Anaphylaxis/Do you need to carry injectable epinephrine?
Anaphylaxis is a very severe allergic reaction that can occur within moments of exposure to an allergen. People can die from this if it isn't treated. It can be triggered by an allergy to a particular food (peanuts or shellfish are among the most common), biting or stinging insects (like bees), medication (like antibiotics), latex (the type of rubber many balloons are made from) or a variety of other allergic triggers. Allergic reactions occur when the body mistakenly identifies something as harmful and overreacts. With anaphylaxis, this reaction can be life threatening. Symptoms usually start within seconds or minutes of the exposure, but there are exceptions. Once in awhile, a reaction can be delayed by several hours. This of course makes it much harder to figure out the culprit.
In an anaphylactic reaction there may be different parts of the body involved.
The first time that someone has a severe allergic reaction is very frightening. Unfortunately subsequent reactions can be even more severe. It is essential to recognize symptoms that need immediate attention.
Several years ago, a patient in our practice had been given yogurt for the first time.The child’s face began to swell and she started to have labored breathing. Mom’s first instinct was to call me; I redirected her to call 911 immediately. If it feels like an emergency situation, 911 beats the advice nurse. Of course, we want to be kept in the loop and help with any follow up. This child turned out to be severely allergic to milk. Interestingly she had no trouble with breast-milk. It is very important that folks figure out what the trigger is so that the you can try to avoid future reactions, although there are cases that remain a mystery.
Knowing that your child is at risk for anaphylaxis is very unnerving to say the least. It is very important to educate your child (age appropriate) and all teachers and caregivers about how critical it is to keep your child from being exposed to the allergen.
One case comes to mind of a school aged patient who was at Costco with some friends. The child was allergic to nuts. The friends parents allowed him to taste something from one of the samples. They had done a cursory check of the ingredients and thought it was safe. It turned out the the knife used to cut the samples had also been used to cut something with nuts, and the child ended up in the ER. Some kids are so sensitive that cross contamination (in this case, the knife) can cause a full reaction.
Here is another story of one of our patients with an anaphylactic reaction:
This little 9 month old was already teething and fussy, which complicated things. She also is prone to eczema, so rashes are not unusual. The family had had a recent checkup and had come home motivated to increase solids and calories to fatten up their slender child. Dinner that evening was some Chinese take out. Our little patient was offered bits of foods from the various containers. They didn’t offer any foods that struck the parents as obviously new, but one of the containers was a shrimp dish. Although the baby didn’t actually eat any shrimp, she started to get very fussy and swiping at her face and ears.
After several moments of excessive fussing from no overt cause, mom and dad opted to give her a bath and start the bedtime process. When they removed her clothing they saw that she was covered with hives. At that point they wisely opted to go into the ER. It had been about 20 minutes since the food. The baby was fairly inconsolable and her face and ears were swelling. Luckily she did not appear to be having labored breathing (that would be a reason for a 911 call.) Once in the ER she vomited. She was given epinephrine and kept overnight for observation. She was singing and happy the next morning with no seeming ill effects. The current plan is to avoid any mystery foods and follow up with an allergist within a few weeks. The family will have an epipen on hand just in case.
As a caution, I recommend to try all first time foods when there is time to observe for a little while to make sure there is no reaction. Giving something brand new and then putting a baby straight to bed is not a good plan. This is especially important with high risk foods like nuts, milk, eggs, shellfish, and any medication. It is also a good idea for every household to own Zyrtec liquid (scroll down for dosage chart.)
If your child is old enough,talk to them about the fact that just about everyone has a little something special going on, and it their case they need to be careful about whatever their trigger is. Check out this book, available on Amazon. Perhaps pick one up for the class and make sure the teacher reads it out loud. No Nuts for Me
Make certain that any babysitters or friends caring for your child know what allergens are potential hazards so that they can be certain to avoid them They should also have an injector handy just in case.
If you go to a restaurant, ask to speak to the chef so that you know the restaurant understands the importance of avoiding the ingredient in question. In serious cases, you might want to call ahead to make sure they are willing and able to accommodate you.
If your child has any mystery reaction to something, it is worth having a visit with the doctor so that we can help pinpoint the cause. In some cases we will refer you to see an allergist. Mild allergic reactions can be treated with a dose of Zyrtec or Benadryl. Keep in mind that Benadryl might make some kids sleepy and it could muddle your assessment. For an anaphylactic reaction epinephrine is the only first line treatment. It relaxes the muscles in the lungs to improve breathing. To quote Dr. Fast, a local allergist, “Epinephrine is what saves lives. It is never wrong to give epinephrine."
One of my mom readers shared her story with me after this post first went out. She recently spent five days in the hospital due to an allergic reaction. She had 4 of the 7 symptoms (including full body hives), but was NOT given epinephrine early because she wasn't having respiratory distress. It took several days to get the allergic reaction under control.
Not only does epinephrine help with the respiratory distress, but it lessens the release of the chemicals that are causing the reaction in the first place. The world health organization would agree with Dr Fast that using epi early is a "no Brainer"
Auto injector options
Epipen comes in 2 strengths. The junior (0.15mg) is for anyone under 66 pounds. Anyone over 66 pounds gets the full adult strength (0.30 mg) .Epipens have been in the news due to high cost and recent shortages. If you have an epipen, check out the lot numbers, some of them have extended their expiration date
May 2019 update
The avilailability of the epi pen junior has been very spotty. Auvi Q is available directly from the website.
Auvi Q is a competing product that I always preferred. I liked it because it is flat and easy to stick in a pocket. It also actually talks you through the steps. When you are in the midst of a patient having a reaction, that can be more helpful than you would imagine. It was recalled several years ago due to trouble with the needles. I was thrilled to find out that AuviQ is available again, and believe it or not...drum roll please…. It has a ZERO copay to anyone with commercial insurance or a household with income less than $100,00.00.
Auvi Q comes in 3 strengths:
You have several options.
You can go to the Auvi Q website and download the prescription. Have your doctor sign and fax it over to them and they will deliver it directly to your door: https://www.auvi-q.com
The customer service phone number is on the website and I found them extremely helpful.
Of you can now get the Auvi Q at your local walgreens. They signed an agreement just this week (July 2019)
Regardless of which one you use, the auto-injector should be administered into the upper outer thigh. It can be given through thin clothing. The leg should be restrained and the injector should be held against the thigh and then compressed, rather than jabbing it.
In the case of a severe allergic reaction, give the immediate dose of epinephrine but then head over to the ER for some observation. It is possible for the symptoms to rebound. This is called a biphasic reaction. Hours after a patient seems stable, the symptoms can flare up again. Since it is always better safe than sorry, keeping a close eye on the patient is essential for the next 24 hours
Children with reactive airway disease and/or eczema are more at risk for allergic reactions, but they can happen to anyone.
No, of course not everyone needs to carry around epinephrine, but it is SO important to recognize the symptoms and act quickly if you are concerned about the possibility of an anaphylactic reaction.
There is a law, SB 1266, effective January 1, 2015, that mandates all schools keep an epinephrine auto-injector on hand and that someone on site has been trained. Check with your child’s school to make sure that they are complying.
Zyrtec Dosage Chart
The dose of cetirizine depends on age as below:
Zyrtec comes in a 1mg/ml solution (so 2.5 mg = 2.5 ml). There is also a 10mg/ml oral drops preparation (so 5 mg is 1/2 ml). Make sure you check the strength of the solution.