Pediatrics [ALLERGIES]

Intro
When discussing allergies, we’re generally referring to IgE- Type 1 IgE-mediated Anaphylaxis
mediated type 1 hypersensitivity. This will be basis of the Type 2 Cytotoxic, Antibody-mediated Hemolytic anemia
majority of the conditions covered. For review, the full gamut of Type 3 Antibody:antigen complex Serum sickness
Type 4 Delayed T-cell mediated reaction Poison ivy
hypersensitivity reactions is briefly stated to the right.

Acute Allergic Presentations

Anaphylaxis
The dreaded complication of IgE-mediated allergic reactions, this
Clinical diagnoses have significant overlap
can be life-threatening. It can involve multiple organ systems
- Need exposure (can be known for suspicion for)
including: cardiovascular (hypotension), gastrointestinal
- Need two+ organ systems involved:
(diarrhea), skin (hives), and pulmonary (airway edema).
Skin/mucosa
Anaphylaxis requires involvement of at least two organ systems;
Respiratory
it doesn’t need to involve the airway. A confirmed exposure to an
Hypotension or end-organ dysfunction (syncope)
allergen isn’t always needed. Treat with epinephrine (1:1,000
GI symptoms
IM), support the airway with intubation, and blood pressure with
IV fluids and pressors if needed. Adjunctive therapy includes
H1/H2 blockers and albuterol - they have more supporting
evidence than steroids. Provide an epinephrine pen at discharge
and advise staying away from allergic triggers.

Urticaria
This is the skin manifestation of allergic reactions. It’s usually
Check for presence of anaphylaxis!
IgE-mediated (type 1 hypersensitivity) but can also come from
agents that cause non-immunologic mast cell degranulation
Treatment:
(contrast, opiates, Red man syndrome from vancomycin). The
- Removal of offending agent (if possible)
skin will have erythema and wheals which are often pruritic and
- 2nd generation H1 antihistamines
limited to superficial layers of dermis. Always check for
- Additional therapies have limited role
signs/symptoms of anaphylaxis (dyspnea, wheezing, GI
symptoms, etc.). To treat, use 2nd generation H1 antihistamines
(cetirizine, loratadine, fexofenadine) and remove/avoid the
offending agent (if possible). 1st generation H1 antihistamines
can be used but have the side effect of sedation. Additional
therapies such as H2 blockers, leukotriene antagonists, and
steroids have a limited role; they’re typically reserved for more
chronic causes of urticaria.

Angioedema
Similar to urticaria but the swelling often involves deeper layers
Compared to urticaria, angioedema has deeper involvement of
of the dermis and mucous membranes (which include lips,
tissue and potential for mucous membrane involvement.
airway, and GI tract). Learn these as independent of histamine
(this is debatable). It can be seen with urticaria, as part of
Check for evidence of anaphylaxis or airway involvement!
anaphylaxis, or completely independent (think of ACE-inhibitor
reactions). As with urticaria, screen for anaphylaxis but typically
Treatment:
treatment is aggressive given concern for airway edema. Secure
- Removal of offending agent (if possible)
the airway, with intubation if needed. Time will get them
- Intubate
through this. If there’s concern for hereditary angioedema, C1
- H1/H2 and Steroids probably don’t work
inhibitors can be administered, but the safe bet (from an
- FFP if hereditary angioedema!
availability perspective) is FFP.

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 Pediatrics [ALLERGIES]

Chronic Allergic Conditions
Many of these conditions are often together in some combination.
As such, note that there’s a significant overlap in therapy.

Asthma
This is covered extensively elsewhere so we won’t address it here.
Just know that there can be a significant allergic component
involved.

