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Course: Pediatric Nursing

Topic: Nursing care of child with immunological disorders (III)

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Module Goals

Learners will be able to:

Define anaphylaxis and Transient Hypogammaglobulinemia of Infancy (THI).
Identify common triggers for anaphylaxis in children.
Describe the pathophysiology of anaphylaxis.
Discuss signs and symptoms of anaphylaxis and THI.
Describe common diagnostic procedures for these disorders.
Describe the management of anaphylaxis and THI.
Discuss nursing management of a child with anaphylaxis and THI.

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Anaphylaxis

A serious, generalized or systemic, allergic or hypersensitivity reaction that can be life-threatening or fatal.

Reber, Hernandez, & Galli, 2017

NHS, 2019

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Anaphylaxis: Triggers

Food is the most common associated trigger.

Insect bites and stings

Bees, wasps, jack jumper ants, green ants and fire ants.

Medicines:

Penicillin, aspirin, and herbal preparations.

Better Health, 2021

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Critical Thinking Question

An anaphylactic reaction can be as simple as developing a rash after exposure to an allergen.

True
False

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Anaphylaxis

Eight foods or food groups account for most serious allergic reactions in the United States:

Milk, Eggs, Fish
Crustacean
Shellfish
Wheat
Soy
Peanuts, and
Tree nuts

CDC, 2021

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Pathophysiology

Delves, 2020

Triggers release of histamine, leukotrienes, and other mediators

Bronchoconstriction,vomiting, vasodilation

Diffuse smooth muscle contraction

Interaction of antigen with IgE on basophils and mast cells

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Critical Thinking Question

Which is the most common trigger for anaphylaxis in children?

Food
Medication
Insect bite
Pollen

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Anaphylaxis Symptoms

image by, Reber, Hernandez, & Galli, (2017)

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Anaphylaxis: Signs and Symptoms

Central Nervous System: Fussiness, irritability, drowsiness, lethargy, reduced level of consciousness.

Skin: Urticaria, pruritus, angioedema, flushing, edema.

Upper airway:

Stridor, hoarseness,laryngeal edema, uvular edema, swollen lips/tongue, sneezing, rhinorrhea.
Upper airway obstruction.

Cheng, 2011

NHS, 2019

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Anaphylaxis: Sign and Symptom

Lower airway: Coughing, dyspnea, bronchospasm, tachypnea, respiratory arrest.

Cardiovascular: Tachycardia, hypotension, dizziness, syncope, arrhythmias, diaphoresis, pallor, cyanosis, cardiac arrest.

Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain.

Cheng, 2011

NHS, 2019

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Critical Thinking Question

During anaphylactic shock the mast cells and basophils release large amounts of histamine.

What effect does histamine have on cardiovascular system during anaphylactic shock? (Select all that apply)

Decreases heart rate
Increases heart rate
Hypertension
Hypotension

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Anaphylaxis: Diagnosis Criteria

Anaphylaxis is likely when any one of the two criteria are met:

Criteria 1

*Acute onset of symptoms (minutes to several hours) with involvement of the skin, mucosal tissue, or both and at least one of the following:

Respiratory compromise
Reduced blood pressure
Severe gastrointestinal symptoms

ASCIA, 2021

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Anaphylaxis: Diagnosis Criteria (Continued)

Criteria 2

*Acute onset of hypotension or bronchospasm or laryngeal involvement after exposure to a known or highly probable allergen for that individual (minutes to several hours), even in the absence of typical skin involvement.

ASCIA, 2021

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Anaphylaxis: Diagnosis

Medical history:

Questioning about what led up to the event.

Physical examination (signs and symptoms).
Blood tests:

To check for the presence of specific antibodies.

Skin prick tests to confirm or rule out suspected triggers.

Better Health, 2019

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Anaphylaxis: First Aid Treatment

Lay child flat or hold young child flat, not upright If unconscious - do not allow them to stand or walk.
If unconscious place in recovery position.
If breathing is difficult allow them to sit with legs outstretched.
Give adrenaline injector.

150 mcg for children 7.5-20kg.
300 mcg for children over 20kg.
300 mcg or 500 mcg for children and adults over 50kg.

Australasian Society of Clinical Immunology and Allergy, 2021

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What Would the Nurse Do?

A child had sudden and severe anaphylactic reaction to a medication.

The nurse immediately called a rapid response. Audible wheezing is noted along with facial redness and swelling. What should be the first initial treatment a nurse do for the child?

IV Diphenhydramine
IV Normal Saline Bolus
IM Epinephrine
Nebulized Albuterol

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Anaphylaxis: First Aid Treatment (Continued)

Initiate emergency call- Get help, ambulance, 911, etc.
Further adrenaline may be given if no response after 5 minutes
Transfer child to hospital (requires least 4 hours of observation)

*Always give adrenaline injector first, if someone has severe and sudden breathing difficulty (including wheeze, persistent cough or hoarse voice)

Australasian Society of Clinical Immunology and Allergy, 2021

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Anaphylaxis: Supportive Care

Monitor pulse, blood pressure, respiratory rate, pulse oximetry, conscious state.
High flow oxygen
IV access in tachycardic and/or hypotensive children
IV normal saline 20 mL/kg rapidly if hypotensive
Additional medicines:

Antihistamines and steroids help relieve symptoms.

