With schools preparing to open their doors, the pediatric office was filled with students bored of summer and eager to hit the books. Well, for the kids maybe not so much, but for my staff, yes, the office was really busy.
During school and sports physicals I reviewed everything from eating habits to academic performance to new medical symptoms. My staff made sure that allergies were listed on the proper forms and medications were refilled and available for school use.
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One outstanding student was looking healthy and her only request was for a refill on her inhaler, which she rarely used. Since a peanut allergy had been confirmed on a recent visit to the allergist, I also asked if the girl had the epinephrine device prescribed by the specialist. The mom, who was very much on top of all of her daughter's eye appointments, dental visits and eczema treatments, seemed surprised. "Oh, she doesn't need one of those, she just stays away from peanuts!"
I reminded the mother that peanut allergies were potentially dangerous, and that readily available and rapidly administered epinephrine can be a true lifesaver in the event of an accidental peanut exposure. While acknowledging that the device is a bit pricey, I advised the mom to treat it like car insurance, a necessary investment which with luck will never be needed.
I'm not sure I completely convinced her, but I had an ace in the hole. No school form, no school. No sports form, no sports. I plastered "peanut allergy" and emergency action information all over her forms so that the school nurse would be well-aware of the girl's medical condition and would require that epinephrine be sent to school with the student. I was confident we were set.
I left that room, and who should I see next but a boy of similar age, also with a peanut allergy. As I went over medications with his mother, she asked for three epinephrine prescriptions. She had no desire to play around with food allergies and wanted to make sure that she, her son, and the school nurse were all armed with fresh epinephrine two-packs for the new school year.
In his article in Pediatrics, Dr. Hugh Sampson reports that each year in the U.S. approximately 30,000 individuals receive emergency department treatment for serious allergic reactions to foods, referred to as food anaphylaxis. Fatalities occur in 150 to 200 of these cases. Peanuts, tree nuts, fish and shellfish cause the most severe food anaphylactic reactions.
According to physicians Scott Sicherer and F. Estelle Simons of the American Academy of Pediatrics Section on Allergy and Immunology, fatal anaphylactic reactions in kids are particularly associated with asthmatic conditions, improper administration of epinephrine and the adolescent age group.
Teenagers are considered at greater risk of fatal reactions due to their higher incidence of risk-taking behavior, failure to recognize triggers, denial of worsening allergic symptoms, and their overall reluctance to carry and to administer medications.
Sicherer and Simons explain that epinephrine is still the medication of choice for anaphylactic episodes. Liquid antihistamines (liquid forms are more readily absorbed than pills) such as diphenhydramine -- trade name Benadryl -- and asthma inhalers are "adjunctive" therapies used during allergic reactions.
Antihistamines can take one or more hours to work and though they can help treat skin symptoms, they do not treat respiratory distress or cardiovascular shock. Inhalers can decrease wheezing and shortness of breath in asthmatics, but do not decrease the upper airway swelling that can accompany anaphylaxis.
Injectable epinephrine is available by prescription and comes in two pre-measured doses of .15 mg or .30 mg. The AAP team generally recommends the .15 mg autoinjectors for children weighing from 22 to 55 pounds, with the .30 mg dose given to children weighing 55 pounds or more. Dosing for infants under 22 pounds or for children at borderline weights should be based on a child's clinical condition and underlying risks after consultation with the patient's allergist.
Epinephrine autoinjectors should be injected intramuscularly and preferably into the lateral thigh. If clothing cannot be removed quickly enough, the epinephrine injection can even be administered through clothing, though the authors caution that pant seams and filled pocket areas should be avoided.
Epinephrine autoinjectors are sensitive to the elements and need to be kept out of direct sunlight and protected from temperature extremes. Though it's tempting to stretch the prescription and split the prescribed two-packs into "one-for-home and one-for-school," it is best practice to keep the two-packs together.
Sicherer and Simons note that studies show a second dose of lifesaving epinephrine is required in 18 percent to up to 35 percent of cases of anaphylaxis, And, in the event of an anaphylactic reaction, remember that when one member of the first-aid team is grabbing the epinephrine autoinjector, another should be reaching for the phone and calling 911 to activate the emergency response team.
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights.