MMCH 032 - Guidelines on the management of allergic ... - management of... · Appendix 4 Care Plan...

G/Everyone/Medicines Management Community Services/Guidelines/MMCH 032 - Guidelines on the management of

allergic reactions in children and young persons. Version 1. June 2013. 1 of 39

Guidelines on the management of allergic reactions in children and young persons

Version 1 Approved by the Drugs and Therapeutic Committee Date: 21 June 2013 Review date: 21 June 2016

Document Reference MMCH 032



These guidelines endeavor to deliver care in such a way as to treat patients fairly and respectfully regardless of age, gender, race, ethnicity, religion/belief, sexual orientation and/or disability.

The care and treatment provided will respect the individuality of each patient. These guidelines should be read in conjunction with the following Pennine Care Policies: CL15 Medicines Policy CL9 Resuscitation Policy C020 Records Management Policy



Contents

1. Introduction/Acknowledgements 4 2. Scope/Purpose 5 3. Definition of terms 6 4. Competence 7 5. Referral Pathway 8 6. Referral 9 7. Signs and symptoms of allergy/anaphylaxis 10 8. Adrenaline dosage 15 9. Contraindications/other considerations 21 10. Evaluation/Audit 21 11. References 22 12. Appendices

Appendix 1 Staff competency form Appendix 2 Professionals Checklist Appendix 3 Allergy plan/information pack Appendix 4 Care Plan

.



1. Introduction

Allergies are highly prevalent in the human population, and can trigger reactions which

cause symptoms such as allergic conjunctivitis, rashes, itchiness, and runny nose. In

some people, severe allergies to environmental or dietary allergens or to medicines

which may result in life-threatening reactions and potentially death, this is referred to as

anaphylaxis.

Anaphylaxis is a medical emergency and a good outcome depends on early recognition

and appropriate treatment.

It is essential that those health professionals looking after children with allergies are

appropriately trained in the recognition of symptoms and administration of the

medicines.

As children become older and gain more independence, it is important they carry

information regarding their allergies and their medicines, and are empowered to learn

how to prevent and manage severe allergies/ anaphylactic reactions.

The purpose of this guideline is to provide guidance to staff, parents, carers, children,

and young persons on the safe management of severe allergic reactions in a

community setting.



2. Scope

These guidelines are intended for use by registered nurses caring for children aged 0-

16 years, (0-19 years for children with complex health needs or cared for by School

Health Team) employed within Pennine Care NHS Foundation Trust (PCFT), who care

for children who are at risk of severe allergic reactions, or who provide guidance to staff,

parents, carers and children on the management of the child at risk of severe allergic

reactions in a community setting. This includes nursing staff in the Children’s

Community Team, School Health team and Health Visitors. These guidelines will allow

those health professionals to provide accurate, up to date information and advice to

children, parents, carers on the safe management of allergic reactions in a community

setting.

Nurses delivering intravenous (IV) therapy, immunisations or vaccinations should

adhere to Pennine Care Foundation Trust’s Adrenaline PGDs (PGD 3 and PGD 42) and

Basic life support (2011) guidance which also need to be read in conjunction with the

listed policies.

Statement of best practice: The brand of adrenaline auto injector pens would be

determined and prescribed by the Consultant/GP and would usually be Epipen or Jext

pen, these are the products of choice for use across PCFT, as they are

easy/convenient and safe for patients/carers to use in an emergency situation. In the

event of a different adrenaline auto injector pen being prescribed, the administration

instructions, detailed in these guidelines are not applicable and manufacturer’s

administration guidelines would need to be followed.



