We often about hear about food allergies in school kids. But what about when food allergies develop in the youngest children – babies and toddlers?
Researchers are learning that the symptoms of serious food allergy reactions in infants and toddlers can be quite different from those in older children. In guidelines for allergists, an expert panel writes: "the diagnosis and treatment of anaphylaxis may be even more challenging in infants."
This leaves moms and caregivers to wonder: "Will I be able to recognize a food allergy reaction in my baby?" Other questions arise, too. How do you treat a young child? Can I use an epinephrine auto-injector on a baby?
To shed light on this topic, Allergic Living's Gwen Smith sits down with Dr. Jennifer Kim. The Chicago area pediatric allergist-immunologist shares illuminating insights into babies and food allergies.
During their conversation, she touches on specific symptoms, tips for safe food introduction, teaching parents and caregivers about epinephrine, and more. This is a must read for parents and pediatricians alike.
Interview with Dr. Jennifer Kim
Gwen Smith: Dr. Kim, first, anaphylaxis has a range of symptoms and can be challenging to recognize. Large U.S. studies show that a top barrier to parents using epinephrine during anaphylaxis is simply that they were unsure about when to administer it. Give us your thoughts on what makes anaphylaxis particularly hard to recognize in a baby?
Dr. Jennifer Kim: Well, infants are not able to tell us in words what they're experiencing. So it becomes more about interpreting their behavioral changes. Examples would be if the child is suddenly fussy or not as happy or playful as they were after consuming a potential allergen. Is this a severe reaction brewing?
More obvious signs would be tongue thrusting or pulling at their tongue or ear, or their cry becoming hoarse. Then, if there's swelling, if there's a rash, if there's vomiting, those are more significant symptoms.
While respiratory symptoms may be what caregivers often associate with anaphylaxis, skin and stomach reactions are most common in infants and toddlers. Severe symptoms such as trouble breathing or involvement of two or more body systems (i.e. skin and stomach) indicate anaphylaxis and should be treated immediately with an epinephrine auto-injector, like AUVI-q® (epinephrine injection, USP) 0.1 mg, which is for infants and toddlers 16.5 to 33 pounds.
A milder reaction is when there's a localized skin reaction, or a runny nose or sneezing or a mild stomachache. Talk to your doctor about how to respond to mild, single system symptoms.
Learning to Act, Not Wait
GS: Have you had the experience where a parent says, 'We ended up in the ER, but I really wasn't sure it was anaphylaxis?'
Dr. Kim: So the No. 1 issue with this is education. Sometimes in the doctor's office, all the symptoms are washing over the parent who's just learning about food allergies. Then in the situation where your child is having a reaction, sometimes, there's panic.
But if the child already has a diagnosis and an epinephrine device, I try to educate the parents on when to use it, emphasizing the warning signs of a severe reaction. The signs I share include: head-to-toe skin reaction, vomiting, especially vomiting with hives, voice hoarseness, coughing, wheezing after eating.
Importantly, do not wait until the cough turns into the infant gasping for air. Use the epinephrine early to prevent symptoms from worsening. Other signs include a change in the child's color and, again, how they are behaving. Other examples include being lethargic or going limp.
GS: Sometimes people are concerned about giving their child epinephrine, or concerned they'll have to take the child to the ER if they use epinephrine. With a baby or toddler, what counsel do you give on the safety of epinephrine to treat anaphylaxis?
Dr. Kim: The first thing is administering epinephrine is the first-line treatment for anaphylaxis. When it is recommended that you seek medical attention after giving epinephrine, this is not to suggest epinephrine is dangerous. It isn't. The recommendation is because there's an allergic reaction severe enough for you to administer epinephrine. This means there needs to be monitoring afterwards.
If a parent or care provider is home by themselves with other children, I say to call 911. Do that, rather than trying to get all the kids into the car and then drive to the emergency room in a panic. That's risking an accident. So, it's better to have the EMS come to your home and evaluate the child.
Babies and When to Use Epinephrine
GS: What about needing epinephrine for allergic babies and toddlers at risk for anaphylaxis. Can you tell us about appropriate epinephrine options for that age range?
Dr. Kim: There are three different epinephrine auto-injector doses, and they are weight-based. The 0.1 milligram (mg) dose is only available from AUVI-q. This AUVI-q was designed specifically for administering epinephrine to babies and toddlers 16.5 to 33 pounds.
The device also has audio-visual cues. So another helpful aspect is that, you pull off the cover, and the device tells you what to do step by step. I've heard from parents that the verbal cues are very helpful.
Since the AUVI-Q first came out, in the 0.15 mg and the 0.3 mg doses, I've been hearing patients say the voice instructions of AUVI-Q helped them feel confident administering epinephrine to their child.
Babies and Food Allergies at Daycare
GS: In a lot of families, both parents work, and that means handing your child with food allergies off to another care provider. Our readers are familiar with needing to warn daycare centers about food restrictions. But what should they also be ensuring about the daycare's readiness with epinephrine?
Dr. Kim: We educate the families on how to recognize anaphylaxis or allergic reactions. Then, in turn, they need to educate caregivers, and this includes daycare staff. There's usually a written emergency plan that we allergists provide. Yet we fit it on one page. So a lot of the nuances of symptoms and using epinephrine are not necessarily in the written plan. That's where the verbal discussion is helpful.
