“Failure to treat promptly with epinephrine unifies virtually every death that’s ever happened from a food reaction,” Dr. Robert A. Wood, the chief pediatric allergist at Johns Hopkins Children’s Center, told an allergy group May 18.
Speaking about anaphylaxis management at Food Allergy Research & Education’s 20th annual food allergy conference in Arlington, Va., Dr. Wood said he gives the same message to other allergists, pediatricians, and parents: ”It’s very hard to find reactions where epinephrine was given promptly where there was a bad outcome.”
Driving the point home, the internationally recognized food allergy expert said that of the three recent deaths from food allergies: the college kid in Boston, the 11-year-old child in Utah, and the 8-year-old child in New Jersey; none of them received epinephrine promptly when they started to react.
While fatal food-induced anaphylaxis is fairly uncommon, it unfortunately is more common than it should be at about 150 deaths per year, he said.
For parents like me who have a child with food allergies, the possibility that our kids may experience a food-induced anaphylactic reaction is a constant stress. Throughout his presentation, Dr. Wood addressed these concerns and more. (See related stories on specific nutritional factors that may be contributing to the rise in food allergies and risk factors for being prone to more severe allergic reactions.)
How will I know if it’s anaphylaxis?
To start, Dr. Wood addressed what is always on my mind: Will I be able to recognize an anaphylactic reaction in time? His definition of food-induced anaphylaxis is a good refresher on what to look for:
- a systemic allergic reaction that involves multiple organ systems;
- an acute onset where you usually react within minutes of eating the food;
- IgE-mediated, so you can do a skin or blood test to identify the cause;
- manifestations that vary from relatively mild to fatal; and
- may be uniphasic (where symptoms don’t recur after treatment), biphasic (30-40%), or prolonged (rare).
“Importantly, you should remember that manifestations of anaphylaxis can range from relatively mild, self-limited, go away without treatment; to severe, life-threatening, and even fatal,” he explained. “You may have reactions that begin appearing mild but then progress rapidly to something that’s more dangerous.”
A biphasic reaction “is the situation where you have your initial wave of symptoms, you actually often look better for two to four hours, and then have another wave of reactions two to four hours later,” he said.
“Biphasic reactions are something that should worry you, because they are common enough and they’re often associated with more severe reactions,” he said.
It’s also important to understand the five clinical manifestations of anaphylaxis: skin, upper respiratory, lower respiratory, gastrointestinal (GI), and cardiovascular.
First, about 80 percent of reactions present themselves on the skin, where someone may be flushed, itchy, and have hives or swelling, he said. However, part of Dr. Wood’s presentation involved what he called dispelling the myths of anaphylaxis. One of these myths is that anaphylaxis always shows up with cutaneous, or skin manifestations, he said.
“Even more importantly, 20 percent of anaphylactic reactions have no skin symptoms,” he said.
“So if you’re used to relying on whether your child has hives or swelling as part of their allergic reaction, and they don’t have it, do not breathe a sigh of relief,” he said.
In fact, Wood warned that life-threatening, fatal allergic reactions usually don’t present on the skin. “That’s the scary part of this picture of anaphylaxis,” he said, noting that someone can easily go from a reaction where they’re exposed to a food and their skin is fine, to one where their breathing shuts down.
One particular point that Dr. Wood made that surprised me was that reactions in children aren’t usually cardiovascular. “In children, their heart and blood pressure are so able to withstand the allergic reaction that when you have a really dangerous reaction in kids, it’s usually not because their blood pressure is low; it’s usually because their airway is shutting down,” he explained.
“The degree of symptoms is usually the threshold at which we decide when to give epinephrine,” he said. “I usually divide my reactions between those that are relatively localized–something like itching around the mouth, a few hives around the mouth, but nothing spreading–to anything that is spreading.”
So what happens if the reaction starts as hives, but now it’s occurring elsewhere on the body? In that case, Dr. Wood said it’s usually going to be best to give epinephrine. Also, if there are breathing symptoms, then you give epinephrine. “That’s easy,” he said.
