Anaphylaxis in Child Patient - Case Study Example

Clinical Assessment of Anaphylaxis in Child Patient Introduction This clinical assessment is a source of vital information for the development of effective modules for nurse practitioners in lieu of managing child patients suffering from anaphylaxis. Initially, the history and etiology of the disease including its common signs and symptoms and prescribed treatment and medications are presented. Then the case of the patient will follow suit; after which a comprehensive analysis of the case shall be provided. Lastly, upon reflection on the overall findings and clinical assessment, a conclusions and recommendations of a module for effective management of the patient shall be put forth. History and Etiology of Anaphylaxis Anaphylaxis is a term referring to hypersensitive reaction to specific allergen which is mediated by immunoglobulin E (IgE) (Kinsey et al., 2003). This is also called as True Food Allergy (Cohen, n.d.) indicating serious or life-threatening allergy. The term Anaphylaxis was coined when scientists tried to protect dogs against a poison by immunising them with small doses. However, the research did not succeed as the dogs died after getting the poison again. Since the term ‘prophylaxis’ means protection through immunization. The word ‘Anaphylaxis’ was coined referring to the opposite of protection (Stern, 1998-2003). This is different from ‘anaphylactoid reaction’ as it is not immune-mediated. In the assessment of visible signs and symptoms, they seemed to have no difference. There is immediate manifestation of redness in the skin or urticaria (i.e. hives) and swelling of throat which results to difficulty in breathing. Symptoms are manifested based on the severity of the condition. Restlessness is evident for patient suffering severe pruritus from urticaria. Albeit usual presence of tachycardia, in serious and severe reactions, brachycardia may occur. Hypotension is also common in this condition and without immediate treatment such may also result to fatality of the patient (Krause, 2008). Causal Factors of Anaphylaxis Common culprits for anaphylaxis are usually foods rich in protein especially peanuts, eggs, cow’s milk, and also some fish crustaceans, mollusks, wheat and soy. Food antigens may also be ‘hidden’ in cookies, cakes, cereals, candies or other foods (Simons, 2004). Another factor which triggers this allergic condition are certain drugs especially antibiotics (i.e. penicillin), beta-blockers (used to treat high blood pressure and other heart conditions), RCM (Radiocontrast Media), intravenous anesthetics drugs, aspirin and other noncorticosteroidal anti-flammatory agents, and opioid analgesics (Neugut et al., 2001). Latex is also a culprit for the development of anaphylactic reaction. Initial allergic reactions to latex may manifest as dermatitis and then progress to more severe allergic conditions. Health care workers and patients are the most common victims of anaphylaxic reaction in this case due to their frequent exposure to latex-made hospital instruments and other medical products (Stern, 1998-2003). Children at high risk of fatal allergic reaction usually have history of respiratory or gastrointestinal symptoms as well as urticaria or angioedema immediately after introduction to food allergen. Therefore, this condition must not be taken easily by parents or primary caregivers since the condition may result to serious or life-threatening situation. Prevalence of Anaphylaxis in Children Based on two surveys conducted by CDC’s National Center for Health Statistics, reported food allergy has significantly surged among children of all ages in the United States over the past decade. Children with food allergy are two or four times as likely to experience other allergic conditions such as asthma compared to children without food allergy. It was also stressed that children with accompanying food allergy and asthma are more susceptible to anaphylactic reactions to foods and be at higher risk of fatality. Key findings of the surveys include that in 2007, an approximately 3 million children under age of 18 years old (3.9%) were reported to have a food allergy or digestive allergy in the previous 12 months. This also entails an 18% increase in prevalence rate among children under age 18 years from 1997 to 2007. And there were approximately 9, 500 hospital discharges per year from 2004 to 2006 that relates to diagnosis of food allergy among this age group (Branum and Lukacs, 2009). Pharmacological Treatment for Anaphylaxis Most common treatment for anaphylaxis is the use of adrenaline (epinephrine). This is usually in injection kit and is dangerous if used incorrectly (‘Take action, prevent reaction’, 2009). Therefore proper training is highly important to avoid any risks. Through comprehensive training and education about the proper usage and method of epinephrine injection particularly in emergency cases, many lives will be saved. This has been particularly noted in a study that evaluated the Epinephrine use of Emergency Medical Technicians for patients with presumed anaphylaxis. Study showed that EMT is able to provide effective discriminatory manner in overall assessment of the cases (Rea et al., 2004). Epinephrine treatment suppresses release of mediators of inflammation from mast cells and basophils, and it directly decreases vasodilation, edema and bronchoconstriction. It has been suggested that epinephrine be administered immediately