This webinar was recorded on November 29, 2023
Between 1.6% and 5.1% of people in the US have experienced at least one episode of anaphylaxis. The most common triggers are certain foods, certain medications and insect stings. Many people with food allergies also have allergies. Since respiratory symptoms are common in both conditions, it can be challenging to know whether someone is experiencing a severe allergic reaction or an asthma flare because they have similar symptoms. Asthma, food allergy and a high risk of anaphylaxis can occur together, and asthma can increase the risk of fatal anaphylaxis. In this webinar, Dr. Alice Hoyt how to plan for emergencies with both asthma and anaphylaxis.
Alice Hoyt, MD, FAAAAI
Hoyt Institute of Food Allergy
Dr. Hoyt is the Chief Allergist at the Hoyt Institute of Food Allergy in New Orleans, LA. She has been practicing academic, evidence-based medicine for over a decade. Dr. Hoyt is board certified in internal medicine, pediatrics and allergy & immunology. During her fellowship at the University of Virginia, Dr. Hoyt launched a now national allergy-focused non-profit organization, The Teal Schoolhouse supporting the Code Ana Program which teaches medical and non-medical school personnel and child care providers about medical emergencies.
At Vanderbilt University, Dr. Hoyt continued her food allergy-focused efforts before transitioning to Cleveland Clinic where she helped launch its Food Allergy Center of Excellence. Dr. Hoyt decided to bring her food allergy knowledge to families in her home state and launched the Hoyt Institute of Food Allergy. In addition to leading the institute, Dr. Hoyt hosts the top-ranked food allergy podcast Food Allergy and Your Kiddo and chairs Code Ana.
This Advances webinar is a partnership with the American College of Allergy, Asthma and Immunology. ACAAI offers CME’s for this webinar.
Sponsored by the American College of Allergy, Asthma and Immunology
Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.
Lynda Mitchell: Hi, everybody. Thank you we will let more people filter into the room and then we will get started in about a minute. Ok. I’ll go ahead and get started. There are still people joining us remotely, but I’ll just kind of got going and — get going and by that time everybody will be ready to go. Thank you for joining us here today. I Lynda Mitchell. amCEO for the Allergy and Asthma Network. We are pleased to welcome Dr. Alice Hoyt as today’s presenter. We have a few housekeeping items before we get started, all participants will be on mute for this webinar. We will be recording this webinar and we will post it on our website in a couple of days. You can find all of our recorded webinars on our website at allergy asthma network dt org — dot org. We have all the webinars listed there and you can click the link you are interested into view the notes and recording. This webinar will be one hour in length and that includes time for questions. We will take those questions at the end of the webinar or we might stop Dr. Hoyt to ask anything that is relevant at that time. Please put your questions and the Q&A. We have someone monitoring the check. If you have questions or need help technically. We will get to as many cushions as we can before we conclude. This is a webinar presented in partnership with the American College of allergy, asthma, and immunology. The college offers CMEs for this webinar and we have a certificate of attendance if you need it for your records. A few days after the webinar, you will receive an e-mail with supplemental information and a link to download the certificate of attendance if you need it. We will also try to add the link to the certificate and the chat during today’s webinar. Let’s get started. Today’s topic is one that is dear to my heart, emergency planning for children with asthma and anaphylaxis. Between 1.6 and 5% of people in the U.S. have experienced at least one episode of anaphylaxis. The most common triggers are certain foods, medications and insect stings. Many people with food allergies also have asthma. Since respiratory symptoms are common with both conditions, it can be challenging to know whether someone is experiencing a severe allergic reaction or an asthma flare because of the similar symptoms. Asthma food allergy and food allergy combined but people at risk for a higher — at higher risk for anaphylaxis. It is my pleasure to introduce our speaker, Dr. Alice Hoyt. The chief allergist at the Hoyt Institute of allergy. Board set in internal medicine and pediatrics and immunology. During her fellowship at the University of Virginia, Dr. Hoyt launched a no national nonprofit organization that supports the code and a program which teaches medical and nonmedical score personnel and childcare providers about medical emergencies. We’ve got the right person here talking to us today. At Vanderbilt University, Dr. Hoyt continued her food allergy focus efforts before transitioning to the Cleveland clinic where she helped launch its food allergy Center of excellence. Dr. Hoyt decided to bring her food allergy knowledge to families in her home state of Louisiana and launched the Hoyt Institute of food allergy. In addition to leading the end is to — the Institutem she hope — The answer to, she hosts a foot and allergy podcast. Thank you for being here today. I will let you go ahead and get started.
