Alterations in

Immunological Status:

Allergies, JRA

Allergies

Reactions involving immunologic mechanism,

usually IgE responses

Allergens

Foods (Box 13-2, p. 528 Hockenberry 9th ed.)

Lactose IntoleranceAvoid foods HIGH in lactoseInfancy-- Soy formula In older children NO MILK Lactaid, etc

Atopic Dermatitis (eczema) (Box 13-5.p

541) Treat pruritis and inflammation,hydrate skin, prevent 2ndary infectionsTopical corticosteroids—1st-line tx

Symptoms of Milk Allergy

p. 530 Box 13-3 (Hockenberry, 9th ed.)GIRespiratoryOthersPREVENT FOOD ALLERGIES

No solids for 4-6 months of ageUntil 12 months of age = no cow’s milk, eggs, fish, corn, citrus, peanuts, chocolateIntroduce foods 1 every 5-7 days

Drug Allergies

Usually skin responseOr

ANAPHYLAXSIS !!

Environmental

AirborneHouse dust mitesCigarette smokeCat/Dog Dander

DiagnosisHX & Physical

Skin Testing

Specific IgE Immunoassays—

No patient risk other than blood draw

Not influenced by medications

May be used for patient’s with rashes

Lower sensitivity than skin testing (~70%)

Only a potential of allergy

Not as cost effective as skin testing for

screening.

RAST test(Radio/allergo/Sorbent Test)—

Skin Testing

Prick

Safe for any ageRapidMultiple testsMinimal discomfortResults in 15 minutesOver 80% accuracy for inhalantsOver 90% accurate for foods

Intradermal

Not tolerated by young patientsMore sensitive (1000X)Results in 15 minutesIf negative, results are near 100% predictiveNot used for foods

TreatmentMeds—

Topical corticosteroids, Oral Antihistamines, Nasal steroid sprays, Leukotriene antagonists, Nasal antihistamines, oral decongestants

Desensitization shotsTakes months to show effect, over 80% efficacy

Environmental ChangesMattress & pillow covers; wash bed linens weekly

Ø carpet especially shag; reduce humidity level

Ø blinds; should be replaced with curtains

Ø pets; no stuffed animals unless washableFrequent filter changes on furnace

Treatment for Food Allergies#1—Avoidance!!Research studies are being performed at Duke and Mt. Sinai specifically focusing on food desensitizations

10 years from now, there may be other treatmentsAt this time, only research protocols exist

Management of Food AllergiesHave an individual management plan—know food triggersHave a Food Allergy Action PlanEducate yourself and others—know school interventionsSeek help from food allergy resources: www.foodallergy.org Join a food allergy support group

Epipen and Epipen Jr.

Epipen: patients over 66 lbs (33kg)Epipen Jr: patient 33 lbs –66 lbs (15-30kg)

Patients who require the use of an Epipen should go to the Evergency Room for further evaluation

TO MAKE SURE THE EMERGENCY IS OVERTO PREVENT RECURRENCE OF ANAPHYLAXIS (MAY OCCUR 6-8 HURS AFTER INITIAL SYMPTOMS)

Juvenile Rheumatoid Arthritis (JRA)

Inflammatory Disease with an unknown etiology

PathophysiologyNIH resource

Chronic inflammation of synovial lining of the joint with fluid buildup (effusion)

into joint space joint erosion, and adhesion

formation

Incidence

Also called juvenile chronic arthritis or idiopathic arthritis of childhoodPeak ages: 1to 3 years and 8 to 10 yearsGirls > boysOften undiagnosed

Prognosis

Actually a heterogenous group of diseases

Pauciarticular onset (involves ≤4 joints)Polyarticular onset (involves ≥5 joints)Systemic onset (high fever, rash, hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy)

Poorest prognosis w/systemic onset; > 4

joints

Common symptoms

StiffnessPain & SwellingLoss of mobility in affected jointsWarm to touch, usually without erythemaTender to touch in some casesSymptoms increase with stressorsGrowth retardation

Affiliated symptoms

Iridocyclitis/uveitisInflammation of iris and ciliary bodyUnique to JRARequires treatment by ophthalmologist

90% children have negative rheumatic factorSymptoms may “burn out” and become inactive Chronic inflammation of synovium with joint effusion, destruction of cartilage, and adhesion formation as disease progresses

Diagnostic Evaluation

No definitive diagnostic testsElevated sedimentation rate in some casesX-ray 1st: widening of joint space,

2nd: fusion and articular erosionAntinuclear antibodies (ANA) common, but not specific for JRALeukocytosis during exacerbationsDiagnosis based on criteria of American College of Rheumatology

American College of Rheumatology Diagnostic Criteria

Age of onset younger than 16 yearsOne or more affected jointsDuration of arthritis more than 6 weeksExclusion of other forms of arthritis

Management Goals

Preserve Joint Function

Prevent Physical Deformity

Relieve Symptoms w/o further

complications

TreatmentExercise/PTMedications

NSAIDS Ibuprofen, Tolmetin, Naprosyn

SAARD’sD-Penicillamine, Gold, Quinine

OthersCytoxic drugs (Methotrexate) & Corticosteroids

TNF Blockers—new kid on the block

Etanercept (Enbrel) IM 2X/wk self administeredInfliximab (Remicade) IV q 2mos

Nursing Measures

Careful AssessmentAdminister medications and teach family about managementMoist heatReferrals

American Juvenile Arthritis Organizationhttp://www.arthritis.org