3. Definition of Terms

Allergic reaction: An allergic reaction is a sudden release of chemicals including histamine, from cells in the blood and tissues where they are stored causing a variety of symptoms. Anaphylactic reaction/Anaphylaxis: Anaphylaxis refers to a rapidly developing and serious allergic reaction that affects a number of different areas of the body at one time. Severe anaphylactic reactions can be fatal. Brittle Asthma: is a term used to describe two rare phenotypes of asthma distinguishable by recurrent, severe asthma attacks. The cardinal symptoms of an asthma attack are shortness of breath (dyspnoea), wheezing, and chest tightness. Adrenaline: A hormone produced naturally by the medulla of the adrenal gland, released in response to stressful stimuli, it can be given artificially in circumstances Such as anaphylaxis. It makes the heart beat stronger and faster. It increases blood flow to main vessels and allows smooth muscle to relax. Adrenaline auto injector pen: A pen device which is pre loaded with a single dose of adrenaline, to administer in the case of anaphylaxis. The BNFC (2012-2013) state: Child body weight under 15kg = 150micrograms repeated after 5 to 15 minutes as necessary. Child body-weight 15 to 30kg = 150micrograms (but on the basis of a dose of 10micrograms/kg, 300 micrograms may be more appropriate for some children) repeated after 5 to 15 minutes as necessary. Child weighing above 30kg: 300 micrograms repeated after 5 to 15 minutes as necessary. Please check the most recent British National Formulary for Children, (BNFC) for up-to-date dosages. Tachycardia: Increased heart rate. Throughout this guideline the word nurse may be used as a generic term to include Children’s Community Nurses, Staff nurses, Health visitors and Nursing staff for the School Health Team.



4. Competence

Prerequisite: In order to achieve competence the nurse (as stated in definition of terms,)

must have attended the PCFT’s train the trainer course, must also be up to date with

PCFT’s annual mandatory training in basic life support, (BLS) and anaphylaxis.

Following this they must attend a taught educational session on management of

allergies and the use of adrenaline auto-injector pens, provided by PCFT’s learning and

development team. Once this session has been attended and their names entered on

the generic database competency can be assessed.

The Nurse will be assessed on their knowledge of allergic reactions/ anaphylaxis & how

to administer the adrenaline auto injector pen, by completing a supervisory training

session under the supervision of a competent Nurse, and completing the staff

competency form, (see appendix 1.)



5. Referral Pathway for professionals/Parents/Carers

Children at risk of allergic reactions/anaphylaxis

with adrenaline auto- injector pen

prescribed

Referrals from any Professionals/ Health Professionals/Parents/Carers (If diagnosis

confirmed by a health professional.)

Pre-school Child

Children’s community nursing team/ Health visitors in Oldham will

provide yearly updates and support for parents, carers/ nursery staff.

A referral to relevant School Health Practitioner at school age

Child referred to Children’s Community Nursing Teams HMR and

Bury for 1st contact. Allergy Management plan and information pack given. (In Oldham 1st contact

made by Health Visitor/School Nurse)

Initial training carried out Allergy plan/ information pack

given to Child/Family

School aged Child

Children’s Community Nursing Team/ Health Visitor (Oldham) to promptly discharge to relevant School Health Practitioner for further management. School Health practitioner to provide support for school/parents/carers and

offer yearly updates.



6. Referral to the team

Children, who are considered to be at risk of allergy/anaphylaxis and have

adrenaline auto injector pens prescribed, can be referred to the Children’s

Community Nursing Team (CCNT)/ (Health Visitors in Oldham) for training.

Referrals are accepted by Professionals and parents/carers (if diagnosis is

confirmed by a Health Professional).

From referral to the CCNT, the child and family can expect:

• The health professional to liaise closely with the child and family.

• A referral, to the paediatric allergy specialist services at Central Manchester

Foundation Trust, if appropriate, based on health professionals assessment,

• Guidance at home for the family/carers on recognition and treatment of allergies

and anaphylaxis.

• Children under school age and their carers will be supported by the CCNT who

will offer annual updates (or sooner as the need dictates) and advice or support if

their condition/circumstances change for child/family/nursery.

• School aged children and their families will receive the initial training by CCNT at

home, and will then be discharged to the care of the School Health Practitioner.

Annual updates for child/family/school will then be offered by School Health

team.

• Child/Parents/Carers will be offered a yearly update, by letter which will be

copied to child’s General Practitioner/ lead Consultant.

• Child and family will receive an allergy plan and information pack, containing

information on recognition of symptoms, administration of treatment, pen storage,

and useful contacts; this will be given at initial training, and reviewed annually or

if any changes are required to the plan of care. Copies will be provided for

school/nursery and also stored in the child’s notes.

• All Children/Families/Carers will have an opportunity to receive up to date

education/ask questions and use practice pens.