Dr. Hoyt: Thank you so much, Lynda. I’m so excited to be here and honored that you all asked me to present on this topic. I hope this is — I think this is arguably one of if not one of the most important topics we can discuss when it comes to our kiddos who have food allergies, who have asthma, who have both. Guys, you are out there — as you are listening to this, I want you to be as engaged as possible as you can be any webinar, so definitely put your questions into the chat and if we don’t get to them in the middle of a top, we will get to them afterwards — talk, we will get to them afterwards. Think into the Allergy and Asthma Network for hosting this important presentation. We will dive in and get started.
You guys know, the mission of the Allergy and Asthma Network is to end the needless death and suffering due to asthma, allergies and related conditions through outreach, education, advocacy and research, through webinars just like this. Definitely put your questions in the chat. No relevant disclosures. Ok, what are you going to walk away with if you sit there and pay attention and engage in this presentation today? You were going to know how to do the following after this presentation — he will be able to list and described the preparedness measures needed for children with asthma, list and describe the preprint is measures needed for children who are at risk for anaphylaxis, or have other severe food allergies, and you are going to be able to develop an emergency plan for children who have asthma and/or are at risk of anaphylaxis. That’s a lot to put into this time, but we have a lot of resources an info in this talk, you going to love it. Let’s start. Typing to the chat, please, — Type enter the chat, please, what is your role in keeping kids safe? Rua parent, health care professional — Rua parent, health care professional? I am the parent of a little baby who has a food allergy. I am the wife of a man who has a food allergy. I live in Louisiana. I’m looking at the chat and we’ve got school nurse. Connecticut, Virginia. Lots of school nurses. Karen, respiratory therapist. Illinois, Washington, Texas, oh my gosh, I love it. Keep that going. I’m so glad everybody is here. Wow. As you all know, and any presentation, you need to have a hope that gets people’s attention. Probably the worst thing to grab our attention is what we are all thinking here, a whole reason we are all here, we want to keep these kids safe. What do we want to keep them safe from? A life-threatening reaction, a severe asthma exacerbation. I wanted to put up here — This is from the National Food allergy death registry which sounds terrible but is a very important thing to keep. It is ran by a friend of mine, she is lovely, she does this, which is amazing. This is what we are all concerned about. Right? The other reason I put this map up here is because death from a food allergy is like a shark bite. That should never happen when a child goes to the beach and if it happens, we hear about it. So I want this to be something that’s grabbing your attention, this is what absolutely we are trying to prevent, it is rare when it happens, but does it matter if it happens to your child? By the end of this talk, you are going to know was to prevent this from happening.
I think before we move on, I believe we have some questions. Here we go. Here is our full. — our poll. We’ve got to have some engagement while doing these webinars. Please answer the question, how often do you worry that your child or a child in your care might have an allergic reaction or an asthma exacerbation? Select one. The next question, how confident are you in your own ability to manage your child or a child in your care who is having an allergic reaction or asthma exacerbation? Then the third question, this is one of the reasons I wanted to hear who our audience is made up of, a lot of school nurses out there, thinking of all your child’s caregiving as a whole, how confident are you in other caregivers’ ability to manage if that child is having an allergic reaction or asthma exacerbation? If you are a school nurse, how confident are you that your nonmedical colleagues, the teachers and counselors are going to be able to manage that child? If you are a parent, how confident are you that the school is going to be able to take care of your child? Go ahead and put your answers in there. We have probably had enough times to have people select their choice. Can we go ahead and close that? Are we able to show the answers? Here we go. Ok. Emergency planning webinar poll, number one, how often do you worry? 43% of you sometimes, 37% often worrying, 12% always worrying. Let’s get going — keep going to that second question. How confident are you in your ability to manage? While most of you are fairly confident and very confident, some of you are somewhat confident. Then it kind of flips, with other people’s ability to manage, not at all confident, 52% of you were somewhat confident. By the end of this talk, you will have resources that are not just going to help you. Based on this, a lot of you guys feel pretty good about your ability. But you are not feeling too good about other people’s ability to keep those kids safe. We are going to fix some of that at the end of this. Let’s keep going. Preparedness measures needed for children with asthma.
