MARY REIGNS BUHAT BSN 2 LEVINE

A. COMMON ALLERGIC REACTION

1. ANAPHYLACTIC SHOCK
 Is an immediate, life-threatening, type 1 hypersensitivity reaction that occurs after exposure
to an allergen in a previously sensitized child
 Must be recognized and treated immediately because it can be fatal

Anaphylaxis can be caused by:

 Exposure to foods such as milk, egg, peanut, and tree nuts

 Stinging insects such as yellow jacket, honeybees, paper waasps hornets, fire ants
 Certain drugs like antibiotics, NSAIDs
 Latex

Assessment:

Symptoms of anaphylaxis
 Breathing: wheezing, shortness of breath, throat tightness, cough, hoarse voice, chest
pain/tightness, trouble swallowing, itchy mouth/throat, nasal stuffiness/congestion
 Circulation: pale/blue color, low pulse, dizziness, light-headedness/passing out, low
blood pressure, shock, loss of consciousness
 Skin: hives, swelling, itch, warmth, redness, rash
 Stomach: nausea, pain/cramps, vomiting, diarrhea
 Other: anxiety, feeling of impending doom, itchy/red/watery eyes, headache, cramping
of the uterus

Therapeutic Management:

(Preventing and recognizing anaphylaxis are as important as how to respond when it occurs.)

 Avoiding the common triggers of anaphylaxis

 Food (extremely difficult to avoid due to unexpected food proteins in the
prepared food and possible cross contamination during food preparation and
packaging)
 Stinging insects (unpredictable but easier to avoid because of its seasonality of
exposure)
 Medications
 Latex (both manageable when a thorough history has been obtained)
 Administration of epinephrine intramuscularly regardless of the cause in the vastus
lateralis or the unaffected arm
(it is the only treatment for anaphylaxis that reduces the risk of prolonged
hospitalization and death)
(epinephrine has a vasoconstrictor effects prevent airway edema, hypotension, znd
shock)
(beta agonist effect increase effectiveness of cardiac contractions and lead to
bronchodilation)
(dilate airway and initiate vessel constriction to prevent shock and death)
  Administration of antihistamines, steroids, and/or albuterol can progress anaphylactic
event
(IgE triggers the mast cells to release intracellular granules – histamines, leukotrienes,
SRA-A, chemotactic substances)
(Histamines and leukotrienes cause peripheral vasodilation and permeability of blood
vessels that leads to lower blood pressure and edema)
(SRA-A cause bronchial constriction)
 All children with history of anaphylaxis need to carry an epinephrine auto-injector device
(anyone who has responsibility for a child with history of anaphylaxis needs to know
how to recognize the symptoms of anaphylaxis and how to administer epinephrine using
auto-injector device)
(they need to practice to avoid using it incorrectly and accidentally puncturing their
thumb)
 Children who have had an anaphylactic reaction need to be observed for a minimum of
4 hours to ensure that a reaction has subsided
(anaphylactic event stops with a single dose of epinephrine but in some cases, it only
stops the reaction temporarily and once the dose has been metabolized, the reaction
come roaring back, others reactions involve second wave of symptoms several hours
later)

2. URTICARIA
 Hives
 Macular wheals surrounded by erythema arising from the chorion layer of skin
 Intensely pruritic (have burning sensation)
 May occur so closely together what they tend to coalesce (blend together)
 Dilatation of capillaries and venules with increased permeability occurs around the lesions
3. ANGIOEDEMA
 Edema of skin and subcutaneous tissue
 Most frequently in the eyelids, hands, feet, genitalia, ang lips – areas where skin is loosely
bound by subcutaneous tissue
 Can be distinguished from other edemas because it is not dependent, generally
asymmetrically distributed, and usually occurs with conjunction with urticaria
 Severe angioedema – larynx may be involved; serious problem because laryngeal edema
could be so extreme that it leads to airway obstruction and, subsequently, asphyxiation and
death

Cause:

 Urticaria – Type 1 or immediate hypersensitivity reaction created by the release of

histamine from an antibody-antigen reaction, similar to but lesser intensity than
anaphylaxis
 Chronic urticaria – possible that no causative allergen can be found
 Urticaria and Angioedema – drugs, foods, and insect stings; exposure to hot and cold

THERAPEUTIC MANAGEMENT:
  All children need the causative agent to be identified so it can be avoided
 Immediate therapy – intramuscular epinephrine or the administration of oral
antihistamine
 Long-term therapy – corticosteroids may be prescribed; cyclosporine, an
immunosuppressant; and omalizumab, a monoclonal antibody

B. ATOPIC DISORDER
 Individuals with atopic disease are prone to all types of allergic responses
 Disorders occur most frequently: allergic rhinitis, eczema 9atopic dermatitis) and asthma
 A tendency for sensitivity of antigens or abnormality of this gene is apparently inherited
(higher production of IgE antibodies)
 There are familial tendencies with these diseases but not all family members manifest the
symptoms in the same way

1. ALLERGIC RHINITIS
 Associated with an IgE-mediated inflammatory response to allergen exposure
 Risk factor for the development of asthma
 Cause sleep impairment and decreased work and school performance
 Common chronic conditions affecting people especially among the pediatric population

Cause:

pollens, molds, or irritants rather than foods or drugs.