7. Signs and symptoms of Allergy/ Anaphylaxis

It is important to recognise signs and symptoms of allergic reactions:

Area of body Allergy Anaphylaxis

Skin Redness, itching, wealing Sudden swelling of face or any

part of the body

Mouth Funny taste or irritation Sudden swelling, ‘lump’ in the

throat, difficulty swallowing

Eyes Irritation, watering Sudden swelling, causing eyes to

close

Nose Runny, bouts of sneezing Sudden blockage of both nostrils,

inability to nose breath

Airways Croupy cough Sudden breathing difficulty,

wheeze, croup, stridor

Digestion Vomiting, diarrhoea Abdominal cramp, pain

Cardio-vascular Tachycardia Collapse, faint, low blood pressure

(Resuscitation council 2012.)



Symptoms which may provide a differential diagnosis

Condition Symptoms Treatment

Asthma Attack Breathing difficulty,

Tachycardia, absence of

rash/swelling.

May respond to

Salbutamol inhaler/seek

medical review.

Faint (Vasovagal

episode.):

Tachycardia, breathing

difficulties. No rash or

swelling present.

Symptoms may respond

to patient lying down

and raising legs.

Panic attack Tachycardia, breathing

difficulties. Absence of

hypotension, pallor,

wheeze, rash or

swelling.

Seek medical review for

diagnosis/treatment.

Idiopathic/ non-

allergic Urticaria

Presence of generalised

rash. (Raised nettle type

rash.) With no other

symptoms.



Non allergic

Angiodema

Presence of swelling

usually to hands, feet

genitals.



(Resuscitation council 2012)



Recognition and Treatment of Allergic Reactions

The following symptoms can be recognised as mild, moderate and severe allergic

reactions, depending on the symptoms present, the professional/ parent/carer will

decide the appropriate treatment and course of action following the allergic reaction

pathway.

Organ Mild/Moderate Allergy Severe

Reaction/Anaphylaxis

Skin Redness, itching, wealing,

nettle type raised rash, pallor

or flushed appearance.

Sudden swelling of face or any part

of the body.

Mouth Funny taste or irritation, mild

swelling, burning sensation.

Sudden swelling, ‘lump’ in the

throat, difficulty swallowing.

Eyes Irritation, watering, mild

swelling.

Sudden swelling, causing eyes to

close.

Nose Runny, bouts of sneezing. Sudden blockage of both nostrils,

inability to nose breath.

Airways Croupy cough,

wheezing/hoarseness

Sudden breathing difficulty, noisy

fast breathing as well as moderate

airway symptoms.

Digestion Vomiting, diarrhoea,

abdominal pain.

Abdominal pain.

Cardio-vascular Fast heart beat, irritable Collapsed, faint, dizzy, irritable.



A severe reaction is more likely to occur when children

1. Have underlying problems, particularly brittle asthma where the patient has

frequent attacks or hospital admissions or heart problems.

2. Are on treatment with beta-blocker drugs (sometimes prescribed for severe

migraine)

3. Ignore mild/moderate allergic reactions (as detailed in previous page.)

Allergic and anaphylactic reactions may be caused by

1. Foodstuffs:

• Cow’s milk and its products such as cheese and yoghurt; eggs.

• Peanuts and other nuts.

• Fish and shellfish and pulses.

• Citrus fruits.

• Vegetables.

2. Idiopathic (cause unknown.)

3. Injections (immunisations, antibiotics, contrast media or anaesthetics.)

4. Latex/ Hair dye

5. Other drugs e.g. local anaesthetic/ non steroidal anti inflammatory / strong pain

killers.

6. Insect stings.



Allergic reaction pathway

Allergic Reaction based on signs/ symptoms

Mild/Moderate, get help and if in doubt ring 999

1. Remove trigger if possible. 2. Administer antihistamine (if prescribed) 3. Administer salbutamol Inhaler (if

available/prescribed.)

Improvement

Yes

Administer adrenaline auto injector (if prescribed) into Vastus lateralis (middle of outer thigh.) Hold in place

for 10 seconds for container to fully empty.

Monitor & Observe Inform parents as soon as safe to do so.

No

Check time, encourage child to find a comfortable position, if feeling faint do not sit or stand Administer inhaler if prescribed/ available.

Child to go to hospital Contact parents, if not present, as

soon as safe to do so

Shout for help/Ring 999 Commence Basic Life Support if indicated at any stage.

Severe/Breathing Difficulties

Patients who are unconscious but breathing place in the recovery position, Left side if pregnant.



8. Adrenaline auto-injector pen dosage

Children requiring an adrenaline auto injector pen should be under the care of a

Consultant. The adrenaline dosage is based on the recommendation of the

consultant/GP who has prescribed the adrenaline auto injector pen.