First we will talk about asthma. What really is asthma? Asthma is a catchall term for conditions that cause reversible airway obstruction, there’s allergic asthma — different types of asthma. There is viral-induced wheezing asthma. The symptoms include coughing, wheezing, chest tightness, shortness of breath. And a lot of children have asthma. According to the CDC, 6.5% of children have asthma. I think that’s a little bit on the low side. But still, that is a lot of kids that have asthma. Asthma exacerbations are all too common. So, looking at some of these data, the national prevalence of asthma attacks among children and adults with current asthma from 2021, looking specifically at this table, we have the characteristics, age, less than 18, kiddos, adults, the number of asthma attacks, in the percent — and the percent. Ultimately what this is showing us is that not only do a lot of kids have asthma but they are having asthma exacerbation. Why is this important? An asthma exacerbation really indicates that a child’s asthma is not well-controlled and management needs to be stepped up. We need to improve our management. So glad there are so many school nurses on this call. Sometimes it is the school nurses that are the gatekeepers. They are the ones forcing, oh, — who are seeing, oh, this Cato has to keep coming into use albuterol. Clearly there is a problem here if he has to come into have albuterol. His asthma is not well-controlled. Thank goodness you are there to recognize that because in some cases where there are no school nurses, someone might think that it’s normal for a kido to use — kiddo to use albuterol everyday after P.E. because there wheezing. Some of you might recognize, this treatment might needed to step up — to be stepped up. At one point you want to start the care to not have these exacerbations to start with. How do you treat asthma exacerbation? Albuterol or leave albuterol — Levalbuterol. Coming down the inflammation. The steroid burst. Then your pediatrician is probably going to adjust the maintenance medication. I know I do a lot of oral immunotherapy in my practice and I have really honed in on kids that I thought maybe they had mild intermittent asthma, but as I’m trying to make sure that inflammatory diseases, the allergic disorders are very well controlled, I’m actually realizing, a lot of these mild intermittent asthmatics are mild persistent. And I was trying not to step up management because no parent wants to put their kiddo on medication. Moreso than that, no parent wants their child suffering. I am more keenly aware now of what kiddos are mild intermittent compared to mild persistent and that is important because we don’t even want one asthma exacerbation. Anytime a kiddo is having trouble breathing, that is serious for all parties, we want to prevent that by stepping up management. Inpatient treatment, if a patient management fails, there’s going — they are going to get admitted for more aggressive asthma management. We would really like to prevent that. Most asthma exacerbations can be prevented with adequate control of asthma. Controlling asthma really should include — this is from JACI in Practice 2017. It’s more than pharmacological management. It is really patient education. We have all seen that “House” episode, with the inhaler networking, and she puffed the inhaler like perfume. These inhalers are not necessarily intuitive. So having that patient education, taking that time — those extra 30 seconds to two minutes that it takes to make sure the patient knows how to use the medication is so important.
Monitoring the symptoms in lung function. This is where school personnel could be so helpful to us. That school nurse is seeing, compared to other kiddos, how that child is running around and getting out of breath and needing albuterol where sometimes parents might not see them running around with their peers. I think it’s amazing whatever I got to see my kiddos interact with other children because it is not something that we see a whole lot of when they are doing activities and stuff. It’s just the basic everyday. It’s the nuances there. Another shout out to school nurses. Love school nurses. Then controlling of triggering factors and comorbidities. I am biased because the evidence shows that if we control allergic disorders like allergic rhinitis, we can improve asthma. A blood for allergists out there. And appropriate pharmacological therapy. Where do asthma exacerbations happen? Happen everywhere. Home, school, airplanes, church, playground, everywhere. That means we have to be prepared everywhere. Do not be like me and drive without my child’s are be literal — child’s albuterol. Thankfully my mother had Albuterol. I was able to put an inhaler into a cup, she breathed it in, it was like magic. It was not magic. It was the correct medication. If I had been a little bit more prepared, it would’ve been a much better experience for everybody. The stages of childhood and asthma. As for pediatrician, and Glenda mentioned I am board certified — Glenda mentioned I am board certified in that piece and allergy. One of the most important parts of the training I would say is focusing on that transition from the pediatric care model to the adult care model. If you go to Got Transition, you can learn a lot about this. Many have not been taught inhaler education. It takes intervention. Even mild, is intervention. It all comes back to planning. — easy intervention. It all comes back to planning. You can set a goal with a toddler. You want to start legal thing with — the goal thing with kiddos. They need to be involved in their asthma management. Have a policy or guide. This could be at your doctors or your school. This is something we should definitely be doing with kiddos with asthma and allergies. Take a look at Got Transition. So many of you guys are school nurses. These are things you can do at the beginning of the year. Do they have their Albuterol inhaler? I would encourage anyone that has a child to be self carrying the asthma medication, they have to have a spot check, some sort of quality measure to make sure that kids who are supposed to have their medicine have it. Because high schoolers sometimes are matured 35 euros and sometimes they are like five-year-olds. This is probably no surprised to anybody, this is an asthma management strategy plan. If you are in the green column, you are doing well. If you are in the red column, this is serious business. Every child with asthma should have an asthma action plan. It should be at home. It should be at school. More than just the parent should know about it. Every child was asthma should have an action plan. Ideally, it really should be completed through shared decision-making in the office with the physician, parents, and child. How this goes is — Before school starts, the physicians’ offices get inundated with all these forms and hopefully they get filled out, but in a perfect world, there needs to be a back-to-school visit. I love having a back-to-school visit.
