Allergy" is a term often applied to a variety of conditions caused by a reaction of the immune system to normal substances in the environment. Some of these substances--dust mites, animal dander, molds or pollens--can be inhaled while others are ingested, such as food.

Allergies can affect the lungs, causing asthma; the nose, causing allergic rhinitis; and the skin, causing eczema or hives. When allergies affect the entire body at once, it is called an anaphylactic reaction, and such reactions can be life threatening.

Allergies are the most common chronic disease in childhood. Symptoms can often interfere with a child's quality of life and performance in school. Allergic emergencies are rare, but can be life threatening. Policies aimed at helping prevent reactions and responding quickly to symptoms when they do occur are the best way to prevent catastrophe.

Allergens

Substances that cause allergic immune reactions are called allergens. Most food allergies in children are caused by just five substances--wheat, eggs, milk, peanuts, and soy. As children get older, tree nuts, shellfish, and fish can become important allergens. Life-threatening anaphylactic reactions are most commonly caused by peanuts, shellfish, and fish.

Common inhaled allergens include dust mites, hair/dander from animals, feathers, molds, and pollens from trees, grass, or weeds. Inhalant allergies can start in the first years of life, but usually are more common in children three-four years of age or older.

Symptoms

The symptoms of allergies depend on the organs involved. If a child has allergies that affect the eyes, common symptoms are itching, tearing, redness and swelling of the eyelids. When the nose is involved, symptoms commonly seen are sneezing, runny nose, nasal congestion, and nasal itching. Many diseases other than allergies, including viral infections or colds, cause similar symptoms to allergies, and the two conditions can be difficult to tell apart. Allergies usually are more chronic, perhaps lasting for weeks, cause more itching and sneezing, and are not generally associated with fever or feeling ill as are colds. Allergies that affect the gastrointestinal (GI) tract can cause nausea, vomiting or diarrhea. Skin reactions such as itching and redness or hives can often accompany GI tract allergies.

The most serious form of allergic reaction to inhalants is asthma, in which allergens can cause inflammation in the airways of the lungs, leading to narrowing of the airways and an increased tendency of the muscles around the airways to contract. Symptoms include a sensation of tightness or pressure in the chest, wheezing, cough or shortness of breath.

Both inhaled and food allergens can cause a chronic, red, itchy and scaly rash that often affects the face and neck in infants and the creases in front of the elbow or behind the knees in older children. This is called eczema, or atopic dermatitis.

Anaphylactic reactions can produce symptoms involving all of these organs plus the heart and blood vessels. Typically patients will develop a flushing of their skin, often with hives. This may be followed by swelling in the throat, leading to trouble swallowing, and also by wheezing and shortness of breath. In severe reactions, blood pressure can drop and the child could lose consciousness. Early recognition of these symptoms leads to early treatment and can be life saving. Allergens that typically cause anaphylaxis in a school or childcare setting include foods, medications, and insect stings.

Prevention

• The best way to prepare for allergic reactions is to have policies and procedures in place that prevent such reactions from occurring. When a child enrolls, obtain information from the parent about the specifics of a child's allergies and medications used to treat the reaction. Each child with a history of allergies should have a management plan on file, as well as written permission from the child's physician to administer medication for a reaction. Staff must be educated to recognize the symptoms and signs of an anaphylactic reaction.
• Food preparation areas and utensils should be cleaned before being used on different foods to prevent cross-contamination. In general, it is recommended to prepare foods for allergic children first.
• Surfaces where children eat also can be contaminated with food allergens, and should be cleaned carefully after eating. Remember to clean tables used for food and craft projects. Allergic reactions can occur when allergenic foods such as peanut butter are used in craft projects.
• Be cautious if foods are brought for special occasions. If you are unable to assure that foods are free of allergens, then the most practical approach is to have the parents of allergic children prepare snacks for their own children for special occasions. Of course, precautions need to be in place to discourage food sharing.
• To reduce exposure to inhaled substances use floor coverings other than carpet. Banning furry pets from the environment may be helpful for children with dust mite and animal allergies. Choosing play options indoors on high pollen days may help children with seasonal allergies.
• Eating indoors is the best way to decrease exposure to stinging insects. Play areas should be inspected for nests, and children should always wear shoes.

Treatment for Severe Reactions

Early recognition of the symptoms of a severe allergic reaction, and prompt treatment (including administration of epinephrine if prescribed) are the keys to successful treatment. Waiting to see what happens, trying to call the parents first or giving other medications such as antihistamines, delays proper treatment, and may increase the risk of a poor, or even fatal, outcome.

Epinephrine comes in two forms, a filled syringe that contains enough medication for two-four doses, and a spring-loaded syringe with a single dose. The filled syringe is just like a regular syringe used in the doctor's office, and requires familiarity with the technique of administering shots. The spring-loaded epinephrine syringe, often referred to as an "epi pen," is easier to use, ensuring that the dose is administered appropriately. It is important that staff be trained in recognizing symptoms of a serious reaction and proper use of an epi-pen. Emergency help (911) should be contacted for any severe allergic reaction.

By Paul V. Williams, MD
Northwest Asthma & Allergy Center

RESOURCES

Allergy & Asthma Network Mothers of Asthmatics, 2751 Prosperity Ave., Suite 150, Fairfax, VA 22031; 800-878-4403; www.aanma.org

American Academy of Pediatrics,141 Northwest Point Blvd., Elk Grove Village, IL 60007-1098; 847-434-4000; www.aap.org

Asthma and Allergy Foundation of America (AAFA), 1233 20th Street, NW, Suite 402, Washington, D.C. 20036; 202-466-7643; www.aafa.org

INTERNET RESOURCES

www.asthmaandallergycenter.com