FCPS Paediatrics TOACS · Interactive Station

✅ Candidate's answer:
• Diagnosis: Acute urticaria (hives) secondary to peanut ingestion – a cutaneous IgE-mediated allergic reaction.
• Why NOT anaphylaxis? Anaphylaxis requires involvement of ≥2 organ systems OR respiratory/cardiovascular compromise.
- This child has only cutaneous symptoms (urticaria).
- No respiratory symptoms (no wheezing, stridor, dyspnea, hypoxia).
- No cardiovascular symptoms (normal BP, no dizziness, no syncope).
- No persistent GI symptoms (no vomiting, no diarrhea).
• NIAID anaphylaxis criteria not met: Criterion 1 requires skin/mucosal involvement + respiratory compromise OR reduced BP. Criterion 2 requires ≥2 organ systems (skin + GI/respiratory/cardiovascular). This patient has only skin involvement.
• Therefore, this is mild allergic reaction (urticaria only), not anaphylaxis.

✅ Candidate's answer:
• No, epinephrine is NOT indicated for isolated cutaneous symptoms (urticaria without anaphylaxis).
• Immediate management:
1️⃣ Oral antihistamine: Cetirizine 5-10 mg (0.25 mg/kg) or diphenhydramine 1 mg/kg (max 50 mg).
2️⃣ Observation: Monitor for progression to anaphylaxis (respiratory symptoms, angioedema, vomiting, hypotension) – observe for at least 1-2 hours.
3️⃣ Cool compresses for itching.
4️⃣ Avoid further peanut exposure.
• Do NOT give epinephrine – it is not indicated for cutaneous-only reactions and may cause unnecessary side effects (tachycardia, hypertension, anxiety).
• However, advise the mother to observe for any signs of respiratory distress, throat tightness, or vomiting – if these develop, administer epinephrine immediately and seek emergency care.

✅ Candidate's answer:
• NIAID criteria – anaphylaxis is highly likely when any one of the following is met:
  Criterion 1: Acute onset (minutes to hours) + skin/mucosal involvement AND (a) respiratory compromise OR (b) reduced BP.
  Criterion 2: Two or more of the following after likely allergen exposure: (a) skin/mucosal, (b) respiratory, (c) reduced BP, (d) persistent GI symptoms.
  Criterion 3: Reduced BP after exposure to known allergen.
• When to give epinephrine (IM 0.01 mg/kg, 1:1000, lateral thigh):
- Any respiratory symptoms (wheezing, stridor, dyspnea, hypoxia).
- Hypotension or syncope.
- Persistent vomiting or diarrhea.
- Involvement of ≥2 organ systems (e.g., skin + respiratory, skin + GI).
- Do NOT delay epinephrine for isolated cutaneous symptoms alone.
- This patient has only skin involvement → observe, do not give epinephrine.

✅ Candidate's answer:
• Cetirizine (second-generation, preferred – less sedation):
- Dose: 0.25 mg/kg (max 10 mg). For a 20 kg child: 5 mg once daily.
- Age 6 years: 5 mg (½ of a 10 mg tablet or 5 mL of syrup).
• Diphenhydramine (first-generation, sedating – alternative):
- Dose: 1 mg/kg (max 50 mg). For a 20 kg child: 20 mg (4 mL of 12.5 mg/5 mL syrup).
- Can cause drowsiness – advise mother that child may become sleepy.
• Both are effective for urticaria and pruritus. Cetirizine is preferred due to less sedation.
• Do NOT use topical antihistamines (they are not effective for widespread urticaria).