Please refer to the current British National Formulary for Children, (BNFc) for

recommended dosages. Request an individual plan of care from the child’s consultant

for any prescriptions outside of BNFc guidelines.



Advice on use of adrenaline auto injector pen

Procedure Rationale Evidence

Explanation of

allergies/anaphylaxis and

management.

To develop understanding of

process of

allergies/anaphylaxis

(Anaphylaxis

campaign 2012,

Resuscitation

council 2012.)

Explanations of allergy

plan/Information pack.

To develop understanding of

when adrenaline auto

injector pen should be used.

(Anaphylaxis

campaign 2012,

RCPCH 2011.)

Ensure child has two

adrenaline auto injector

pens, (one for home and

one for school/nursery.) If

two pens are prescribed,

(based on clinical need),

a further two pens will be

required for home and

school/nursery. Remind

parents/carers the

importance of checking

the expiry regularly.

So adrenaline auto injector

pens are always available.

(Anaphylaxis

campaign 2012,

BNFC 2012/13,

RMCH 2008.)

Demonstrate use of


pen with training pen and

observe the individual

use pen. (Trainer pens for

parents/carers should be

encouraged and are

available direct from the

manufacturers).

To ensure trainee has hands

on practice and check

technique.

(Anaphylaxis

campaign 2012.)

Fill in professional’s

checklist and sign (See

appendix 2).

To adhere to Trust/NMC

policy for record keeping.

(NMC 2010.)



Give child and family

allergy plan/ information

pack

Include School Health

Practitioner (SHP)

contact details if

appropriate.

To provide written as well as

verbal information.

(Anaphylaxis

campaign 2012.)

Confirm any further

advice/support required

and dates and ask

child/family to request an

annual update.

Refer to School Health

Practitioner if applicable.

To give parents/carers

responsibility for annual

updates.

(Anaphylaxis

campaign 2012.)



Directions for using Adrenaline auto injector pen: Call 999 prior to administration.

Only the thigh area should be used for administration. Injection into the hands or

feet could result in loss of blood flow to these areas. If this occurs the person

affected should go to their nearest Accident and Emergency Department


The pen should be checked

for correct dosage/ expiry.

The adrenaline auto injector

pen should be held firmly in

the hand by clasping it with

a fist. (Do not hold like a

writing pen as it may slip.)

Ensure pen is safe to

use. Ensure a firm grip

and avoid error in

administration.

(Anaphylaxis

campaign 2012.)

Pull off the safety cap To allow the device to

activate

(Anaphylaxis

campaign 2012.)

The injection should be

given into the thigh muscle,

which is the middle outer

quarter of the leg. (Vastus

lateralis muscle.

The Intra muscular

route allows adequate

absorption and

distribution of the

medicine and is

recognised as the safest

administration technique

of adrenaline in a

community setting.

(Anaphylaxis

campaign 2012,

BNFC 2012/13,

RCPCH 2011.)

Refer to pen device

guidance and as directed

with trainer pen: Using mild

force, swing and jab the pen

in to the outer thigh or if

stated, press the adrenaline

auto injector pen into the

leg. A click will be heard.

Clothes do not need to be

To ensure enough force

is used to activate the

pen’s mechanism.

(Anaphylaxis

campaign 2012)



removed, except for denim

jeans.

Hold the Adrenaline auto

injector pen against the leg

for 10 seconds.

To ensure all of the

medicine is delivered

into the muscle.

(Anaphylaxis

campaign 2012)

Remove Adrenaline auto

injector pen and massage

injection site gently for 10

seconds.

To encourage

medication to spread

through muscle.

(Meda 2011.)

After use the adrenaline

auto injector pen needle

may have an automatic

needle cover, if not ensure

the pen is placed in the

safety container, ensure

pen (s) are given to the

ambulance crew.

To minimise the risk of

needle stick injury.

To update health

professionals of

treatment received.

(Anaphylaxis

campaign 2012.)

If no improvement is seen

within 5 minutes, and a

second pen is prescribed,

this can be administered.

This should ideally be given

in the other leg; if this is not

achievable the second

injection site should be at

least 5cm away from the

first injection site.

To attempt to resolve

allergy/anaphylaxis if

first dose has not been

successful.

To allow optimum

absorbency of

medication according to

manufacturer’s

instructions.

(Anaphylaxis

Campaign 2012,

BNFC 2012/13.)