Australasian Society of Clinical Immunology and Allergy, 2021

NHS, 2019

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Anaphylaxis: Prevention

Avoid triggers

Food:

Always read food labels
Check food labels and ingredients
Inform restaurant staff about allergen
Some types of food may contain small traces of potential allergens-for example, some sauces contain wheat and peanuts

Better Health, 2019

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Anaphylaxis: Prevention

Educate child and parents

Stress the importance of only accepting food from trusted adults such as parents or caregivers.
Never share food.
Obtain epinephrine emergency syringe and instruct in use

Inform the childcare service, kindergarten, school about child’s allergy.
Aware of environments that may increase the risk of insect sting or bite.

Better Health, 2019

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Anaphylaxis: Nurses Role

Assess Airway, Breathing and Circulation
Administer Epinephrine the child has anaphylaxis
Provide oxygen
Start 2 large-bore IVs
Educate on the avoidance of allergens
Monitor vital signs
Wear medical Identification bracelet
Teach patient and caregiver to read food labels

Lopez et al., 2022

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What Would the Nurse Do?

A nurse is providing education to a parent whose child has a severe peanut allergy. What instruction should the nurse include in the teaching. (Select all that apply)

Always check the food levels and ingredients
Stress the importance of only accepting food only parents or caregivers
Teach child not to share food with others
Obtain epinephrine emergency syringe and instruct in use
Introduce foods that the child is allergic to in small amounts over a long period of time

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Transient Hypogammaglobulinemia of Infancy (THI)

A type of antibody deficiency that affects infant and children typically below the age of 6 years (IgG)
Production of normal amounts of immunoglobulins is delayed
Levels become low starting at age 3 to 6 months and return to normal at about age 12 to 36 months

(Fernandez, 2021)

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Transient Hypogammaglobulinemia of Infancy (Continued)

Not thought to be a true immunodeficiency
Rarely leads to serious infections
A few infants develop frequent:

Sinus
Lung, or digestive tract infections
Candidiasis (a fungal infection) and
meningitis

More common among premature infants

Fernandez, 2021

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Critical Thinking Question

At what age would Transient Hypogammaglobulinemia of Infancy (THI) affect the child?

Below one month
Below six months
Below one year
Below 9 months

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Transient Hypogammaglobulinemia of Infancy

(Continued)

Unknown cause.
Disorder may last for months to a few years but usually resolves without treatment.

Vaillant & Wilson, 2022

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Transient Hypogammaglobulinemia of Infancy:

Diagnosis

IgG is at least two standard deviations below expected controls.
Blood tests to measure levels of immunoglobulins.
Evaluate immunoglobulin production in response to vaccines.

Vaillant & Wilson, 2022

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Transient Hypogammaglobulinemia of Infancy:

Management

Antibiotic treatment with prophylactic antibiotics is reasonable.
If allergic rhinitis occurs, treat with topical nasal corticosteroids and antihistamines.
Routine immunizations should be performed.

Vaillant & Wilson, 2022

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Transient Hypogammaglobulinemia of Infancy:

Nurses Role

Education regarding the risk of infections.
Precautions for infection prevention.
Compliance with medications, including antibiotics, immunoglobulins, and antihistamines, needed to reduce complications.

Vaillant & Wilson, 2022

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Critical Thinking Question

Transient Hypogammaglobulinemia of Infancy usually resolves without treatment

True
False

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Red Flags

Anaphylaxis:

Acute and severe onset of allergic reactions followed by difficulty in breathing and hypotension.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References:

ASCIA. (2021). ASCIA Guidelines - Acute Management of Anaphylaxis. https://www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines

Australasian Society of Clinical Immunology and Allergy. (2021). ASCIA First Aid Plan for Anaphylaxis. https://www.allergy.org.au/hp/anaphylaxis/first-aid-for-anaphylaxis

Better Health. (2021). Anaphylaxis. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/anaphylaxis

CDC. (2022 February 24). Food Allergies. https://www.cdc.gov/healthyschools/foodallergies/index.htm

Cheng A. (2011). Emergency treatment of anaphylaxis in infants and children. Paediatrics & child health, 16(1), 35–40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043023/

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References:

Delves,P. J. (2020). Anaphylaxis. MSD Manual. https://www.msdmanuals.com/professional/immunology-allergic-disorders/allergic,-autoimmune,-and-other-hypersensitivity-disorders/anaphylaxis

Fernandez, J. (2021). Transient Hypogammaglobulinemia of Infancy. MSD Manual. https://www.msdmanuals.com/home/immune-disorders/immunodeficiency-disorders/transient-hypogammaglobulinemia-of-infancy

Lopez, C.M., Yarrarapu S.N.S., & Mendez, M.D., et al.(2022). Food Allergies (Nursing). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570550/

NHS. (2019). Anaphylaxis. https://www.nhs.uk/conditions/anaphylaxis/

Vaillant, AA. J.,&, Wilson, A. M. (2022). Transient Hypogammaglobulinemia of Infancy. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544356/

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