✅ Candidate's answer:
• Observation period: At least 1-2 hours (some guidelines suggest 2-4 hours for food-induced reactions).
• Signs that would prompt epinephrine administration (progression to anaphylaxis):
1️⃣ Respiratory symptoms: Wheezing, stridor, difficulty breathing, hoarse voice, persistent cough, oxygen desaturation.
2️⃣ Angioedema: Swelling of lips, tongue, uvula, or throat.
3️⃣ GI symptoms: Persistent vomiting, abdominal pain (especially in children).
4️⃣ Cardiovascular symptoms: Hypotension, dizziness, syncope, pallor, lethargy.
5️⃣ Worsening or spreading of urticaria despite antihistamine.
• If any of these develop, administer IM epinephrine immediately (0.01 mg/kg, 1:1000, lateral thigh) and call emergency services.
- This child is currently stable – observation is appropriate.

✅ Candidate's answer:
• YES – this child should be prescribed an epinephrine autoinjector.
• Rationale:
- Although this reaction was cutaneous only, any future accidental exposure could cause anaphylaxis (more severe reaction).
- Peanut allergy is unpredictable – severity can vary with each exposure.
- All patients with food allergy should have epinephrine autoinjectors available for emergency treatment of anaphylaxis.
• Dose for this child (20 kg, 6 years): EpiPen Jr 0.15 mg (for children 15-30 kg).
• Prescribe TWO autoinjectors (second dose may be needed if symptoms persist or biphasic reaction occurs).
• Train the mother on how to use it (blue to the sky, orange to the thigh).
• Do not give epinephrine now – it is for future anaphylaxis.

✅ Candidate's answer:
• Written emergency action plan (to be given to parents, school, caregivers):
1️⃣ List of allergens to avoid: Peanuts and all peanut-containing products.
2️⃣ Signs of mild allergic reaction (cutaneous only): Hives, itching, mild swelling (not involving throat). Action: Give oral antihistamine and observe.
3️⃣ Signs of anaphylaxis (severe reaction): Difficulty breathing, wheezing, stridor, throat tightness, persistent vomiting, dizziness, change in voice, swelling of lips/tongue/throat, lethargy.
4️⃣ Action for anaphylaxis: Give epinephrine autoinjector immediately, call 911, lie child flat with legs elevated (or sitting if respiratory distress), give second epinephrine if no improvement in 5-15 minutes.
5️⃣ Emergency contact numbers.
6️⃣ Instructions for school: Keep epinephrine autoinjector accessible, staff trained in administration.
• Provide a copy to the mother and encourage her to share it with school, babysitters, and relatives.

✅ Candidate's answer:
• IgE-mediated food allergy (most likely – peanut).
• Viral exanthem (urticarial viral rash) – often associated with fever, coryza, and less well-demarcated lesions.
• Drug allergy (e.g., antibiotics, NSAIDs).
• Contact urticaria (from direct skin contact with allergen).
• Physical urticaria (dermographism, cold urticaria, cholinergic urticaria).
• Acute spontaneous urticaria (idiopathic) – no identifiable trigger.
• This patient's history of known peanut allergy and accidental ingestion makes peanut-induced urticaria the most likely diagnosis.

✅ Candidate's answer:
• “No, you should NOT give epinephrine for hives alone if there are no other symptoms.”
• “Epinephrine is a life-saving medication for severe allergic reactions (anaphylaxis). It is not needed for mild reactions that only involve the skin.”
• “If your child has only hives and itching, give oral antihistamine (cetirizine or diphenhydramine) and watch closely.”
• “However, if at any point she develops difficulty breathing, wheezing, throat tightness, hoarse voice, persistent vomiting, or becomes dizzy or weak, THEN give the epinephrine autoinjector immediately and call 911.”
• “Using epinephrine unnecessarily can cause side effects like fast heartbeat, anxiety, and tremors. So reserve it for when you see signs of anaphylaxis.”
• “But do NOT hesitate to use it if you are unsure – it is better to use epinephrine if there is any suspicion of anaphylaxis, because the risks of anaphylaxis far outweigh the risks of epinephrine.”

