesignated devices, the incremental cost-effectiveness ratio was high at $268 811 per QALY in the base-case simulation. However, the cost of the supplemental model fell below $100 000 per QALY when the annual undesignated epinephrine acquisition costs did not exceed $338 per school (compared with stock epinephrine unavailability). The universal model dominated all others and was associated with significant cost savings ($7419 per student at risk who would otherwise be prescribed an individual school epinephrine supply). CONCLUSIONS AND RELEVANCE Undesignated school stock epinephrine is cost-effective at device acquisition costs not exceeding $338 per school per year, although a universal model vs a supplemental model is associated with superior health and economic outcomes.
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Affiliation(s)
- Marcus S. Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Matthew J. Greenhawt
- Section of Allergy and Immunology, Food Challenge and Research Unit, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora
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Tarr Cooke A, Meize-Grochowski R. Epinephrine Auto-Injectors for Anaphylaxis Treatment in the School Setting: A Discussion Paper. SAGE Open Nurs 2019; 5:2377960819845246. [PMID: 33415240 PMCID: PMC7774401 DOI: 10.1177/2377960819845246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 03/04/2019] [Accepted: 03/23/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction:Anaphylaxis is a serious, life-threatening systemic allergic reaction that may occur in individuals not previously diagnosed with an allergy. Emergency first-line treatment of choice for acute anaphylaxis is intramuscular administration of epinephrine via an auto-injector. In the school setting, students with known allergies typically keep or carry an epinephrine auto-injector (EAI). For students who do not have a known allergy or for those whose personal EAIs are unavailable, an anaphylactic event could have serious adverse outcomes if an EAI is not available via an undesignated stock supply in the school. Methods:We searched the published literature from 2000 through 2018 in CINAHL, MEDLINE, and PubMed using the following search terms: anaphylaxis, school setting, epinephrine auto-injector, and food allergies. Throughout this article, undesignated stock EAIs, stock EAIs, EAI stock, and open-order EAIs are used interchangeably. Conclusion:Anaphylaxis is increasing worldwide as the incidence of food allergies increases. Although stock EAIs for students in schools can have important benefits, the availability of EAIs in the school setting is limited. Barriers to undesignated stock EAIs include the lengthy administrative process for developing school policies and protocols; gaps in nurses' self-perceived knowledge versus objective knowledge on the topic of anaphylaxis; limited resources in many school districts; and complex role demands, lack of confidence in trained staff, or insufficient school nurse staffing. It is important that epinephrine be readily available in schools. Barriers to facilitating stock EAIs include those that can be addressed directly by nurses and those that may require policy changes. Nurses, particularly those working in school settings or pediatrics, could take the lead in discussions about the benefits of stock EAIs in schools, advocating for policy changes as warranted. Fully informed nurses can be better prepared to serve as advocates in ensuring that EAIs are available in school settings.
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Affiliation(s)
- Abigail Tarr Cooke
- Department of Nursing, San Juan College, Farmington, NM, USA
- College of Nursing, University of New Mexico, Albuquerque, NM, USA
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39
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Abstract
Food allergies are on the rise, for reasons that are not fully understood. However, there is a tendency to overestimate their frequency, mostly based on parents' reports or on the assumption that a positive skin or blood IgE test implies the existence of clinically relevant allergy. It is imperative to base food allergy diagnosis on well-defined criteria, avoiding "alternative" tests that are available to the general public. Non-celiac gluten sensitivity is a misnomer and should be abandoned in favor of non-celiac wheat intolerance, an entity suffering from lack of biomarkers and still not convincingly described in children.
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Affiliation(s)
- Catherine DeGeeter
- Division of Gastroenterology, Hepatology, Pancreatology, and Nutrition, Stead Family Department of Pediatrics, University of Iowa Health Care, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Stefano Guandalini
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Chicago, 5721 S. Maryland Avenue, Chicago, IL 60637, USA.
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The Health and Economic Outcomes of Peanut Allergy Management Practices. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:2073-2080. [DOI: 10.1016/j.jaip.2018.04.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 04/16/2018] [Accepted: 04/21/2018] [Indexed: 11/17/2022]
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Mustafa SS, Russell AF, Kagan O, Kao LM, Houdek DV, Smith BM, Wang J, Gupta RS. Parent perspectives on school food allergy policy. BMC Pediatr 2018; 18:164. [PMID: 29753332 PMCID: PMC5948763 DOI: 10.1186/s12887-018-1135-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 04/30/2018] [Indexed: 11/24/2022] Open
Abstract
Background Food allergy affects up to 8% of children in the U.S. There is minimal research to date on food allergy policies that are currently in place in schools and the opinions of parents of children with food allergy on the effectiveness of or need for these policies. Methods An electronic survey was disseminated to parents of children with food allergy. Frequencies were calculated to describe respondent characteristics and responses. Chi-square tests were performed to examine associations between school and child characteristics and outcomes. Results Of the 289 parent respondents, 27.4% were unsure or felt school was unsafe for their child with food allergy. While the majority felt that the polices in their child’s school were helpful, most also believed that implementation of additional polices was necessary, including availability of stock epinephrine (94.2%), lunch menus with allergen information (86%), ingredient labels on food items (81%), and direct food allergy education for students (86%). There were significant differences in school food allergy policy depending on the age of the student body, private versus public school, and geographic location. Conclusions While most schools reportedly have one or more food allergy policies in place, many parents have concerns over the safety of their child at school and feel that additional policies are necessary to improve the safety of the school environment for children with food allergy. The availability of stock epinephrine, improved allergen labeling of food and menus and increased food allergy education may be key policy areas on which to focus.
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Affiliation(s)
- S Shahzad Mustafa
- Rochester Regional Health, Rochester, NY, USA.,University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Anne F Russell
- Food Allergy & Anaphylaxis Michigan Association, Ann Arbor, MI, USA
| | - Olga Kagan
- Molloy College, Rockville Centre, New York, USA
| | - Lauren M Kao
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Diane V Houdek
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bridget M Smith
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. Veterans Affairs Hospital, Hines, IL, USA
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruchi S Gupta
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA. .,Center for Community Health, Northwestern University Feinberg School of Medicine, 750 N Lake Shore Dr., 6th Floor, Chicago, IL, 60611, USA.
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Current trends in food allergy-induced anaphylaxis management at school. Ann Allergy Asthma Immunol 2018; 121:174-178. [PMID: 29684568 DOI: 10.1016/j.anai.2018.04.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/11/2018] [Accepted: 04/16/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To review the evidence and current policies regarding the use of epinephrine at schools and child care centers DATA SOURCES AND STUDY SELECTIONS: A narrative review was performed based on the result of conference proceedings of a group of interprofessional stakeholders who attended the USAnaphylaxis Summit 2017 presented by Allergy & Asthma Network. RESULTS Anaphylaxis is a well-recognized medical emergency that requires prompt treatment with intramuscular epinephrine. Anaphylaxis can be associated with poor quality of life. There is renewed recent focus on anaphylaxis management in schools. This interest has been spurred by an increase in the number of children with food allergy who are attending school, data that support up to 25% of first-time anaphylactic events occurring on school grounds, and a well-publicized fatality that helped to initiate a movement for stock, undesignated, non-student-specific epinephrine. Stock epinephrine is now available in 49 states, with an increasing number of states instituting mandatory reporting for use of such devices. Nursing efforts are paramount to support and implement stock epinephrine programs. Many states do not have clarity on delegation of authority for who can administer stock epinephrine, and there is evidence of variability in storage of stock devices. Few states have outcomes data that support successful implementation of stock epinephrine programs. CONCLUSION Additional data are needed to demonstrate successful implementations of stock epinephrine programs and their outcomes. Such programs should include support for school nursing and clearer delineation of authority for medication administration as well as standards for where and how devices are stored.
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Greenhawt M. Environmental exposure to peanut and the risk of an allergic reaction. Ann Allergy Asthma Immunol 2018; 120:476-481.e3. [PMID: 29555352 DOI: 10.1016/j.anai.2018.03.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/07/2018] [Accepted: 03/12/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To review the evidence of the risk of environmental exposure to peanut to a peanut allergic individual. DATA SOURCES AND STUDY SELECTION A narrative review was performed using a PubMed search of relevant articles involving peanut environmental distribution, environmental peanut abatement, and public policy regarding peanut restriction. RESULTS Data from 4 studies have shown that peanut butter vapors and smeared peanut butter on skin do not cause systemic reactions, that peanut can be abated from hands and surfaces using appropriate cleaning agents, and that shelled peanut dust does not become airborne. Studies have recently confirmed dose of 1.5 mg of peanut protein would be generally tolerated by approximately 95% of the peanut-allergic population based on objective symptoms in challenge-based studies, affirming earlier research. Restrictive policies that focus on bans (or restricted presence in certain areas) of peanuts or peanut-containing products in environments such as schools or on commercial aircraft are not backed by evidence that such measures work, which may raise an uncomfortable clash between accommodations that lack any medical evidence of necessity and a desire to provide measures that comfort our patients. CONCLUSION There is little risk posed from non-oral exposure to peanut in the environment, from casual contact, proximity, or inhalation. If 5% of the population may tolerate a threshold of approximately 1.5 mg of peanut protein, this may help liberate behavior and situational-decision making regarding the necessity of certain avoidances and restrictions. Continued work is needed to dispel myths about the mechanisms of how peanut may induce an allergic reaction.