Allergic Rhinitis
An IgE-related inflammation of the nasal mucosa. Time to Precipitating factors can be seasonal or perennial
develop a sensitivity and late environmental exposure are two
factors needed to produce disease. Presenting symptoms include Key exam findings:
rhinorrhea, sneezing, and nasal itching. Precipitating factors can - Allergic shiners
be seasonal (grasses, weeds, outdoor mold) or perennial (pets, - Allergic salute
dust mites, indoor molds). - Pale/boggy nasal mucosa
- Cobblestoning of posterior oropharynx
There are several physical exam findings you may be tested on
(which are useful in real life as well). Starting with the face, Diagnostic testing
venous congestion underneath the eyes (known as “allergic - Skin testing is usually first line
shiners”) or a transverse nasal crease (“allergic salute”) from - Serum testing (RAST) may overcall allergens
excessive upward wiping of the nose are often seen. The mucosa
of the nose can be pale and boggy and polyps may be present in
older children. The posterior oropharynx may have
cobblestoning as a consequence of post-nasal drip.

Diagnostic testing usually isn’t needed as 1) environmental Treatment preferences:

history can uncover causes and 2) identification of specific
antigens may not change management unless immunotherapy is
considered. Treatment includes allergen avoidance (dust mite
bed covers, animal removal), intranasal medications (steroid,
antihistamines), oral medications (antihistamines, leukotriene
antagonists), and immunotherapy (in severe or refractory cases).
- Allergen avoidance is key
- Intranasal corticosteroids are the MOST effective
- Intranasal antihistamines are also considered 1st line
- Oral antihistamines (2nd > 1st generation) frequently used
+/- leukotriene antagonist
- Immunotherapy has unclear magnitude of effect

Allergic Conjunctivitis
Often seen concurrently with allergic rhinitis, the mechanism and Treatment:
triggers are exactly the same as noted above. Symptoms include - Avoid triggers
ocular pruritus, redness, and discharge. Look for eye discharge, - Combination eye drops (mast cell stabilizers + antihistamines)
conjunctival redness (injection) and swelling (chemosis), and - Oral antihistamines (especially if allergic rhinitis component)
“allergic shiners.” Treatment involves avoid of allergens
(shocker!), artificial tears (provides barrier), medicated eye
drops (combinations of mast cell stabilizers and antihistamines),
as well as oral medications (2nd generation H1 antihistamines).
Immunotherapy can also be given consideration as well.

Atopic Dermatitis
Typically seen in younger children, it appears as scaly skin on the
extensor surfaces (infants/young children) or flexor surfaces Beware of high potency steroids in areas of thin skin (such as the
(older children and adults). The skin can be pruritic and become face) as this can cause further thinning.
secondarily infected if severely excoriated. Causes can be
related to environmental exposure or food ingestion. Use
emollients and moisturizers as baseline therapy. Topical steroids
can be used as first line for exacerbations.

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 Pediatrics [ALLERGIES]

Food Allergies
See association with atopic dermatitis. Reactions can be varied. Common food allergies:
They can be as mild as oral or cutaneous pruritus, as bothersome - Wheat
as vomiting and diarrhea, or as severe as anaphylaxis (see prior - Soy
heading). Typical triggering foods include wheat, eggs, soy, milk, - Milk
tree nuts, peanuts, shellfish, and finfish. About 85% will outgrow - Eggs
allergies to wheat, eggs, soy and milk while the nut and fish - Nuts (tree nuts and peanuts)
allergies are fairly persistent. The best way to treat is to avoid - Fish (shellfish and finfish)
the offending food. An epinephrine pen can be provided if the
symptoms result in anaphylaxis. Of note, this can occur in breast Avoidance is the mainstay of treatment!
feeding infants; in that scenario the offending formula (or food in
mother’s diet if breastfeeding) should be avoided.

Milk-Protein Allergy
A subset of the above, it’s seen in children around 6 months of
age. Symptoms such as feeding intolerance, vomiting, failure to
thrive, and bloody stool will be the tip-off. There’s cross-
reactivity with soy. Treat by avoiding cow’s milk protein until 2-
3 years of age. Use hydrolyzed formula in the interim.

Insect Sting Allergy

Local reactions (erythema, edema) are most common. Remove
the stinger without grasping the venom sac. Optionally treat with
local cold compresses. Treat anaphylaxis (see prior heading) if
present and provide epinephrine pen if needed.

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