Because I want to go through all this with my patients. Especially for asthma. This is your assessment and plan. How well are they doing? What is their plan? Depending on the age of the kiddo, they need to know all this. When it is around the 10-12-year-olds, I’m having much more of a conversation with the kiddos than the parents. I expect the parents to be here listening and not on their phones. Usually the parents are engaged, too. But this is arguably the most important thing that a physician can do with their patient. We just looked at how many kids who have asthma reported asthma at asthma have an action plan, and it is a fraction — at school have an action plan and it is a fraction of the kids. Does that mean that the school nurse does not know to give Albuterol when the kid is wheezing? No, the school nurse knows. But it is a red flag that that child does not have an engaged care plan with his or her physician. I could also mean that their asthma is not optimized. If it’s not optimized, they are at risk of having an exacerbation. That’s what I say, this is our Ghibli the most important part of asthma management. Ok. Preparedness measures needed for children at risk of anaphylaxis. I believe we have a question here. Ok. How many definitions of anaphylaxis are currently defined by major academic allergy societies? 1, 2, 3, or 4 definitions of anaphylaxis. Five more seconds to vote. Go ahead and close that, please. Pull up the answer. Wow! Quite a spread. 28% of you think there is one definition, 20% think two, 32% think three and 21% think four. Very nice. The three’s are correct. There are three definitions for anaphylaxis. Back when I was in allergy fellow at the University of Virginia, Dr. Larry boorish, an asthma export powerhouse, amazing dude, he would explain anaphylaxis as having a systemwide reaction to a local action, which I think is pretty brilliant. Simple country people like me. You get stung here and you are not just having a local reaction, you are having a symptom wide reaction. You are stung by something and you start having hives and swelling, a drop in blood pressure. Although things are happening somewhere other than where it happens. That’s a pretty good rule of thumb. But let’s look at these three different criteria which as you probably know are based on the graphic that came out of a JACI article.
Anaphylaxis is likely when one of the three criteria are fulfilled, number one, you can have sudden onset illness of skin, lungs are both, but skin has to be involved. In this first definition of anaphylaxis, skin symptoms have to be involved. Please note thats kin symptoms — skin symptoms include swollen lip and tongue. You have to have some sort of skin manifestation in addition to coughing, wheezing, drop in blood pressure. Definition number two is sort of the more classic example of two systems, you can have hives and coughing, or you can have coughing and vomiting, or you can have vomiting in sudden drop in blood pressure — and sudden drop in blood pressure. In a combination of those two symptoms. The third — Any combination of those two symptoms. The third definition is reduced blood pressure after exposure to a known allergen. That we are mostly going to see in an ICU setting or venom allergy. The quick brief exposure causing a dramatic vascular collapse — traumatic macular collapse. — traumatic vascular collapse. The syndrome of galactose is a delayed onset anaphylaxis. You may eat a cheeseburger and it is not until like three hours later that you are having Hives and vomiting. But it is still Hives and vomiting and you still have these criteria here except it’ll be delayed. For every other anaphylactic condition, it is happening within minutes to hours. How common is anaphylaxis? It is too common. 5% of kiddos had food allergy at age six in the health nuts study. 44 point 6% reported an adverse reaction to a food in the last 12 months. So half of those kiddos. In 30.7% of food allergic children, they had more than one reaction. 5% of kids, you guys the numbers range depending on the setting and how the setting was done, but just like with asthma, where asthma is common, but exacerbations don’t have to be common but they are common, it is the same with anaphylaxis. Food allergy is common and the reactions are common. We have to make them less common. And there are ways to make them list,. And part of that is planning. — them less common. And part of that is planning. That is why you are here. 28 children reported 29 reactions that met the studies criteria for anaphylaxis within the previous 12 months. As I alluded to, the true incidence of anaphylactic’s — anaphylaxis, it is difficult to measure for many reasons but it is far too common, safe to say. Let’s talk about anaphylaxis in Littles. What this graph is showing is weighted ED visits per 100,000 visits. The bold line is ED visits and the dotted line is hospitalization. Even though ED visits have increased for anaphylaxis, actual hospitalizations have decreased.
