CHAPTER 16
Nut Allergy – Anaphylaxis Management

Susie Wilkie

SCENARIO

Katie is a four-year-old child who lives with her parents in a five-bedroom house in a semirural location. She has a three-year-old brother and her mother is 25 weeks pregnant, expecting her third child. Katie was diagnosed with atopic eczema at the age of one month, and asthma at the age of two years.

Whilst attending a family wedding reception, Katie becomes distressed. Her eyes have swollen, and she says her ‘tummy aches’, and subsequently she vomits. Katie’s concerned parents notice she appears to have a nettle rash on her face. Her parents take her home, and she gradually starts to feel better.

The next day her parents contact their GP, who arranges for Katie to be referred to a specialist allergy clinic to be tested for suspected nut allergy. There is a four-month waiting period.

ANSWERS TO QUESTIONS

Question 1. How prevalent is nut allergy in children?

Foods have been known to cause adverse reactions in susceptible individuals for almost 2000 years. Both Hippocrates and Galen reported allergic reactions to milk. One of the earliest references to food allergy is found in the often quoted aphorism:

‘One man’s meat is another man’s poison’

Lucretious, BC 55, cited by Vojdani et al. (2014)

According to Du Toit (2015), peanut allergy in children has doubled within the last 10 years in Western countries. National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries (CKS) (2018) placed the figure as high as 1 in 50 children being affected. Whilst Conrado et al. (2021) reported UK data to show a significant increase in hospital admissions for anaphylaxis during the period 1998 to 2018, it also shows a decrease in fatality rates. The age of onset is decreasing, with children often being diagnosed in the first year of life.

Possible causes

The reason for the significant increase in this allergic disease remains unclear, although it is thought to be influenced by increased exposure to widespread use of peanuts in food manufacture. The hygiene hypothesis also asserts that too hygienic an environment may set the stage for allergic disease later in life as immunity is not being challenged in affluent homes. The emergence of nut allergy also appears to relate directly to the increase in prevalence of allergic asthma and eczema, in predominantly western populations.

Drug trials have been positive with treatments being developed to aid peanut desensitisation, for what has long been considered a lifelong condition, finding that up to 50% could tolerate a small amount of exposure reducing risk of severe anaphylaxis (NICE 2022).

Allergy to peanuts and other types of nuts and seeds is the most serious form of food allergy, characterised by more severe symptoms than other food allergies, wherein sensitivity is often extreme, with minute amounts of the allergen being capable of triggering a rapid and severe type 1 allergic response. The course of anaphylaxis is by nature rapidly progressive, and failure to recognise the severity of these reactions and to administer adrenaline promptly, significantly increases the risk of a fatal outcome.

Question 2. Explain the current approaches to diagnosing nut allergy

Diagnosis is based on clinical history, along with skin prick test, or quantisation of allergen-specific immunoglobulin E (IgE), and oral food challenges, when indicated in a specialist allergy clinic.

IgE specific blood tests venepuncture

Assess: as the children’s nurse caring for the needs of the child and family whilst undergoing these tests in an allergy clinic, what approaches would you consider appropriate to help the child cope with the anticipated skin prick test and venepuncture?

How would you support the family in terms of the anxiety whilst undergoing these procedures and awaiting confirmation of diagnosis in the clinic?

Details of how a skin prick test is carried out can be found at the following link for NHS website information on allergies and diagnosis:

www.nhs.uk/conditions/food-allergy/diagnosis

Plan/implement:

Give family information in advance of procedure.
Explore with the family any previous experience the child has had of injections or venepuncture. This can provide valuable information for planning the procedure.
Work in conjunction with a play specialist where possible. For younger children, consider providing a teddy or medical kit for the child to ‘practise’ with, to gain some familiarity and element of control.
Provide choices – would they prefer to sit on the parent’s lap, be sitting up, use the right or left hand, choose their sticking plaster.
Ensure provision of adequate pain relief – local anaesthetic cream or ethyl chloride spray.
Encourage child to have had a good fluid intake – if they are well hydrated this promotes easier venous access.
Ensure child keeps warm – to promote vasodilatation and easier venous access.
Consider using age-appropriate distraction during the procedure – read from a book, sing a favourite song, count backwards or blow bubbles.
Comfort and praise child.

Supporting parents: this is an uncertain and anxious time. Give parents information on an ongoing basis and provide opportunities for clarification. Receiving the diagnosis for some parents can be like a bombshell and has the potential for profound changes in family life.

The technique involves using either a needle or lancet to puncture the epidermis through an extract of a food by specifically trained staff. The test site is examined after 10–20 minutes. A local weal and flare response indicates the presence of food specific IgE antibody. The preferred site is either along the inner forearm or on the child’s back.

Question 3. Discuss the current approaches to management of nut allergy at home/school

Most studies and guidance recommend complete avoidance of the allergen once identified. This may appear relatively straightforward, but as Anagnostou and Clarke (2015) suggest, avoidance is easier to advocate than to undertake. There is the potential risk of inadvertent cross contamination in food manufacture, children sharing food, etc. The literature is replete with accidental exposure to the very allergen they are trying to avoid (Brough et al. 2014).

Adults responsible for the care of children are therefore advised to diligently read food labels. This level of constant vigilance creates the conditions for living under the threat of inadvertent exposure and consequent severe reaction.

In addition, parents and other adult carers need to be taught how to recognise the signs of anaphylaxis, and to administer adrenaline (epinephrine) via auto injector (i.e. Epipen®, Jext®) when necessary and to be able to give basic life support/CPR (Resuscitation Council 2021).

The groups of adult carers who will need to be advised on Katie’s nut allergy management will include her parents, nursery/school staff and other family members. A management plan will be required for Katie’s school/nursery.

For specific guidance on managing medicines in schools, nurseries and similar settings, visit www.allergyinschools.org.uk and www.medicalconditionsatschoolOrg.uk. In 2017, The Human Medicines Regulations (2012) was amended to allow schools in the UK to purchase and hold spare adrenaline auto injector for use in a child with known anaphylaxis who has had a failure of their own pen or it cannot be located.

Question 4. What is anaphylaxis?

Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. There is an exaggerated response to an allergen, characterised by rapidly developing, life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes.

When the specific allergen has been ingested it can react in widespread areas of the body with basophiles of the blood and the mast cells located immediately outside the small blood vessels, giving rise to a widespread allergic reaction throughout the vascular system and in closely associated tissues.

The large quantities of histamine released into the circulation causes widespread peripheral vasodilatation as well as increased permeability of the capillaries and marked loss of plasma from the circulation. This leads to potentially catastrophic circulatory shock within minutes, unless treated with epinephrine to oppose the effects of histamine.

Also released from the cells are leukotrienes, which cause spasm of the smooth muscle of the bronchioles, giving rise to asthma-like symptoms.

Urticaria results from antigen entering specific skin areas causing local reactions. Locally released histamines cause:

Local vasodilatation, inducing an immediate red flare.
Increased local permeability of capillaries that leads to swelling of the skin, known as hives.

Angioedema is deep swelling around the eyes, lips, and sometimes the mouth and throat.

Refer to Box activity 16.1 for more information on Katie.

Tags: Care Planning in Children and Young Peoples Nursing 2e

Mar 23, 2024 | Posted by admin in Uncategorized | Comments Off

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Nut Allergy – Anaphylaxis Management