at the onset of initial symptoms like itching or swelling of the lips or mouth, tightening of the throat or nausea. This is to avoid further severe reactions that may occur such as respiratory distress, stridor and wheezing (Sampson et al., 1992). Proper dosage is important to prevent further complications or risks, the following are the prescribed dosage for children of epinephrine: (Ana kit/ EpiPen) Ana-Kit: 0.05-0.12 mL SC* for children weighing < 12  kg, 0.12-0.25 mL SC for those 12-25 kg and 0.25-0.3 mL SC for those > 25 kg EpiPen: 0.15 mg IM* (EpiPen Jr) for children weighing 12-25 kg and 0.3 mg IM (regular dose) for children > 25 kg Antihistamines may help in mild anaphylaxis but is certainly not adequate as a replacement for epinephrine especially in severe cases (Simons FER and Simons KJ, n.d). Other researchers suggest other forms of alternative treatment like desensitization for food allergies. Such treatment has been a standard therapy for environmental and insect allergies though applying it to food allergies of human beings is still under critical debate. This method ascertained to minimize the amount of exposure that it takes to trigger the reaction rather than to completely eliminate the food allergy. However, this is still risky thus the presence of a medical practitioner is highly advised (Montgomery, 2009). Prevention of food allergen is also necessary to avoid the risk of allergy attack. However, this is perceived easier said than done by most patients. Therefore, increase rate in anaphylaxis occur in communities in absence of health care practitioner. To provide first-aid treatment of aphylaxis, epinephrine injected intramuscularly in the castus lateralis (lateral aspect of the thigh) must be applied (Simons, n.d). Improper or inaccurate application might be detrimental to the patient’s condition. Thus, proper training and education is stressed. Indeed, Epinephrine is the most effective of all treatment mentioned above for Anaphylaxis conditions. Currently, children with such condition are more often than not equipped with an injectable epinephrine and even schools are encouraged to have this medication always available in their clinics (Pediatr Pharm, 2008). Patient’s History Tanya, not her real name, aged 7 years old, slightly obese yet an active and happy kid. Though she has asthma which was diagnosed since she was 2 years old; such ailment does not stop her from doing what she loves to do, eating and sketching. She had history of frequent hospitalisations due to upset stomach, redness of skin and difficulty in breathing. Initial findings of her condition were anaphylaxis as a reaction to walnuts. Her mother loves to eat nuts of different types. Though the child has strictly limited to eating the food culprit, still, she suffers from allergic reaction in different occasions. Anaphylaxis also aggravates Tanya’s asthma. In October 2000, her emergency admission to the hospital has resulted to high decrease of blood pressure and severe manifestations of urticaria thus doctors were prompted to inject epinephrine as initial treatment for the severe reaction incurred by Tanya. Other standard intervention followed such as high-flow oxygen, cardiac monitoring, and IV access. Apart from epinephrine, she was also provided with other medications to alleviate the severe symptoms of anaphylaxis. This include Ventolin (0.03-0.05 mL/kg 0.5% soln in 2.5 cc of NS via nebulizer q15min) , and antihistamine (H1 receptor-blocker) particularly diphenhydramine in 1-2 mg/kg IV/IM q4-6h. After Tanya’s recuperation, she continued to take antihistamine for 2-3 days. Moreover, her mother began to equip Tanya with the prescribed epinephrine injectable (EpiPen) which she brings even at school. Her mother has also provided the school’s physician a record of her child’s history of anaphylaxis. Analysis of the Case The child’s condition is one of the complicated ones suggested in the professional literature. Having anaphylaxis also entails susceptibility to other allergic reactions or conditions such as asthma. Thus it has been more aggravating due to complicating symptoms that may occur during allergic attacks. Her allergic reaction to inciting agent particularly walnuts indicate true food allergy or anaphylaxis. Since this type of food is specifically identified as culprit for the increase in IgE which results to anaphylaxis. Though the patient has been strictly prohibited to eat walnut any food that might contain it even in a small amount, she may still manifest allergic reaction because her mother loves to eat nuts. Based from the literature, anaphylaxis reactions can occur even in a trace amount of the food allergen directly or indirectly ingested by the patient. Moreover, the emergency incident due to severe allergic reaction may be caused of the recurrent introduction to food allergen as well as poor management of her health condition. She was only provided with an injectable epinephrine by her mother after the serious incident. Meaning, prior to that, she has no source of immediate treatment when she experiences sudden allergic attacks. On the other hand, the treatment provided by the hospital staffs is indeed appropriate. Good assessment of the patient’s overall physical and behavioural conditions leads them to promptly apply the right treatment for anaphylaxis. After Tanya’s recovery, her mother’s decision to equip her child with EpiPen is absolutely a good one as it will prevent her child from further detrimental