We can talk about why that might be. I like to think that is because we are recognizing anaphylaxis more promptly. But also people are more prepared to properly treat anaphylaxis with epinephrine. It used to be, ok, if you are having anaphylaxis, to take a Benadryl and wait and see if it gets better. And we know based on data that prompt recognition of anaphylaxis and probably utilizing epinephrine — promptly using epinephrine is going to prevent the outcome. Delayed administration is what can result in a poor outcome. We also know that epinephrine when administered from an autoinjector is incredibly safe. It is the right concentration of epinephrine and the right dose of epinephrine. The right volume going in. And it is from an autoinjector. It is intramuscular, not IV or something like that. These auto adjusters — autoinjector’s are incredibly safe. We make epinephrine. Our adrenal gland is making epinephrine right now. Epinephrine is the treatment for anaphylaxis. And we cannot be nervous about giving it. So what is nice about this slide is that although ED visits have increased, the hospitalization rate has decreased. That is good. So, how do you really treat anaphylaxis? You first have to recognize that anaphylaxis is occurring and you want to activate an emergency system, typically 911, MediRedi — mediReady. He want that person to be laying down. That will help the medication circulate. Then you are going to administer epinephrine. Epinephrine my ministration, if you are on this call, — Epinephrine administration, if you are on this call, likely you know how to use an autoinjector. There has been a lot of discussion among and — among allergists especially after COVID about emergencies go into the emergency room after one dose of eppi. That is a decision between the family and their allergist. With many families, we feel comfortable saying, if there is an accidental ingestion, they use epi and the child is promptly improving, they don’t need a second dose, the airway is not involved, then active observation at home, that is fine. But that is a medical decision that is being made between the family and the doctor. That should all be well decided before we — before reaction occurs. We will talk in a minute about an anaphylaxis action plan. How do you prevent anaphylaxis? Avoidance of an allergen is the only way to prevent anaphylaxis. You can to immunotherapy to help with tolerance. Ultimately help a child not have an allergic reaction, if they do have an ingestion of their allergen. But the only way to prevent is is to avoid the allergen. So there are ways — I just talked about this induced tolerance. I will not go into that. Just like asthma exacerbation can happen anywhere, like a grandmother’s house, where does anaphylaxis occur? This is from the Health Net study — Health Nuts study. It is occurring at home. This is where it gets scarier for families. What if it is at a friend’s house or restaurant or at school or somewhere else? The friend houses are the ones I hear a lot of concern from my patients. Just like we talked about the transition, the health care models, I can’t underscore enough the importance of this transition, starting when they are young. Get them used to setting goals for their health. Start having that conversation about care. Self-care he does not it will — does not equal self-administer. Sometimes schools conflate these things. A child can absolutely self-care even if they are not prepared or are developmentally ready to self administer the medication. That has to be differentiated. You have to be very clear about, is this child capable of self carrying, yes or no? Counsel them on the importance of, this is not a toy. You are responsible for this medication. When they are with mom and dad, do they always have backups? Yes. Should schools have stocked epinephrine? Yes, absolutely. But at some point the child has to start self managing. It is a small baby step goals. We don’t want them to turn 18 and suddenly, oh, wait, I’ve got to carry this? I don’t know how to call my doctor’s office for a refill. So start young. Here are some examples of the anaphylaxis action plan. One if from FARE, another from AAP. Just like with asthma, every child who has a diagnosis of an anaphylactic food allergy should have an anaphylaxis action plan. It is a honeybee, they should also have a plan. This should be completed through shared decision-making in the office with the doctor. Have that back-to-school appointment. That is so important. I know one of our patient moms — patient’s mom scheduled all the appoints at the end of July, so she could have all the forms completed. She could have the medications that they need. And also just like with asthma, there are new treatments coming out so often.