The other thing I would recommend is – these devices come with trainers that don't have a needle or medication. So, it's easy and important to demonstrate how to use the device.
Then also have the person who might need to use it, practice using it. That way, they're comfortable with how to use it, and how to hold the child's leg stable while injecting the medication. Repeat that guidance with any staff who are going to be responsible for recognizing and treating symptoms.
GS: We spoke about AUVI-q's 0.1 mg device and the voice instructions. I would think they're helpful as well with caregivers – from the daycare to the babysitter. Your thoughts?
Dr. Kim: I have parents who want AUVI-Q devices for grandparents or a nanny, or a babysitter. This device is easy to use and while no experience is required, it only requires a few minutes to go through the basics and demonstrate using the trainer.
I suggest also providing them with the anaphylaxis emergency plan, reminding the caregiver about the symptoms and explaining safe foods.
In your own home, things tend to be safer, because you have safe foods available for your child. But with a daycare, you have to have a plan. Are they going to supply the food? Are you going to supply the food? These are the details that must be sorted out in advance.
Infants and When to Allergy Test
GS: Now, we've been talking about diagnosed infants. But what about a suspected food allergy? How, as a pediatric allergist, do you decide when to test a baby?
Dr. Kim: At my office, the first thing is to get a history, starting with what exactly happened. What did they eat? What were the symptoms? How much time passed between eating and the symptoms? How often had they eaten the food before?
The history is paramount in trying to determine if testing is appropriate. I ask very detailed questions, like 'how much are they eating?' Is it chewing on some bread or are they having, say, a quarter cup of cream of wheat?
Starting Babies on the Allergy Suspects
GS: Introducing solid foods to a baby is generally a happy time. You're opening the door to what will be your child's diet. And of course, we now know that introducing early the potentially allergenic foods is important for preventing food allergies. But unfortunately, some children will still develop food allergies. Any food introduction tips?
Dr. Kim: Yes. When introducing new foods, I'm less worried about, say, fruits and vegetables. A parent doesn't want to have too much anxiety, such as 'I'm going to choose one food and do that for five days and then do the next food.' That's a chore rather than enjoyable.
However, for the Top 9 highly allergenic foods, I would recommend introducing those one at a time, and gradually increasing. For example, with a thin peanut butter purée, try a quarter teaspoon of peanut butter the first day, half a teaspoon of the next, and then onto a full teaspoon.
I should emphasize as well, the data show the risk of a severe allergic reaction in infants is very low, which is important to put caregivers at ease during the introduction process.
Aside from introducing the allergenic foods early, incorporate them into the diet. It's really important to keep the food in the diet two or three times a week. That's what has been shown to prevent the development of allergy. So: introduce and incorporate.
Other tips would be: don't do food introduction before a nap or at bedtime. You want to monitor them for an hour or two afterwards, especially with a new, highly allergenic food.
This article was supported by Kaléo, Inc. Dr. Kim is a paid adviser to Kaléo.
Related Reading:
For more information, visit AUVI-Q's website
AAFA’s Infants and Toddlers with Anaphylaxis Study
Important Safety Information
Indication
AUVI-Q® (epinephrine injection, USP) is a prescription medicine used to treat life-threatening allergic reactions, including anaphylaxis, in people who are at risk for or have a history of serious allergic reactions.
Important Safety Information
AUVI-Q is for immediate self (or caregiver) administration and does not take the place of emergency medical care. Seek immediate medical treatment after using AUVI-Q. Each AUVI-Q contains a single dose of epinephrine. AUVI-Q should only be injected into your outer thigh, through clothing if necessary. If you inject a young child or infant with AUVI-Q, hold their leg firmly in place before and during the injection to prevent injuries. Do not inject AUVI-Q into any other part of your body, such as into veins, buttocks, fingers, toes, hands, or feet. If this occurs, seek immediate medical treatment and make sure to inform the healthcare provider of the location of the accidental injection. Only a healthcare provider should give additional doses of epinephrine if more than two doses are necessary for a single allergic emergency.
Rarely, patients who use AUVI-Q may develop infections at the injection site within a few days of an injection. Some of these infections can be serious. Call your healthcare provider right away if you have any of the following symptoms at an injection site: redness that does not go away, swelling, tenderness, or the area feels warm to the touch.
If you have certain medical conditions, or take certain medicines, your condition may get worse or you may have more or longer lasting side effects when you use AUVI-Q. Be sure to tell your healthcare provider about all the medicines you take, especially medicines for asthma. Also tell your healthcare provider about all of your medical conditions, especially if you have asthma, a history of depression, thyroid problems, Parkinson’s disease, diabetes, heart problems or high blood pressure, have any other medical conditions, are pregnant or plan to become pregnant, or are breastfeeding or plan to breastfeed. Epinephrine should be used with caution if you have heart disease or are taking certain medicines that can cause heart-related (cardiac) symptoms.
Common side effects include fast, irregular or ‘pounding’ heartbeat, sweating, shakiness, headache, paleness, feelings of over excitement, nervousness, or anxiety, weakness, dizziness, nausea and vomiting, or breathing problems. These side effects usually go away quickly, especially if you rest. Tell your healthcare provider if you have any side effect that bothers you or that does not go away.
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