reactions due to anaphylaxis. Still, the environment of the house where Tanya lives should also play an important or significant source of change for prevention of further exacerbation of the condition of the child. Thus, since main food allergen is walnut, the mother must also take into consideration the importance of her own self-control in eating her favorite food such as nuts. Moreover, the school ought to be a support role also in fostering well-being of the child. Thus, they should be completely equipped with proper medications for such kind of allergic attacks in children. And their staffs must be strongly trained in attending to emergency situations as a reaction of anaphylaxis. Medical history of every child is also important as it provides adequate details and information as to the child’s weaknesses and limitations such as food allergies, asthma and many more. Conclusion Effective care management plan is vital for children with anaphylaxis. The right treatment for mild to severe attacks must be effectively attended to by her parents and/or primary caregiver (i.e. school clinic). Prevention is also a key factor in this situation. Therefore, the patient must strictly manifests self-control to prevent risks. The entire community of the child extending from family to school must be supportive of the overall well-being of the child with anaphylaxis in order to further alleviate or avoid any serious and life-threatening situations concerning the disease. Recommended Management of anaphylactic reactions to food in children I. Diagnosis a. Obtain the medical history of the child to identify risk-patients b. Identify risk foods associated with the history of the child c. Conduct appropriate testing to confirm diagnosis II. Prevention a. Provide proper education and training to parents and patients about the effect of inciting agents found to trigger the anaphylactic reaction of the child. b. Provide medical histories to school where the child attends to. This will provide great details and information about the child’s sensitivities. c. Parents must be advised about the importance of carrying injectable epinephrines (Ana-Kit or EpiPen) at all times. This is very helpful in situations that need prompt treatment for the child’s allergic reaction. d. Provide proper training for parents and patients about the proper usage and dosage of epinephrine to avoid further risks. III. Treatment a. In severe cases, comprehensive analysis of the patient’s condition must be determined to avoid wrong diagnosis. b. If the diagnosis is indeed correct, prompt treatment using appropriate medication such as epinephrine should be provided to avoid exacerbation of the condition. c. Laboratory examinations must also be conducted to further determine the condition of every organs and systems particularly respiratory, cardiac, platelets, oropharynx, skin test, and others. d. Correct dosage and frequency of every medication must be given to the patient to help in the fast recovery e. Follow-up after the treatment is also important as this will strengthen the fast recuperation of the patient. References Krause, RS, 2008 Oct 06, Anaphylaxis, Emedicine, Medscape. [Online] Accessed on 06 Apri 2009. Available at: Rea, TD, Edwards, C, Murray, JA, Cloyd, DJ, Eisenberg, MS 2004, ‘epinephrine use by emergency medical technicians for presumed anaphylaxis’, Prehospital Emergency Care, vol. 8, no. 4, pp. 405-410. [Online] Accessed on 06 Apri 2009. Available at: Career and Technical Education database, item: 731125051. Simons, F, n.d. ‘First-aid treatment of anaphylaxis to food: Focus on epinephrine’, Journal of Allergy and Clinical Immunology, vol. 113, no. 5, pp 837-844. Pediatr Pharm,  2008, Childrens Medical Center, University of Virginia , vol. 14, no. 5. [Online] Accessed on 06 Apri 2009. Available at: Simons FER, Simons KJ, n.d. ‘The pharmacology and clinical use of H1-antagonists’, New England Journal of Medicine. ‘Sampson HA, Mendelson L, Rosen JP, 1992, ‘Fatal and near-fatal anaphylactic reactions to food in children and adolescents’. New England Journal of Medicine, vol. 327, pp. 380-384. Branum, AM, and Lukacs, SL, 2009 March, ‘Food Allergy among UC Children: Trends in Prevalence and Hospitalizations’, Centers for Disease Control and Prevention’s National Center for Health Statistics. [Online] Accessed on 06 Apri 2009. Available at: Stern, M 1998-2003, ‘Anaphylaxis – Life-threatening allergy’, AAIR. [Online] Accessed on 06 Apri 2009. Available at: Cohen, M. n.d. ‘Food Allergies’. Food Reaction. Community: Special Needs. [Online] Accessed on 06 Apri 2009. Available at: Kinsey, T, Pugh, J 2003, ‘Anaphylaxis Treatment Guidelines (Children)’, Redditch and Bromsgrove. [Online] Accessed on 06 Apri 2009. Available at:< www.RandB-pct.nhs.uk> Neugut, AI, Ghatak, AT, Miller, RL 2001 Jan 08, ‘ Anaphylaxis in the United States. An investigation into its epidemiology’, Arch Intern Med., vol. 161, no. 161, pp. 15-21. [Online] Accessed on 06 Apri 2009. Available at: Simons, FER 1994, ‘Fatal Anaphylactic Reactions to food in children’, CMAJ, vol. 150, no. 3, pp. 337-339, Canadian Paediatric Society. [Online] Accessed on 06 Apri 2009. Available at: Montgomery, S 2009 February 24, ‘Research may help deadly allergies; English researchers publish study examining effectiveness of desensitization for food allergies’, The Times - Transcript,D.2. [Online] Accessed on 06 Apri 2009. Available at:Canadian Newsstand Complete database, item:  1650247281 Read More