Paediatric Allergy Clinical Network

Purpose of the network

We aim to promote and support evidence based best practice for those involved in the health care of New Zealand children and young people with allergies, with a focus on quality improvement to make sure there is equal access to care and resources.

The network will work to achieve this through:

  • Encouraging development of services

  • Improving access to existing resources

  • Generating guidelines

  • Enhancing workforce education

Allergies affect over 20% of New Zealand children, and often begin in infancy with the development of food allergy. The burden of allergies on both children and their families can be significant. Early diagnosis and appropriate clinical management can minimise the long-term impact on quality of life for these children and their families.

The contents of the following pages include guidelines as well as links to resources and training for health professionals, and resources such as handouts for families. Some links are to overseas websites which have been approved by the Allergy Clinical Network (Allergy CN) as providing valuable information relevant to New Zealand health professionals. Where necessary the Allergy CN will develop guidelines and resources specific to New Zealand.

The Allergy Clinical Network has produced a number of guidelines which are on the Starship Clinical Guidelines: food allergy, bee and wasp sting allergy, and environmental allergy. In addition, they have produced the following resources:

Allergy prevention

The Allergy Clinical Network supports the guidelines on Infant Feeding and Allergy Prevention published by the Australasian Society of Clinical Immunology and Allergy (ASCIA). First published in 2016, they have been updated to reflect further evidence in relation to the early introduction of food, and optimising eczema management. These guidelines are relevant for all families, including those in which siblings or parents already have food allergies or other allergic conditions.

The reasons for the continued rise in allergic diseases, such as food allergy, eczema, asthma and allergic rhinitis (hay fever) are complex and not well understood. Although infants with a family history of allergic disease are at higher risk of allergies, infants with no family history can also develop allergies.

Risk factors identified for the development of food allergies¹:

  • An infant with an immediate family history (first degree relative) of allergies, is considered at increased risk of developing food allergy. 

  • Severe eczema, defined as persistent or frequently recurring eczema with typical morphology and distribution, assessed as severe by a healthcare professional and requiring frequent prescription-strength topical corticosteroids, calcineurin inhibitors or other anti-inflammatory agents, despite appropriate use of emollients

  • Infants with severe eczema and/or egg allergy are at increased risk of developing peanut allergy. Introduction of peanut before 12 months of age in these infants significantly reduces the risk of
    developing peanut allergy³,⁴.

If an infant already has an allergic disease (such as severe eczema or food allergy), it is recommended parents discuss what specific measures might be useful with their doctor.

Information for Health Professionals

  1. Go to the ASCIA website (https://www.allergy.org.au/health-professionals/papers/infant-feeding-allergy-prevention) to access:

    1. ASCIA Guidelines - Infant feeding and allergy prevention

    2. ASCIA Information on how to introduce solid food to babies

    3. ASCIA Guide for introduction of peanut to infants with severe eczema and/or food allergy

  2. National Allergy Strategy Food Allergy Prevention Project (https://preventallergies.org.au/)
    This website includes information for health professionals as well as patient resources. Please note that this was developed for Australia and while most information is relevant to NZ there some differences such as in availability of health services and medications, and contact details – e.g. dial 111 for an emergency in New Zealand.

    1. Information about infant feeding for allergy prevention

    2. Practical infant feeding information

    3. How to optimise eczema for allergy prevention

    4. The website includes practical information, videos and FAQs.

  3. A PHARMAC forum on 'prevention of paediatric food allergy and eczema' was held June 2017 with sessions by Dr Jan Sinclair, paediatric allergy specialist, and Dr Diana Purvis, paediatric dermatologist, Starship Child Health. This is available as an online seminar and is approved for continuing medical education (CME) for GPs:  https://www.pharmac.govt.nz/seminars/seminar-resources/allergy-and-eczema/

  4. An 'Update on infant feeding and food allergy prevention' (November 2017) was written for BPAC and is available here to download as a pdf

Information for Patients, Consumers and Carers

The ASCIA website (https://www.allergy.org.au/patients/allergy-prevention) has two pdfs which can be downloaded and provided to patients, parents and carers as appropriate. These are:

National Allergy Strategy Food Allergy Prevention Project – www.preventallergies.org.au

  • This website includes information and resources for parents, carers and families. Please note that this was developed for Australia and while most information is relevant to NZ there some differences such as in availability of health services and medications, and contact details – e.g. dial 111 for an emergency in New Zealand. The website includes practical information, videos and FAQs on:

  • Infant feeding for allergy prevention

  • Introducing solid foods

  • How to optimise eczema for allergy prevention

Food Allergy

Anaphylaxis

Anaphylaxis is the most severe form of allergic reaction, usually occurring within 20 minutes of exposure to the trigger, and is potentially life threatening.

It must be treated as a medical emergency, with the administration of intramuscular adrenaline as the first line treatment.

The most common trigger in infants, children and young people is food allergy; other triggers include allergy to insect venom (bee or wasp), drugs (e.g. penicillin), and latex.

Definition

Any acute onset illness with typical skin features (urticarial rash or erythema/flushing, and/or angioedema), PLUS involvement of respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms.
OR
Any acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is considered possible, even if typical skin features are not present. (ASCIA)

Signs and symptoms that an allergic reaction is anaphylaxis include:

RespiratoryDifficulty/noisy breathing
Swelling of tongue
Swelling/tightness in throat
Difficulty talking and/or hoarse voice
Wheeze or persistent cough
CardiovascularLoss of consciousness
Collapse
Palor and floppiness (in young children)
Hypotension

Acute management

There is a Starship Clinical Guideline on the Management and Treatment of Anaphylaxis.

