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Food Allergies:
-may or may not be mediated by which immunoglobulins?

IgE mediated and non-IgE mediated


Characteristics of IgE mediated rxns?

Non-IgE mediated rxn characteristics?

IgE mediated
-rapid onset
-GI tract
-Resp Tract

-occur hours to days after exposure
-usually present in infants
-present as chronic skkin conditions or GI sx;

*Think contact dermatitis, rxn to lotions, irritation or inflammation of the GI.


90% of IgE mediated rxns in children are from what 8 sources? Which of these 8 are lifelong and which resolve by age 5?

-cows milk
-tree nuts

-tree nuts

Resolve by age 5:
-cows milk


Sx of Food induced allergic rxns (IgE and non-IgE)
-upper resp
-lower resp
-GI oral
-lower GI

-cutaneous: erythema, pruritis, urticaria, angioedema

-ocular: pruritus, conjunctival erythema, tearing, periorbital edema

-upper resp:nasal congestion, pruritus, rhinorrhea, sneezing, laryngeal edema, hoarseness, dry cough

-lower resp: cough, chest tightness, dyspnea, sneezing, intercostal retractions

-GI oral: angioedema of lips, tongue, or palate, oral puritus, tongue swelling

-lower GI: nausea, colicky abd pain, reflux, vomiting, diarrhea

-CV: tachycardia, hypotension, dizziness, fainting, LOC


Food Allergy Dx & Tx

-Hx!!!!! if lab test isnt consistent with hx then its not an allergy. (eg if test shows allergy to cows milk but pt can tolerate cows milk you have them continue to drink cows milk)

-Skin prick test
-Allergen specific IgE (serum test)*
-oral food challenge

-Epi-pen for tx of anaphylaxis


MC associated sx w/ food allergies

-atopic dermatitis(eczema), acute urticaria.


Nasopharyngeal sx associated with food allergy?

-acute rhinitis NOT chronic rhinitis


Skin prick allergy testing
-what is a positive result?
-describe specificity and sensitivity of this test?
-be sure to discontinue what medications prior to this test?

Positive result: wheal at least 3mm greater than the negative control.

-95% sensitive, 50%, better at ruling out allergy than ruling in; many false positives.

-Antihistamines should be discontinued prior to testing.


What is serum IgE testing? What is needed to make dx?

-Serum IgE testing is a blood test that detects IgE to specific allergens. There are cut off values that aid in determining if the pt is actually allergic.

Need to make sure pt has clinical hx of food allergy to confirm dx.


Gold Standard for dx of food allergy?

oral food challenge is gold standard for dx of food allergy.


What is oral food challenge?

What is atopy patch test? When do we use this?

pt is given gradually increasing amounts of suspected food allergen over a period of time of hours to a day. Requires close medical supervision

Atopy Patch Test: used to dx delayed hypersensitivity T-cell mediated rxn such as contact dermatitis.

-this is not recommended for IgE food allergies.


Does the level of serum specific IgE or the size of wheal response determine the severity of an allergy?



T/F, if consuming food without experiencing a clinical rx, SPT, and IgE testing is not warranted?

T/F, for whatever reason testing is conducted and a positive results is observed, it is important to stress to the caregiver that the food continue to be consumed on a regular basis. Why or why not?

True, and true.

What: testing indicates that the child is sensitized to allergen, a prolonged absence of the food from the diet could lead to clinical sx upon re-exposure.


Pollen-Food Allergy Syndrome
-what is this?

aka: oral allergy syndrome

what: IgE mediated rxn that affects the oropharynx, thought to occur from cross-reactivity between proteins present in pollens anad those expressed by fruits and veggies

-tingling & itching of lips, tongue, and palate
*sx do not occur when fruit or veggie is cooked or microwaved.


What fruits are associated with each allergy:
-birch pollen allergy cross reactivity
-ragweed pollen cross reactivity
-grass pollen cross reactivity

-apples, plums, peaches, nectarines, cherries, and almonds.

-melons, bananas, and tomatoes

Grass: melons and kiwi


Dx & Tx of PFAS

-confirmed through skin prick testing to the fresh foods and pollen and also with oral food challenges (rarely do OFC)

-antihistamine to control sx
-avoid consumption of RAW food product that produced sx
-epi pen


T/F, teenagers are at higher risk for fatal food-induced anaphylaxis than younger children.

True, they have poor understanding of when food allergy rxns are severe and when epi is indicated.


What are the MC food allergies in children?

MC food allergies in adults?

MC food allergies in children: milk, egg, and peanut

MC food allergies in adults: shellfish, peanut, and treenut.


Allergic Rhinitis
-peak prevalence

Peak prevalence: 14-25years old, 80% develop sx before age 20.

-nasal congestion
-itching of eyes, nose, palate, ear canals
-postnasal drip, cough
-sleep disordered breathing
-general malaise
-Cognitive and psychiatric issues in children such as:
--ADHD, lower exam scores in peak pollen season, poor concentration, impaired athletic performance, low self esteem.


Dz associated with allergic rhinitis?

-otitis media andd eustachian tube dysfunction
-sleep-related breathing disorders.


PE findings in allergic rhinitis

-allergic salute = transverse crease across nasal bridge

-allergic shiners = dark swollen infra-orbital tissue

-dennie morgan lines = infra-orbital creases d/t edema and thickening of the skin

-post nasal drip

-inflammed mucosa

-pale boggy blue mucosa

-clear nasal discharge


-conjunctival chemosis



Dx of allergic rhinitis

-suggestive hx
-supportive exam
-identify specific IgE


Tx of Allergic Rhinitis

-environmental control

*Tx strategy depends on severity of sx.


Classification of allergic rhinitis

Intermittent: less than 4 days per week or less than 4 weeks

Persistent: greater than 4days per week AND greater than 4 weeks.

-normal sleep
-normal daily activities
-normal work and school
-no troublesome sx

-abnormal sleep
-impairment of daily activities of daily activities, sports, leisure.
-problems caused at work and school
-troublesome sx

*classification can be any combination of mild/mod/severe AND intermit/persistent.


Most effective first line tx in allergic rhinitis?

Medications for allergic rhinitis in children less than 2 years old.


-Cromolyn nasal spray
-2nd gen antihistamine (ceterizine, fexofenadine)
- Intranasal glucocorticoids if severe sx and no response to above therapies.
*dont use steroids first line, they are so little they will have systemic absorption.


Medication tx for allergic rhinitis in children greater than 2 years old.
-persistent severe

Mild sx:
-cetirizine, loratidine, or fexofenidine (2-5hrs prior to exposure; 2nd gen antihistamines)

-intranasal topical antihistamine (azelastine, olopatidine)

-intranasal glucocorticoid (more effective than antihistamine)

-intranasal cromolyn spray 30min prior to exposure.

-intranasal glucocorticoid (Nasonex, Veramyst, Flonase)

-topical nasal antihistamine (azelastine, olopatidine, combo of those two; Dymista)

-oral antihistamine
*start with first med and add on in this order if needed for persistent sx.


Tx of ALlergic rhinitis with allergic conjunctivitis?

Intranasal glucocorticoid + topical ophthalmic antihistamine drops
**This combo is less drying than oral antihistamines.


Allergic rhinitis with asthma tx

Leukotriene modifier
-monteleukast (singulair)


BBW for monteleukast?

depression and suicidal ideations in adults. In kids it may cause hyperactivity, emotional, impulsive.