Storage of Adrenaline auto injector pen device


The adrenaline auto

injector pen (s) should be

stored inside the yellow

tube it is supplied with,

and then inside a named

Tupperware container

with other medication

prescribed.

The yellow tube protects the

medication as it is light

sensitive.

The container is durable so

will protect the pens from

damage.

(Anaphylaxis

campaign 2012.)

Place child’s name on

front of box. Schools may

wish to place a picture of

the child also on the box,

with a copy of the child

specific allergy plan/

information pack (see

appendix 3.)

To ensure the correct

medicine is administered to

the correct child and reduces

confusion in an emergency

situation.

(Anaphylaxis

campaign 2012.)

Ensure expiry dates are

regularly checked.

Paperwork inside the


pen box is completed,

and posted for

registration, to ensure the

family receive expiry

reminders, to request

new pen (s) from GP.

Registration can also be

carried out online.

To prevent the medicine from

being expired.

To provide a reminder of

when the pen will expire.

(Anaphylaxis

campaign 2012.)



9. Contraindications/Other considerations

Pregnancy and lactation:

Adrenaline should only be used in pregnancy if potential benefit of treatment outweighs

the risks for the foetus.

Adrenaline is not orally bio available; any adrenaline excreted in the breast milk would

not be expected to have any effect on the nursing infant.

10. Evaluation/Audit

These Guidelines will be reviewed every 2 years or sooner if new information becomes

available, evaluations will be carried out at each staff education session. Nursing

records will be subject to a periodic evaluation as part of trust policy (PCFT 2012.)



11. References

A.J Frew (2010) what are the ideal features of an Adrenaline auto injector in the treatment of Anaphylaxis? Department of respiratory medicine, Brighton UK. John Wiley and Sons. Allergy UK (2012) Internet available from www.allergy.uk.org accessed May 2012. Asthma UK (2012) Internet available from www.asthma.org.uk accessed June 2012. BNFC (2012/13) British national formulary for children the essential resource for clinical use of medicines in children Basingstoke. RPS publishing. Meda (2011) Epi Pen Guidance (INTERNET) Available from www.epipen .co.uk. Accessed May 2012. NMC (2010) Record keeping guidance for nurses and midwives London. NMC. Paediatric Community Team (2008) Policy for the Management of severe allergic reactions in children. Community team services. Bury. Pearce, D (2011) Guidelines for the management of allergic reactions in children and young people with a known allergy. HMRCHC. Pennine Care Foundation Trust (2012) Medicines Policy V6 Pennine Care Intranet accessed May 2012. Pennine Care Foundation Trust (2012) Records Management Policy Pennine Care Intranet accessed May 2012. Pennine Care Foundation Trust (2012) Resuscitation Policy V6 Pennine Care Intranet accessed May 2012.

Royal college of Paediatrics and Child Health (2011) Allergy Pathways for Children: Anaphylaxis (INTERNET) available from www.rcpch.ac.uk/allergy accessed January 2011. Royal Manchester Children’s Hospital (2008.) Prescribing changes of adrenaline devices.

The Anaphylaxis Campaign (2012) Internet available from www.anaphylaxis.org.uk accessed May 2012. The Resuscitation Council (2008) Emergency treatment of anaphylactic reactions. Available from www.resus.org.uk accessed May 2012.



12. Appendices

G/Everyone/Medicines Management Community Services/Guidelines/MMCH 032 - Guidelines on the management of allergic reactions in children and young persons. Version

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Appendix 1 Staff competency form

NAME: DATE COMMENCED_______ DEMONSTRATE APPROPRIATE KNOWLEDGE AND SKILLS: Allergy, Anaphylaxis and Adrenaline auto-injector pen training: Theory session attended BLS/ Allergies and Anaphylaxis/Adrenaline auto injector pens Date: _____________

CRITERIA METHOD OF ASSESSMENT DATES OF OBSERVATION

COMMENT SIGNATURE, NAME, DESIGNATION

DATE

Anaphylaxis: Explanation of allergy/ anaphylaxis and definition given.

Question verbally/Observe teaching session.

Symptoms: Allergic and anaphylactic reactions and common causes given.

Question verbally Updates/copies of Information obtained.

Treatments: Antihistamine/ bronchodilator (if applicable) Adrenaline auto-injector pen: Demonstrate How to give pen When to give second pen (if applicable.) Pen (s) for school nursery, (if applicable.) How the medications work/affect the body. Procedures to be taken after giving pen (s).