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Affiliation(s)
- Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado School of Medicine, Section of Allergy and Immunology, Aurora, Colorado.
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Abstract
Advances in food allergy diagnosis, management, prevention, and therapeutic interventions have been significant over the past 2 decades. Evidence-based national and international guidelines have streamlined food allergy diagnosis and management, whereas paradigm-shifting work in primary prevention of peanut allergy has resulted in significant modifications in the approach to early food introduction in infants and toddlers. Innovative investigation of food allergy epidemiology, systems biology, effect, and management has provided important insights. Although active therapeutic approaches to food allergy remain experimental, progress toward licensed therapies has been substantial. Mechanistic understanding of the immunologic processes underlying food allergy and immunotherapy will inform the future design of therapeutic approaches targeting the food-induced allergic response. Global strategies to mitigate the substantial medical, economic, and psychosocial burden of food allergy in affected subjects and families will require engagement of stakeholders across multiple sectors in research, health care, public health, government, educational institutions, and industry. However, the relationship between the well-informed allergy care provider and the patient and family remains fundamental for optimizing the care of the patient with food allergy.
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Affiliation(s)
- Amy M Scurlock
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Stacie M Jones
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark.
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Wang J, Bingemann T, Russell AF, Young MC, Sicherer SH. The Allergist's Role in Anaphylaxis and Food Allergy Management in the School and Childcare Setting. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:427-435. [PMID: 29258790 DOI: 10.1016/j.jaip.2017.11.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/13/2017] [Accepted: 11/16/2017] [Indexed: 12/28/2022]
Abstract
Anaphylaxis and food allergy management in childcare facilities and schools are growing challenges. An increasing number of children experience severe allergic reactions on school grounds as evidenced by reports of epinephrine use. Data also suggest that the prevalence of food allergy may be increasing, with a large percentage of school-aged children at risk for anaphylaxis. Moreover, anaphylaxis may occur for the first time in a previously undiagnosed child at school or childcare setting, suggesting that general preparedness is essential. Management includes strategies for minimizing the risk of reactions and allergen exposures as well as readiness to recognize and treat allergic reactions of any severity. The primary objective of this report is to offer health care providers an overview of relevant evidence, resources, and expert opinion to assist with developing interprofessional collaborative counsel on school food allergy management and anaphylaxis preparedness with families, schools, and childcare settings. We present the current evidence base, suggest resources, and highlight areas of current controversy that warrant further study.
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Affiliation(s)
- Julie Wang
- Department of Pediatrics, Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Theresa Bingemann
- Allergy and Clinical Immunology, Rochester Regional Health and the University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Anne F Russell
- Food Allergy and Anaphylaxis Michigan Association, Ann Arbor, Mich
| | - Michael C Young
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass
| | - Scott H Sicherer
- Department of Pediatrics, Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
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Alvarez-Perea A, Tanno LK, Baeza ML. How to manage anaphylaxis in primary care. Clin Transl Allergy 2017; 7:45. [PMID: 29238519 PMCID: PMC5724339 DOI: 10.1186/s13601-017-0182-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/16/2017] [Indexed: 12/13/2022] Open
Abstract
Anaphylaxis is defined as a severe life-threatening generalized or systemic hypersensitivity reaction characterized by rapidly developing airway and/or circulation problems. It presents with very different combinations of symptoms and apparently mild signs and can progress to fatal anaphylactic shock unpredictably. The difficulty in recognizing anaphylaxis is due, in part, to the variability of diagnostic criteria, which in turn leads to a delay in administration of appropriate treatment, thus increasing the risk of death. The use of validated clinical criteria can facilitate the diagnosis of anaphylaxis. Intramuscular epinephrine (adrenaline) is the medication of choice for the emergency treatment of anaphylaxis. Administration of corticosteroids and H1-antihistamines should not delay the administration of epinephrine, and the management of a patient with anaphylaxis should not end with the acute episode. Long-term management of anaphylaxis should include avoidance of triggers, following confirmation by an allergology study. Etiologic factors suspected in the emergency department often differ from the real causes of anaphylaxis. Evaluation of patients with a history of anaphylaxis should also include an assessment of personal data, such as age and comorbidities, which may increase the risk of severe reactions. Special attention should also be paid to co-factors, as these may easily confound the cause of the anaphylaxis. Patients experiencing anaphylaxis should administer epinephrine as soon as possible. Education (including the use of Internet and social media), written personalized emergency action plans, and self-injectable epinephrine have proven useful for the treatment of further anaphylaxis episodes.