I can sit in my office and talk to my patients about the great next thing for food allergy management but if that family is too nervous to go out to eat together or share a meal with their family because of food allergy, then those are issues that we have to address. I would not say that the food allergy is well-controlled. Even if they are doing a good job — not doing a good job, sometimes accidental ingestion’s just happen, but my point is, food allergy and asthma management is so much more than just the medical management. It is very important that we serve families and identify other comorbid issues that go along with these disorders and help families manage those. It’s a little bit outside the scope of today’s discussion. All kiddos who have an anaphylactic food allergy need an action plan — an anaphylaxis action plan. Any kiddo with any food allergy should have an emergency care plan. If you have a kiddo with fpie, that is not an anaphylactic food allergy but it can be incredibly severe. That is when he kiddo eats a food and it seems like they tolerate it and three-ish hours later projectile scary vomiting, they can have diarrhea, they look very sick, they need to be rehydrated. That is a case where epinephrine is not the treatment. But then kid really who has any sort of medical condition that can go acute, as I say, needs an emergency care plan. How do you develop that emergency plan? Let’s talk about that. And child specific needs assessment. — A child-specific needs assessment. When I was at Vanderbilt, I really had to rule out food allergy clinic. So many kids had been told, we are allergic to peanuts. And they had been avoiding all those foods. Even though it sounds easy, just avoid it — If you are telling a family you need to avoid these foods because your child, if your child eats them, it could kill them, that is a big deal. We need to recognize that is a big deal and not put that diagnosis on somebody who does not generally have that diagnosis. So it is very important to revisit these diagnoses annually , because some kids do outgrow your food allergies, or evolve. Asthma improves. Whereas asthma getting worse and the family doesn’t really realize it — We had a family recently where the asthma has gotten a lot better so they are so happy about it but the poor little guy is still having lots of symptoms, so even though they are seeing it as so much better, his care providers are seeing it as, no, we could get it even better and we need to do that. That is our job. If we are not seeing the patient, we don’t know what’s going on. Having those visits, having those follow-ups is so important. The emergency management. Having the updated care plans. Having that shared decision-making is so important. Then preventive strategies. Discussed therapies to prevent acute manifestations or reactions from happening. How do we prevent asthma from happening? Emergency action plan for school, babysitters, for others, anaphylaxis action plan, asthma action plan, action plan for any other medical issues. Do not ever assume — And school nurses, he will know — you ll know. — You all know. What the diagnosis is and what the plan should be. Do you need an IEP? I’m not going to go into significant detail about these but I will say that. In most cases, having a 504 plan is incredibly helpful. Having an individualized health care plan, IHP. And IEP as if educational needs are affected by it. But allergy and asthma network has great resources on these. Definitely check those out. Extracurricular plans. Parent to parent letters. These are some things I found in my practice that we as doctors have not been helpful for our patients in telling them how to manage this stuff. The parent to parent letter is a template you can send the parents and the class — in the class, my child has it so and so allergy, we are trying to not bring in any treats that contain those, if you do, let me know so I can make other accommodations, things like that. Then activity specific plan. Soccer. You want any adult responsible for your child to know how to manage, if there’s an emergency. It all comes back to planning and having that up-to-date plan. So, what school plan? Do you need an action plan? Every kid needs an emergency action plan. A 504 plan. You may need one if you think your child’s foot allergy limit their ability to participate fully in school activities and requires special accommodation. It may be helpful to obtain these. It really helps the student to well at school. An IEP is more if an educational disability is present. That is a quick overview of these. What are their plans — What other plans?
Many children participate in some form of extracurricular activity, whether supervised — with supervise adults that are not their teachers, after school, it is important they are both preventive strategies known to all responsible adults for the child and as kiddos get older it is important for their friends to know, too. This really becomes a beautiful way that kids are being empowered to be leaders and show kindness and love on their friends. . Like advocating for their friends. Then plans for people outside of the school setting, that is that social steering plan I mentioned. Here is a sample child specific needs assessment. I love tables. Here we have the stable that I made with the child’s diagnosis, emergency plan, emergency medications, and what preventative and management strategies we should have in place for this kiddo. This kiddo needs an asthma emergency plan, with albuterol, spacer, and steroids. Steroids might not be at school but something where mom at home is noticing, asthma exacerbation is occurring, maybe that can cal m it down. I will let the pulmonologist know that I’m giving it to them but I will give it to them before it turns onto a full-blown exacerbation. And what are the preventative strategies? The maintenance medication. You can see similar stuff for an analogy — for peanut allergy, etc. Global strategy. All school should be prepared for medical emergencies. It is not a matter of if. It is a matter of one. Medical emergencies are more common than fire emergencies. We have fire drills. We don’t necessarily have medical emergency response protocols. In stock medication — And stock medications. There’s no reason school shouldn’t have stock epinephrine, albuterol, Naloxone, etc. So, I am not overtime — woot woot! Now you know how to describe and list their preparedness measures needed for children with asthma, those with anaphylaxis, and you have the tools you need to develop the emergency plan to have that emergency plan and also know the preventative measures and what your kiddo needs and what ghettos in your care needs — kiddos in your care need. Thank you. You can follow me on social. The next webinar is going to be a good one. OK, Ms. Lynda, do we have questions?