However, it’s the gray areas that are tricky. “It’s all these other times: He’s got seven hives and he’s vomited once. Should you give epinephrine? You probably should. He’s got two systems involved, hives are not just localized, and he may not be able to hold down his Benadryl because he’s vomiting. But those are the tough ones,” he said.
How soon do I need to administer epinephrine?
In addition to worrying about being able to recognize anaphylaxis, perhaps the even larger concern for parents, teachers, grandparents, and anyone looking after a child with life-threatening food allergies is the timing factor. Dr. Wood recognized that all of us in the audience wanted him to do the impossible: Tell us exactly when to give the epinephrine.
Dr. Wood strongly emphasized the significance of administering epinephrine promptly. In particular, he highlighted the significance of a 30-minute time frame, saying that 99 percent of anaphylaxis cases have occurred within 30 minutes of eating the food.
“It’s not like you have to get it in in one minute. In fact, we think five minutes is more than enough time. If that epinephrine is within five minutes of where your kid is at school, that’s fine,” he said.
“It’s 30 to 60 minutes,” he continued. “When you cross 60 minutes, there is a much lesser chance that epinephrine will work; the reaction is set to a point where epinephrine will likely be less effective.”
Don’t be scared to give the epinephrine.
In a similar vein, Dr. Wood stressed the importance of not being scared to administer epinephrine, whether it’s with an auto-injector like the EpiPen or the new Auvi-Q auto-injector with voice instructions. Moreover, the failure or delayed administration of epinephrine is associated with a bad outcome, he said.
He said that another myth he often hears is that the EpiPen is too dangerous to use. “We even hear that from emergency room doctors who said they didn’t give epinephrine because ‘it’s a dangerous drug.’ ”
To dispel this myth, he strongly advised: “Epinephrine is a remarkably safe drug. If everyone in this audience right now pulled the epinephrine out of your purse or pocket and gave yourself a shot, I wouldn’t have a single thought of who’s at risk for a bad reaction. There are not significant side-effects.”
“When you have real anaphylaxis, epinephrine is the treatment of choice,” he said. Except for the elderly or people with known heart disease, there are no contraindications, he continued.
“We would want you to use epinephrine when there is any question about whether it’s needed, and not wait or worry about the side-effects,” he advised.
The risks of anaphylaxis are far greater than the risks of giving epinephrine, Dr. Wood stressed. “You have to have it there and ready to go, and you need to use the appropriate dose,” Dr. Wood said.
What is the appropriate dose?
Dr. Wood also highlighted the fact that dosing is very important.
He advised that there’s a weight range at which the junior strength (0.15 milligrams) of whichever product you’re using will not be adequate to reverse a severe reaction. Specifically, once a child reaches about 50 pounds, they should be on a regular strength device (0.3 milligrams), because a junior strength is a perfect dose for 33 pounds, but for every pound above 33, the junior strength will be under-dosing more and more, he said.
Too, it’s important not to depend on an antihistamine (available in liquid, chewable, and dissolvable tablets) as having a life-saving capacity, he said.
“An antihistamine is really meant to deal with the more mild symptoms like hives; you will not save anyone’s life,” he warned.
While Dr. Wood stressed the importance of education and avoidance measures, he acknowledged that as diligently as we’re trying to avoid them, accidents happen. Thus, he said, “You have to have your epinephrine available, you have to treat promptly, and we need to follow up to make sure we review our action plan regularly.”
Food Allergy Research & Education (FARE) is a nonprofit organization that provides advocacy and education on behalf of individuals with food allergies. This article is my second in a series of special reports on FARE’s 2013 annual conference. For more information about FARE, please visit their website at http://www.foodallergy.org/.
What did you find most helpful about Dr. Wood’s advice? Do you have tips on recognizing mild versus more severe allergic reactions? We’re interested in hearing from you.
The image of the Auvi-Q table above was taken by Mothernova with the permission of Auvi-Q representatives at the FARE conference in Arlington, Virginia.