1. June 2013. 25 of 39

Adrenaline auto-injector Pen storage: Expiry Shelf life Appropriate storage Copy of plan/administration procedures included Labelled Protection from light/extremes of temperature Easy access.


Other considerations: Inform scheme Travel/Insurance Kissing/Contact Allergen avoidance/risk assessments /eating out.

Question verbally/observe teaching session.

Information sharing: If/When to refer to Paediatric allergy specialist. Permission to inform SHP (if applicable) Nursery: arrange training if applicable.


Updates: Advise child and family annual about offer of annual updates, these are offered to nursery/school also. Family are offered updates through CCNT if below school age of SHP if school age.

Observe teaching session/Question Verbally.


1. June 2013. 26 of 39

SHP contact details given if applicable. Questions: Child/family given opportunity to ask questions.

Observe teaching session.

Written information: Individualised Allergy plans and information pack including contact details given to child/family/copy kept for notes.

Observe Teaching session/ Observe completed paperwork.

DATE OF FINAL COMPLETION _____________________________________________________________ Minimum Qualification of Assessor: Competent Practitioner with experience in allergy and its management. Links to: KSF DIMENSION: C1 Communication, C5 Quality, HWB2 Assessment and care planning to meet health and wellbeing needs, HWB3 Protection of health and wellbeing, IK1 Information processing and any other including occupational standards, Standards for Better Health.

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Appendix 2. Professionals checklist for Allergies/Anaphylaxis and Adrenaline auto injector administration

Name of Professional: Date of session: Childs Name: DOB: NHS number: Consultant/GP:

Details of Training Given

Sign and Date Comments

Allergy/Anaphylaxis: Explanation of Allergy/anaphylaxis and definitions given

Symptoms: Allergic and anaphylactic reactions and common causes given.

Treatments: Antihistamine/bronchodilator (if applicable) Adrenaline auto-injector pen: How to give pen When to give second pen (if applicable.) Pen (s) for school nursery (if applicable.) How the medications work/affect the body. Procedures to be taken after giving pen (s).

Adrenaline auto-injector pen storage: Expiry Shelf life Appropriate storage Copy of plan/administration procedures included Labelled Protection from light/extremes of temperature Easy access.



Other considerations: Inform scheme Travel/Insurance Kissing/contact Allergen avoidance/risk assessments/eating out.

Information sharing: Refer to Paediatric allergy specialist if applicable. Permission to inform SHP (if applicable) Nursery: arrange training if applicable.

Updates: Advise child and family annual about offer of annual updates, these are also offered for nursery/school. Family will be offered updates through CCNT if below school age of SHP if school age. SHP contact details given if applicable.

Questions: Child/family given opportunity to ask questions.

Written information: Individualised Allergy plan and information pack including contact details given to child/family/copy kept for notes.

Signed by professional: Date:

Signed by parent(s)/Carer(s): Date:



Appendix 3.

Allergy plan/ information pack

Name:

Address:

Date of Birth:

NHS number:

School/Nursery:



Anaphylaxis/Allergy treatment plan

Name:

Dob: Address (Including parents/carers contact details):

NHS number: Next of kin: School /Nursery/name/address:

School Nurse/ Health visitor name/contact details/base

GP name/address:

Consultant name/address:

Allergies to :

Symptoms at last reaction; Mild/moderate: Severe:

Medication prescribed/Management plan:

Date of last annual update/Due:



After referral to the Children’s Community Nursing Team (CCNT), the child and

family can expect:

• Training at home for the family on the recognition and treatment of allergy,

anaphylaxis and use of the prescribed Adrenaline auto-injector pen.

• Support from the CCN team, who will provide initial training and offer annual

updates, including training and the offer of annual updates for any nursery/

pre-school placements, if under school age.

• An information pack and action plan, which will contain information about

recognition, administration, pen storage, and useful contacts.

• An opportunity to use practice pens, ask questions and receive up to date

information.

• School age children will be referred to the relevant school health

practitioner (SHP) after the initial home training has been carried out by

the CCNT. The SHP will then Offer annual updates and any training or

annual updates required and requested by school/parents and carers.



General Signs and symptoms of Allergy and Anaphylaxis

(Mild/moderate symptoms may not always occur/symptoms will vary, please

follow your individual action plan for treatment options

Organ Mild/Moderate Allergy Severe

Reaction/Anaphylaxis

Skin Redness, itching, wealing,

nettle type raised rash, pallor

or flushed appearance.