Lynda: We do. We have eight or 10.
Dr. Hoyt: Let’s do it.
Lynda: First one is, I give epi when a student has eaten a known allergen, has asthma and states their airways field type. Other providers are not as quick to administer. I’m wondering if I’m being a little too proactive.
Dr. Hoyt: I don’t think you can be too proactive when it comes to epi. Administering epi will not have any long-term adverse effects. It will have — cause pain at the injection site and increase heart rate. Whether a kiddo needs it or not, while we don’t want to wait and see if other symptoms start to occur, because then we are behind the eight ball, we want to properly recognize and properly administer and if you administer and they didn’t really need it, what you actually did was a great job because you cut that anaphylaxis off before it could develop into a threatening reaction.
Lynda: Can you comment on the use of Benadryl at the same time as using epinephrine?
Dr. Hoyt: Sure. Benadryl itself is not a great job, it is an old drug. It can cause an altered mental status, or the opposite, kids get hyper. You don’t want to be administering anything with anaphylaxis that is going to cause an altered mental status. The second reason not to do it is because you don’t want somebody thinking, oh, I need to give the Benadryl first, let me wait and see if I really still need to give the epi. On top of that, epinephrine will shut down those allergy cells that are secreting the histamine. You can give the Benadryl or and I — or any antihistamine to see if it stops the AG symptoms after it comes out, or you can give the epi, which will stop from coming out and help with the itchiness and swelling. Is it wrong to give Benadryl? I tell my patients, throw the Benadryl away. Give Zyrtec or Allegra. Don’t give Benadryl. Antihistamine at the same time as doing epi,
Lynda: Is it normal for a student to use their inhaler before going to PE or outside for recess if they are having no symptoms? We have two students whose parents want them to be using it before PE or recess.
Dr. Hoyt: That is normal. That is an exercise-induced asthma. That is probably the only perfectly appropriate time that someone can use their albuterol before they go out and to exercise. That is perfectly fine. If you feel like they are still getting winded or have a concern about this, that is a great time to have a bilateral leap between you and the doctor so you can talk through together what the appropriate indication of that is and have the parent looped in. We always do total transparency shared decision-making. But I love that you are so mindful of that. That is a strategy that we do incorporate.
Lynda: if a student is using their inhaler before exercise every day, is their asthma considered control?
Dr. Hoyt: The question. If they are using it because their doctor told him you have exercise-induced asthma and you only need it before you exercise, there’s is literally no other time you need it, it’s perfectly fine, we will still say that is well-controlled. I will say that when you sort of dive deeper into those cases, sometimes you can find that they are having symptoms at night, sometimes this. If you try a controlled medication and they are not meeting it before exercise, sometimes stamina can improve. So that is certainly a strategy that we use and it’s not a wrong strategy but there are other strategies to consider. It is really very patient dependent.
Lynda: ok. Have a question for you that hasn’t been submitted. Can you talk about whether you are not sure if it is asthma or anaphylaxis and you should use epinephrine.
Dr. Hoyt: If you are not sure, if it is asthma or anaphylaxis, it is encouraged to use epinephrine. Because it is ourks — our kiddos that have asthma and food allergies that are at risk and we don’t want to mess around waiting for more of those allergy cells to make the reaction more severe. We want to go ahead and cut it off. If it is an asthma exacerbation, epinephrine is actually one of the therapies — not the first line — but one of the therapies that we use it sometimes to treat asthma exacerbations in the hospital setting. Given epinephrine is not going to hurt them, you can absolutely give epi and albute rol at the same time and that is not going to cause any long-term effects. You want to be as proactive as you can. Especially in an asthmatic with a food allergy because they are the risk of fatal anaphylaxis. That’s an awesome question.
Lynda: 30 years ago before — Next question, the problem with self administering epi and Teams is it puts a responsibility on recognizing symptoms and the response to a child. How do you gauge readiness for teenagers?
