Talking Allergies

Last week I attended a presentation by Dr. Allan Becker from Winnipeg. It was organized by Sanofi to support the launch of Allerject, but Dr. Becker did a great job keeping it neutral. The main focus of the presentation was about anaphylaxis. The audience were mostly family physicians so it was tailored as a medical talk. I already knew most of what was presented, so I didn't take a lot of notes. Here are some of the things I jotted down. Discuss! #3 will be a discussion point, for sure...

1. Risk factors for anaphylaxis
- history of severe reaction
- asthma
- delay in administration of epinephrine or failure to carry(most likely teen males)
- denial of symptoms
- failure to inquire about food ingredients
- beta-blocker therapy
- teens and young adults risk-taking behaviour
- lack of awareness by others

2. Parents NEED to be on the same page. He went on to discuss how many reactions happen because 1 parent is more in denial about the allergy or has his /her own ideas about how to manage it.

3. Direct quote: "It is unconscionable to ask school staff to decide between using antihistamines and epinephrine." He was quite passionate about this. He seemed frustrated that so many parents still send Benadryl to school along with an epi and will specify to use Benadryl only / first / instead of epi for xyz symptoms, etc. He went on to stress that antihistamines MUST NOT be used 1st line in anaphylaxis.

My take on point #3 - I agree and have taken this route for several years now but I confess I was guilty of this in the early school years. In a case where an allergist has actually recommended Benadryl for allergy symptoms and has determined that anaphylaxis is not a risk, then it's probably OK. BUT if you have been prescribed epinephrine because of risk, then he said there is no other choice in the event of a reaction - particularly in a school situation. We all know now that Benadryl can only treat itch and hives (and therefore may actually mask more serious symptoms) - it cannot help symptoms of swelling, or any of the other symptoms of a reaction. How does a teacher know that the throat isn't swelling? Or that the blood pressure is dropping? Or the cough isn't from crying, it's from bronchospasm? My son's last reaction 3 weeks ago had no obvious signs other than the rash and the fact that he was telling me he needed the epi - looking back, his voice was quite hoarse and he said he couldn't swallow any water when he tried to take a drink, and it turned out his laryngeal area was very swollen. After the epi, he developed wheeze and bronchospasm which were no doubt kept in check by having taken the epi. His reaction escalated even at the ER. I try not to dwell on the "what ifs" anymore - and focus on the fact that he KNEW he needed it and he did it. There was no pain, he said.

So if anyone is reading this and are still unsure of Benadryl vs epinephrine, the message from the allergist community could not be more clear - there is NO role for Benadryl 1st-line in anaphylaxis. The choice to give it can be made in the ER for symptom management, of course, but it should not be given as an "either/or" option for caregivers. He also went on to conclude that anyone who has had the epi has said afterwards that it wasn't that big a deal, it didn't really hurt, and it made them feel better quickly. They also wouldn't hesitate to use it again if needed. If your family doctor still recommends this course of action, you may want to tell them to read the latest anaphylaxis guidelines - better yet, print them out and leave them with the doctor. I wish I had done that with a cocky resident who told me, as my son laid in the ER after his 1st anaphylaxis - "this was not an anaphylactic reaction because it took too long after he ingested the food. It happens in the 1st 5 minutes." When I gently challenged him that a milk reaction can take longer due to the digestive process required to isolate the protein he said "I just finished my ICU rotation and my patient had suffered anaphylaxis so I am up-to-date on all of the information." I gave up.

ds: 12 yo, asthma, ana to milk, tree nuts, baked milk tx has lead to exercise-induced anaphylaxis AND eosinophilic esophagitis. Last rxn 3 weeks ago and we will never know what caused it

Me, dh, dd (10): no allergies, no asthma

Terrific post MomtoB. Thanks for sharing!

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Allergic to soy, peanut, shellfish, penicillin

Thank you for the great summary!

Our Pediatric Allergist and nurse in Winnipeg both said the same thing about Benadryl. A different Allergist here also said that "Benadryl goes along for the ride" with anaphylaxis because it can not stop anaphylaxis. If the anaphylaxis happens to stop it was not because of the Benadry!

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me: allergic to crustaceans plus environmental
teenager: allergic to hazelnuts, some other foods and environmental

Thanks for the update. I still get parents telling me to give Benadryl for reactions and then hand me an EpiPen for the child. Is there a summary sheet I can print out to give to these parents? This kid has a history of systemic reactions (none in my care, thank goodness.)

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anaphylaxis to tree nuts and peanuts; asthmatic, dairy intolerant, vegan
other family members allergic to to dairy, egg, peanut, peach, banana, sesame, environmentals