Sudden swelling of face or any

part of the body.

Mouth Funny taste or irritation, mild

swelling, burning sensation.

Sudden swelling, ‘lump’ in the

throat, difficulty swallowing.

Eyes Irritation, watering, mild

swelling.

Sudden swelling, causing eyes to

close.

Nose Runny, bouts of sneezing. Sudden blockage of both nostrils,

inability to nose breath.

Airways Croupy cough,

wheezing/hoarseness

Sudden breathing difficulty, noisy

fast breathing as well as

moderate airway symptoms.

Digestion Vomiting, diarrhoea,

abdominal pain.

Abdominal pain.

Cardio-vascular Fast heart beat, irritable Collapsed, faint, dizzy, irritable.



Allergic and Anaphylactic Reactions

Anaphylaxis is a term used to describe an acute severe life threatening reaction.

A severe reaction/Anaphylaxis is more likely to occur when children:

1. Have a severe food allergy

2. Have underlying problems, particularly brittle asthma where the patient has

frequent attacks or hospital admissions or heart problems

3. Are taking certain medications

4. Ignore early warning signs.

Adrenaline auto-injectors:

The brand of adrenaline auto injector pens would be determined and prescribed by

the Consultant/GP and would usually be Epipen or Jext pen, these are the products

of choice for use across PCFT, as they are easy/convenient and safe for

patients/carers to use in an emergency situation. In the event of a different

Adrenaline auto injector pen being prescribed, the administration instructions,

detailed in these guidelines are not applicable and manufacturer’s administration

guidelines would need to be followed.

All children who require Adrenaline auto-injectors to be administered in the

community need to be transferred to hospital via ambulance for further

monitoring/management.



Directions for using adrenaline auto-injector: (EpiPen/Jext)

Procedure Rationale

In the event of a severe

allergic/anaphylactic reaction, dial 999

record the time.

Sit the child in a comfortable position

with legs raised.

Remove the adrenaline auto-injector

from its box and packaging.

For medical help to be on its way.

To be aware of the time adrenaline is

administered.

To counteract the drop in blood pressure

from the severe reaction.

In preparation of administering the

adrenaline auto-injector pen.

The adrenaline auto-injector pen should

be held firmly in the hand by clasping it

with a fist. (Do not hold like a writing pen

as it may slip.)

Ensure a firm grip and avoid error in

administration.

The injection should be given into the

thigh muscle, in to the outer middle of the

leg.

To adhere to manufacturers

guidelines/Safest form of administration

in a community setting.

Pull off the safety cap To allow device to activate

Refer to pen guidance also how

demonstrated with trainer pen: Using

mild force from about 10-50cm away

from the leg, swing and press the pen in

to the outer thigh, or if advised Press

the pen against the leg into the outer

thigh. A click will be heard.

Clothes do not need to be removed,

except for denim jeans.

To ensure enough force is used to

activate the pen’s mechanism/to adhere

to manufacturers guidelines.

Hold the adrenaline auto-injector pen

against the leg for 10 seconds.

To ensure all of the medicine is

delivered into the muscle.

Massage area for 10 seconds.

To adhere to manufacturer’s

instructions, allow maximum distribution

of medication.



After use the adrenaline auto injector pen

needle may have an automatic needle

cover, if not ensure the pen is placed in

the safety container, ensure pen (s) are

given to the ambulance crew.

To provide health professionals with

used pen for disposal.

To minimise any risk of needle stick

injury from an exposed needle.

If a second pen is prescribed and no

improvement is seen within 5 minutes,

the second pen can be administered.

This should ideally be given in the other

leg; if not achievable the second injection

site should be at least 5cm away from

the previous injection.

To treat severe allergic reactions if first

dose has not been successful.

To allow optimum absorbency of

medication according to manufacturers

guidelines.

Only the thigh area should be used for administration of adrenaline auto-

injector pens. Injection into the hands or feet could result in loss of blood flow to

these areas. If this occurs, the person involved should go to the nearest A&E

department.



Storage of adrenaline auto-injector pen

Procedure Rationale

The adrenaline auto –injector pen

should be stored inside the protected

tube and then inside a Tupperware

container with other allergy medication

prescribed.

The tube protects the medication as it

may be light sensitive.