ASSESSMENT:

Common symptoms of allergic rhinitis:

 Congestion, sneezing, nasal engorgement, and profuse thin, watery nasal discharge
 mucous membrane of the nose is generally paler than normal
 may be edematous, adding to nasal congestion
 teary eyes
 conjunctivae may be pruritic and cobblestoning - pebbly appearance
 “allergic salute” - constantly rubbing nose in an upward motion
 allergic crease or Dennie line - long period of rubbing the nose upward leads to a horizontal
crease across the tip of the nose
 “allergic shiners” - blackened areas under the eyes due to back pressure to the bDood
circulation around the eye orbit
 Children older than 6 years of age - may report full frontal headaches
 Recurrent otitis media - because of swollen pharyngeal tissue causing eustachian tube blockage
 smear of the nasal discharge - increased eosinophil count

THERAPEUTIC MANAGEMENT:
Allergic rhinitis is managed by a three-pronged program:
  avoidance of offending allergens
 use of pharmacologic agents (antihistamines, leukotriene inhibitors, or corticosteroids)
 immunotherapy

 (If children always show symptoms at one particular time of the year), parents may be able to
carry out environmental control (for that period of the year) to limit symptoms.
 child needs testing and treatment
- symptoms are increasing in intensity
- if there is associated lower respiratory tract involvement
- if the condition interferes with activities in which the child wants to participate
 children with minor symptoms
- environmental control and medications such as antihistamines and/or intranasal steroids to
reduce symptoms
 choose an antihistamine that causes the least amount of drowsiness (so the medication does
not interfere with schoolwork or, if an adolescent, with safe driving)
 Nasal antihistamine sprays should not be given for more than 3 days - a rebound effect can
occur, the nasal mucosa becomes more edematous

2. PERENNIAL ALLERGIC RHINITIS

 Allergic rhinitis becomes perennial when the allergen is one that is present in the
environment year round
 Because the agent that causes is often something in the house
 Needs treatment just as much because the symptoms otherwise may never go away
 Serous otitis media – accompany the disorder as a long-term consequence
 Environmental control and SLIT can play a big role in the control of allergic symptoms

3. ATOPIC DERMATITIS (INFANTILE ECZEMA)

 highly pruritic, chronic inflammatory skin disease
 often the first manifestation of allergic disease
 develop to allergic rhinitis and asthma
 Food allergy is a major trigger of atopic dermatitis in infants (needs to have a thorough
food allergy evaluation)
 Sweating,heat, tight clothing, and contact irritants such as soap tend to increase the
pruritus associated with eczema
 more annoying in the winter when the skin dries out and heavier clothing is worn
 Other children have eczema triggered by sweating and find the humid, summer months
more difficult

ASSESSMENT:

 Children develop papular and vesicular skin eruptions with surrounding erythema
 vesicles rupture and exude yellow, sticky secretions that form crusts on the skin as they
dry
 Because the lesions are extremely pruritic, (the child scratches and further irritates the
lesions,) causing linear excoriations.
  Secondary infections of open lesions may then occur.
 If a secondary infection occurs, the infant may have a low-grade fever and pus-filled
lesions, and local lymph nodes may be enlarged.
 As the infected lesions heal, dry, flaky scales form.
 Infants usually present with rash on the face, neck, and extensor surfaces
 Infants with atopic dermatitis will rub their face, arms, and legs to relieve the intense
itching.
 As children develop dexterity, they focus on flexural folds of the extremities and neck.
 (Because the lesions. feel so uncomfortable), children with infantile atopic dermatitis
become fussy and irritable.
 (They may not eat well because of this generalized discomfort. The combination of poor
sleep patterns, poor intake, and an increase need of energy to repair damaged skin can
result in a) decrease in nutritional status.
 A child with seborrheic dermatitis needs little therapy while infants with infantile atopic
dermatitis must be referred for long-term therapy.

THERAPEUTIC MANAGEMENT:

 aimed at reducing the amount of allergen exposure, if such allergens can be identified
 avoid foods to which infants are allergic are milk, eggs, and peanuts
 aimed at reducing pruritus so children do not irritate lesions and cause secondary
infections by scratching
 Hydrating the skin by bathing or applying wet dressings (moistened with tap water or
Burow's solution) for 15 to 20 minutes, followed by the application of a barrier to seal in
the moisture is helpful
 In children who develop frequent secondary infections, weekly use of dilute bleach
baths can be very effective
 Regardless of the mode of hydration, the skin should still be wet or moist when applying
lubricants.
 While infants are having wet dressings applied, be conscientious that they don't become
chilled
 Use a stockinette dressing to hold wet dressings in place so you don't have to use any
form of tape
 To prevent corneal irritation, be careful that dressings dont come in contact with the
eyes
 Antihistamine can be useful to reduce itching
 Low potency steroids can be used for maintenance with intermittent and high-dose
topical steroids for exacerbations

4. ATOPIC DERMATITIS IN THE OLDER CHILD

 occurs at later ages is prominent on the flexor surface of the extremities and on the
dorsal surfaces of the wrists and ankles
 often occurs in the eyebrows
  hair loss and scant eyebrows can result by scratching the lesions
 Depigmentation or hyperpigmentation; lichenification can be marked
 child's fingernails have a glossy sheen caused by the buffing action of constant rubbing
and scratching
 the rubbing or scratching leads to irritation of lesions.

THERAPEUTIC MANAGEMENT:

 suggest that adolescents use only a prescription soap or none at all to prevent skin
drying
 Swimming in chlorinated pools may also help for those who experience chronic
secondary infections.
 encourage them to shower well afterward to remove chlorine from the skin
 apply a skin emollient and moisturizer after the shower
 after a period of activity in which sweating occurs, suggest the child take a shower to
remove perspiration so this doesn't irritate the skin
 Avoiding tight clothing at the flexor portions of the extremities
 Medical treatment for older children is basically the same as for the infant with atopic
dermatitis: keeping the skin hydrated and identifying allergens and any psychological
problems that are initiating an itch-scratch cycle.