The New Zealand and Australian Resuscitation Councils published guidelines for First Aid Management of Anaphylaxis in 2016: http://www.nzrc.org.nz/assets/Guidelines/First-Aid/ANZCOR-Guideline-9-2-7-Anaphylaxis-Aug16.pdf

Long term management

Long-term management of anaphylaxis includes:

  • Confirmation of triggering allergens

  • Allergen avoidance measures

  • Prescription for adrenaline auto-injector

  • Provision of Anaphylaxis Action Plan

  • Identification of risk factors

  • Patient education on all of the above

  • Venom immunotherapy/drug desensitisation if relevant.

For infants, children and young people who have had anaphylaxis, referral should be made to the local Paediatric Outpatient Service (or Paediatric Allergy/Immunology Service if available). In the interim, General Practitioners (GPs) should ensure the family has been provided with an Anaphylaxis Action Plan and adrenaline autoinjector ordering information. EpiPen®s are currently the only adrenaline auto-injector available in New Zealand. They are not funded by PHARMAC*.

*ACC provides cover for anaphylaxis as a personal injury caused by accident (PICBA). To make a claim, the patient will need to identify the trigger, the means by which it contacted the body (e.g. ingestion or injection), and confirmation of the injury (anaphylaxis). A GP can assist with the completion of an ACC form, so the family can claim the cost of the ambulance and reimbursement for the cost of the autoinjector (if used in the emergency treatment of their anaphylaxis). More information is available from Allergy New Zealand 

Adrenaline autoinjectors

Be mindful that autoinjectors come in different doses. Recommendations from ASCIA (Australasian Society for Clinical Immunology & Allergy) are as follows:

  • EpiPen® Adult for children >20kg (package insert says over 30kg)

  • Epipen® Jnr for children 10-20kg (package insert says 15-30kg)

  • Recommendation of an EpiPen® to a child weighing <10kg should be discussed with senior medical staff

An EpiPen® is appropriate for those:

  • with anaphylaxis to non-avoidable triggers eg. bee stings and most food

  • with less severe allergic reaction (i.e. not anaphylaxis) but with other risk factors for anaphylaxis eg. asthma, living in remote locations, peanut or tree nut allergy. This decision can generally be made at the Outpatient Clinic.

 See information sheet on Adrenaline autoinjector ordering

Action plans

Individual Anaphylaxis Action Plan forms are available from the ASCIA website: http://www.allergy.org.au/health-professionals/anaphylaxis-resources/ascia-action-plan-for-anaphylaxis. There is a separate version for Allergic Reactions (personal) for use when no adrenaline autoinjector has been prescribed. The patient's details, other medications to be used etc should be filled in online, printed and then signed and dated by the prescribing doctor.

Patient/family education

GPs should ensure that family/carers know when and how to use an auto-injector. GPs and other health professionals can obtain a free EpiPen® training kit by logging in to http://www.count2.co.nz. This includes a 'trainer pen' which the patient/family can practice with. Families should also be encouraged to register with www.epiclub.co.nz in order to receive their own trainer pen, and reminders when their EpiPen® is due to expire. There is also a free e-anaphylaxis training module for carers/community on the ASCIA website.

Update July 2019 

Anaphylaxis information resources for patients and families have now been translated into Maori, Samoan and Tongan, thanks to the support of Starship Foundation and the Australasian Society of Clinical Immunology & Allergy (ASCIA).

The information sheets that have been translated are:

  • Anaphylaxis Patient Information

  • Fact sheet for Parents

  • First Aid for Anaphylaxis

  • How to give EpiPen.

These are new additions to ASCIA’s collection of anaphylaxis resources available in English and other languages including Chinese and Arabic.

These are now freely available from ASCIA’s website: (https://www.allergy.org.au/hp/anaphylaxis#ta5). This website can also be found by using search engine keywords “anaphylaxis resources ASCIA”.

See Resources for Patients, Families and Carers below for more information.

Resources for Health Professionals

The Australasian Society of Clinical Immunology and Allergy (ASCIA) has a range of resources including Anaphylaxis Action Plans, a GP Checklist and free online training. A full list is available at http://www.allergy.org.au/health-professionals/anaphylaxis-resources.

The 'Anaphylaxis Clinical Update' complements the ASCIA anaphylaxis e-training for health professionals. The main purpose of this document is to provide an evidence-based, 'quick reference guide' to assist primary health care physicians including general practitioners, paediatricians and nurses in the management of patients with allergy who are at risk of anaphylaxis.

An 'Anaphylaxis Checklist for Pharmacists' is also available.

Resources for Patients, Families and Carers

Ensure that the family obtains and is instructed in the use of an autoinjector. Currently only EpiPen®s are available in NZ. See adrenaline autoinjector ordering information.

Advise the family in respect to ACC claims for anaphylaxis. Refer to Allergy New Zealand for more information.

Free anaphylaxis information is available from ASCIA in a number of languages including Maori, Samoan, Tongan, Chinese and Arabic. Go there (https://www.allergy.org.au/hp/anaphylaxis#ta5) to view and/or download these.

Free anaphylaxis e-training for patients, families and the community is available from the Australasian Society of Clinical Immunology (ASCIA): http://www.allergy.org.au/patients/anaphylaxis-e-training-first-aid-community

ASCIA also has a checklist for patients transitioning from paediatrics to adult care: http://www.allergy.org.au/images/stories/anaphylaxis/lists/ASCIA_PCC_Anaphylaxis_Checklist_Transitioning_paed_adult_care_2015.pdf

For further information on PSNZ / MoH Clinical Network development, please contact PSNZ CEO, Mollie Wilson, mollie@healthnetworks.co.nz or PSNZ Secretariat Denise Tringham, denise@paediatrics.org.nz