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Affiliation(s)
- Alberto Alvarez-Perea
- Allergy Service, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo, 46, 28007 Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Luciana Kase Tanno
- Hospital Sírio Libanês, São Paulo, Brazil
- Division of Allergy, Department of Pulmonology, University Hospital of Montpellier, Montpellier, France
- Pierre and Marie Curie Institute of Epidemiology and Public Health, Sorbonne Universités, Paris, France
| | - María L. Baeza
- Allergy Service, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo, 46, 28007 Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Biomedical Research Network on Rare Diseases (CIBERER)-U761, Madrid, Spain
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48
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Wang J. A Synopsis of the Synopses, 2016 to 2017. Pediatrics 2017; 140:S171-S172. [PMID: 29196568 DOI: 10.1542/peds.2017-2475d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Julie Wang
- Editor, Best Articles Relevant to Pediatric Allergy, Asthma, and Immunology
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Loaec M, Olympia RP. School Nurses on the Front Lines of Medicine: Take a BREATH: The Approach to a Student With Respiratory Distress. NASN Sch Nurse 2017; 33:29-35. [PMID: 29182886 DOI: 10.1177/1942602x17740142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Students presenting with varying degrees of respiratory symptoms and distress occur commonly in the school setting. It is important to develop a differential diagnosis for respiratory distress, to initiate stabilization of the student with life-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow up at their primary health care provider's office, or directly to the closest emergency department via Emergency Medical Services). This article describes the initial assessment and management of a student presenting with respiratory distress.
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Affiliation(s)
- Morgann Loaec
- Medical student, Penn State Hershey Children's Hospital, Hershey, PA
| | - Robert P Olympia
- Attending pediatric emergency medicine physician, Penn State Hershey Medical Center, Hershey, PA
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Sicherer SH, Sampson HA. Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management. J Allergy Clin Immunol 2017; 141:41-58. [PMID: 29157945 DOI: 10.1016/j.jaci.2017.11.003] [Citation(s) in RCA: 890] [Impact Index Per Article: 127.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 10/31/2017] [Accepted: 11/03/2017] [Indexed: 12/13/2022]
Abstract
This review provides general information to serve as a primer for those embarking on understanding food allergy and also details advances and updates in epidemiology, pathogenesis, diagnosis, and treatment that have occurred over the 4 years since our last comprehensive review. Although firm prevalence data are lacking, there is a strong impression that food allergy has increased, and rates as high as approximately 10% have been documented. Genetic, epigenetic, and environmental risk factors are being elucidated increasingly, creating potential for improved prevention and treatment strategies targeted to those at risk. Insights on pathophysiology reveal a complex interplay of the epithelial barrier, mucosal and systemic immune response, route of exposure, and microbiome among other influences resulting in allergy or tolerance. The diagnosis of food allergy is largely reliant on medical history, tests for sensitization, and oral food challenges, but emerging use of component-resolved diagnostics is improving diagnostic accuracy. Additional novel diagnostics, such as basophil activation tests, determination of epitope binding, DNA methylation signatures, and bioinformatics approaches, will further change the landscape. A number of prevention strategies are under investigation, but early introduction of peanut has been advised as a public health measure based on existing data. Management remains largely based on allergen avoidance, but a panoply of promising treatment strategies are in phase 2 and 3 studies, providing immense hope that better treatment will be imminently and widely available, whereas numerous additional promising treatments are in the preclinical and clinical pipeline.
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Affiliation(s)
- Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Hugh A Sampson
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
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