Dr. Hoyt: Really good question. I think in general, i think teens are incredibly bright. They are incredibly capable. I think that very objective thing you look for when you are trying to d ecide, and has to be the approach like I talked about, let’s start with small roles. If you have a life-threatening allergy, and units of carrier medication, — you need to carrier medication, start with that. Don’t expect them to all of a sudden be able to do all these things at once because for years and has been Mom and dad and grandmothers, somebody other than themselves who have been solely responsible for doing all of this. So it will be completely overwhelming. Start with baby steps. You can have a rewards system in place. Definitely more of a stick than carrot person, a soft stick, you want to have consequences what you want to start with reward systems, you are carrying your epi, great job, we have spot check to you for a week. You have earned a pizza or something with your friends. Things like that. Really don’t expect them to do it immediately but start the conversation. Absolutely the physician needs to be involved. They will start to take the baton. It really is the relay where you are running and they start running with you and your run together for a while before they start going. That’s how this should start. And start with very small questions like, ok, are you ready to self carry? Because were 12 years old now and it is time. Where we don’t do this is in kiddos who have developmental delay. We are not talking about those kiddos. We are talking about those who are in regular education classes, those sorts of things. That’s really how I like to do.
Lynda: Great. Regarding the chart you showed about the signs of anaphylaxis, one of the questions we got was, I’m confused, if they only have respiratory symptoms, do we not treat with epi?
Dr. Hoyt: I love that question. This is — Part of the criteria for diagnosis of anaphylaxis is the Borish criteria of where you have, you eat a food and you start having respiratory symptoms. That comes into the anaphylaxis action plan. And what is the recommendation from the provider? I 1,000,000% recommend my patients will have known food allergies, if they eat something else or having any airway symptoms, if they have more than five hives, that they use epi. I’ve driven in the point of why. Epi’s going to stop the reaction. You are not wrong in thinking, if they are having respiratory issues, shouldn’t I give epi? Yes, you should. If it is stock epi, you have to meet these criteria to use it, you have to be having anaphylaxis. A kid in respiratory stress is not going to be feeling well, there is your second symptom.
Lynda: Can you discuss the potential adverse effects with the overuse of albuterol inhalers?
Dr. Hoyt: Great question. In an acute setting with a kiddo having respiratory distress, it says give two puffs, tw o more a little bit later — in the short term until they got to the emergency room, you just want to get their airways open. Long-term, which is what I think the question is, long-term, using it a whole lot, you can have increases in heart rate. That is ideally never good. Really what that’s also saying is you have significant airway inflammation and you are at risk of having a more severe episode. That’s really why we don’t want somebody using — over using the albuterol so much. It is going to open your airways, but it is going to increase your heart rate which it is fine in the moment but it is really demonstrating the larger problem that children still die from asthma. That there asthma is not well controlled. And it needs to get better control.
Lynda: Should we be giving inhaler if they are complaining of shortness of breath but there is no wheezing presentation?
Dr. Hoyt: It won’t hurt to give the albuterol. In fact, sometimes, a kid’s asthma can be so bad that you don’t hear much of anything. You might not really realize it but some of the worst asthma exacerbations I’ve heard of, efforts were listening and don’t hear any wheezing, but that’s because the airways are so tightened up, and so, if they are coughing, there’s definitely cough variant asthma, you want to try that albuterol and see if that helps them. It won’t hurt them.
Lynda: Got it. What is your initial workup after a child or adult has presented for the first time
withx Dr. Hoyt: — with anaphylaxis?
Dr. Hoyt: The most important thing to do is have a conversation with the person. I hate typing and doing stuff while having a conversation. If I don’t write something down, that is bad. But I got to a point where, I was going to sit and have a conversation with you. Having that eye to eye conversation with a kiddo who is even four or five or six years old, you are directing some question specifically to them, just having a conversation, trying to see, how were the foods prepared, what is the timeline, what symptoms happened, and how long after eating until those symptoms happened? Are they reacting to the tacos? The soy, the pork taco meat? It happens. You want to be an excellent historian and be very detailed. Because 95% of the time, you can get a diagnosis about any sort of testing.
Lynda: Thank you so much, Dr. Hoyt. You were fabulous. So informative. I can see the thank you’s coming in. You have helped a lot of people. I just want to let everybody know, look for the follow-up e-mail. Will be giving you lots of links. We should really include information about the efforts you were involved in. I will follow up with the in-house staff about getting that done. We have two webinars coming up in December. One December 14th for COVID, RSV and flew, how to stay healthy — and flu, how to stay healthy, and in January, “not everything that coughs is asthma.” Thank you sincerely from all of us at the Allergy and Asthma Network. We work together so that everybody can breathe better together. Good night, everybody.