The Tupperware box is durable so will

protect the pens/medications from

damage.

Place child’s name on front of box.

Schools/Nursery may wish to place a

picture of the child also on the box, with

a copy of the child specific action plan.

To ensure the correct medication is

administered to the correct child and

reduces confusion in an emergency

situation.

Ensure expiry dates are regularly

checked. It is recommended that the

paperwork inside the Adrenaline auto-

injector pen box is posted for

registration, via royal mail to address

provided to ensure the family receive a

reminder when it is due to expire. This

can also be carried out online.

To inform parents/carers/professionals

when a pen will expire, to allow them to

order a new pen via their GP.

Plan agreed by Parents/carers: Date:

Children’s community team: Date

Allergic reaction pathway for parents/carers

Allergic Reaction based on signs/symptoms

Mild/Moderate, get help and if in doubt ring 999

1. Remove trigger if possible. 2. Administer Antihistamine (If prescribed.) 3. Administer salbutamol Inhaler (if

available/Prescribed)

Severe/Breathing Difficulties



Improvement

Administer Adrenaline auto-injector (if prescribed) in to middle of outer thigh, hold in place for 10 seconds, and

gently massage area.

Monitor & Observe Inform parents

when safe

No

Check and record the time, encourage child to get in to a comfortable position, if feeling faint do not sit or stand.

Administer inhaler if available/Prescribed.

Child to go to hospital Contact parents, if not present, as soon

as safe to do so.

Shout for help/Ring 999/Commence Basic Life Support (if trained) if needed at any stage based

on symptoms

Patients who are unconscious but breathing, place on their side (recovery position) Left side if

pregnant.



Useful contact numbers

Children’s Community Team/ School Health practitioner/Health Visitor: Please insert

number here:

Anaphylaxis Campaign: 01252 377140

The British allergy foundation: 0845708583

Internet

www.anaphylaxis.org.uk

www.kidsaware.co.uk

www.resus.org.uk.Information

www.allergy.org.uk

This pack has been developed using information from:

Royal college of Paediatrics and child health (2011) Anaphylaxis care pathway

INTERNET available from www.rcpch.org.uk/allergy accessed May 2012.

Anaphylaxis campaign, INTERNET available from www.anaphylaxis.org.uk

accessed May 2012.

Resuscitation council (2008) Emergency treatment for anaphylactic reactions

INTERNET available from www.resus.org.uk accessed May 2012.

Appendix 4



Name: DOB:

Date Problem

….…………………… is at risk of Allergic reaction/Anaphylaxis.

Due to..........................................................................

Signature

Goal To prevent and treat Allergies/ Anaphylaxis. To maintain safety at all times.

Action Ensure that …………………….. Carries his/her medication at all times, ensuring that they are within their expiry dates. Avoid any triggers these include:

......................................................................

....................................................................... Monitor …………………. for signs of Allergy/Anaphylaxis. Vomiting/tummy pain

• Hives / itchy skin rash.

• Difficulty breathing.

• Flushing of the skin.

• Tingling / itching of the mouth.

• Swelling of the throat and mouth.

• Rapid weak pulse.

• Sudden feeling of weakness.

• Collapse and unconsciousness.

3) Administer oral anti-histamine for mild/moderate reactions (if prescribed).

- followed by inhaler (if prescribed) for Wheeze/shortness of breath. Inform Parents/Carers.

4) Ring 999 for an ambulance following severe reaction. Inform the call centre that the patient has had an anaphylactic reaction, administer Adrenaline auto-injector pen and encourage child to sit in a comfortable position with legs raised. Inform parents /Carers.

5) Administer the second Adrenaline auto-injector pen (if applicable) after 5 minutes if no improvement.

References: The Anaphylaxis Campaign: www.anaphylaxis.org.uk accessed 05 2012. The resuscitation council: www.resus.org.uk accessed 01/2012. Royal College of Paediatrics and Child Health, Anaphylaxis care pathway 2011: www.rcpch.org.uk/allergy accessed 01/2012.

Rationale

To ensure appropriate treatment is available at all times. To prevent an Allergic reaction occurring if at all possible.

To be aware of any adverse reactions. To treat an Allergic reaction as quickly as possible. Used Adrenaline auto-injector pens must be stored safely kept to show paramedics/medical staff. Child must attend A&E if Adrenaline auto-injector pen has been administered. As per protocol to ensure reaction is treated accordingly.

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