✅ Candidate's answer:
• LEAP (Learning Early About Peanut) trial (2015):
- High-risk infants (severe eczema, egg allergy) who consumed peanut between 4-11 months of age had a 70-80% reduction in peanut allergy by age 5 years compared to those who avoided peanut.
- Early introduction, not delayed introduction, prevents peanut allergy.
• Current guidelines (NIAID 2017):
- High-risk infants (severe eczema, egg allergy): Introduce peanut as early as 4-6 months after allergy testing (if indicated).
- Moderate-risk (mild-moderate eczema): Introduce at 6 months at home.
- Low-risk: Introduce with other solids at 6 months.
• For this child, prevention is not possible now. For future siblings, early introduction is recommended.

✅ Candidate's answer:
• Peanut allergy persists in 80-90% of children. Only 10-20% outgrow it.
• Factors associated with persistence:
- High peanut-specific IgE level (>15 kUA/L).
- History of severe anaphylaxis.
- Young age at diagnosis.
- Concomitant tree nut allergy.
• Prognosis:
- This child (6 years old with a first reaction) may not outgrow it. She should have follow-up allergy testing every 2-3 years to assess for possible resolution.
- Do NOT attempt home reintroduction – supervised oral food challenge in an allergist's office if allergy is suspected to have resolved.
- Oral immunotherapy (OIT) is an option for desensitization (not cure).

✅ Candidate's answer:
• Epinephrine autoinjector at school – kept in an accessible location (not locked away), with a second device.
• Trained staff (school nurse, teachers) who can recognize anaphylaxis and administer epinephrine.
• Written emergency action plan on file at school.
• Peanut-free table in the cafeteria (or peanut-free classroom for younger children).
• Avoid peanut-containing products in school snacks and parties.
• Education of classmates and parents about food allergies (without singling out the child).
• Field trip planning – ensure epinephrine is carried and staff is trained.
• 504 plan (in the US) – legal document to ensure accommodations are provided.
- The mother should work with the school nurse and principal to implement these measures.

✅ Candidate's answer:
• YES – all children with food allergy should be referred to an allergist.
• Why refer?
1️⃣ Confirm diagnosis: Skin prick testing or specific IgE to confirm peanut allergy.
2️⃣ Assess severity and risk of anaphylaxis.
3️⃣ Determine if the child is a candidate for oral immunotherapy (OIT) – desensitization to peanut (Palforzia).
4️⃣ Provide comprehensive education on allergen avoidance, label reading, recognition of anaphylaxis, and use of epinephrine autoinjector.
5️⃣ Evaluate for possible resolution with serial testing every 2-3 years.
6️⃣ Assess for other food allergies (tree nuts, sesame, etc.) – often co-existing.
7️⃣ Provide written emergency action plan.
- The mother should schedule an appointment with an allergist within 1-2 months.

✅ Candidate's structured answer:
• “Your daughter had a mild allergic reaction today – hives and itching. This is NOT anaphylaxis, and she is not in danger right now. We have given her antihistamine, and she is doing well.”
• “However, because she is allergic to peanuts, any future accidental exposure could cause a more severe reaction. That is why we need to be prepared.”
• “I am prescribing an epinephrine autoinjector (EpiPen Jr) for her. You must keep two of them with her at all times – at home, at school, on trips.”
• “I will teach you how to use it. The most important thing to remember: use it immediately if she develops trouble breathing, throat tightness, hoarse voice, persistent vomiting, or becomes weak or dizzy.”
• “Do NOT use epinephrine for hives alone – give oral antihistamine instead and watch closely.”
• “She must avoid all peanuts and peanut-containing products. Read food labels carefully. Avoid foods that may be cross-contaminated.”
• “We will refer you to an allergist who can confirm the allergy, discuss oral immunotherapy (which may reduce her risk of severe reactions), and help you manage her allergy long-term.”
• “She can live a normal life. With education and preparedness, most children with peanut allergy thrive. You are not alone – there are many resources to help you.”
• “You did the right thing by bringing her in today. We will support you every step of the way.”