When to give an EpiPen?

[an_aurora]

I know this is a dumb question, and one that needs to be addressed by my son's allergist, but all she told us was to use it if he has any symptoms beyond hives (drooling, wheezing, labored breathing, etc). That seems pretty black & white, but at the same time, in the midst of a reaction I've found myself not sure when to use it.

DS is 19m and is allergic to garlic (his most severe allergy), peanuts, eggs, and tree nuts.  A few weeks ago he had an exposure to garlic.  We noticed red spots on his face, and I immediately gave him Benadryl.  Hives went away, and he seemed fine.  He had a bath and went to bed like normal.  Then an hour or so later he woke up screaming, so I went and got him and cuddled him on the couch.  He was making and odd crying sound and grabbing at his throat.  If it was that simple, I would have given him his EpiPen right then.  But, he also had a cold/cough/sore throat at the time, and was congested.  I ended up waiting it out and he fell asleep upright on my chest and was fine (but I was freaked out and sat on the couch holding him most of the night).  That was the closest I have come to giving him his EpiPen.  Since then I have done  a little bit of research online and it seems that most places recommend giving the EpiPen when there is a known exposure.  Now, he definitely reacts to garlic every time he is exposed, but his reaction never progresses beyond hives.  So is he just not that allergic?   

[limette]

Don't food allergies get worse with each exposure? I would be using it with each exposure.

[an_aurora]

Yes, they do, or at least that was my understanding.  

[CarrieMF]

Grabbing at his throat while screaming.  I would have given the epi pen.  Yeah it may have been the cold/sore throat however by the time you found out for sure it may have been too late too.  

[an_aurora]

I guess I'm just torn because so far his reactions haven't gotten worse than the hives.  So yeah I could/should have given it to him last time, but it turned out to not be a bad reaction.  I mean, if I had given it with every exposure, it would have been a lot of unnecessary treatments and ER visits. 

[sbgrace]

Our protocol is any two body symptoms at any point and any known exposure to tree nuts or sesame. But that any known exposure is because my son has had anphylactic reactions to those foods. If you son has only had hive reactions to foods why is the doctor treating him as anaphylactic?

I feel like I'm misunderstanding and maybe he has had ana in the past. My son has had many hive reactions to foods (worst hive reactions with oranges actually) and we never were advised to give (or prescribed) an epi pen. His anaphylaxis started with hives too and I did the antihistamine like we do and remember thinking "hmmm...I've got to call the person who made this bread to see if it had orange juice or something" because the hives were all over and the antihistamine wasn't helping. I was upset and mad at myself because I thought we were going to end up with another round of steroids for oranges. The woman knew of his orange allergy but I hadn't reminded her or asked specifically when she dropped bread by for us. So there I was upset and with no clue it was really trace nuts and we were in for his first anaphylaxis.

I think the known exposure is because a hives and throat swelling reaction in the past could be a sudden drop in blood pressure reaction or throat closes completely this time. Past reactions don't predict future severity and in the case of some reactions once it gets to a point epi pens do no good. That point is actually very early in the reaction.

Now we have epi pens. I still wouldn't epi for oranges with hives.

[an_aurora]

Thanks for your response.  No, he has never had any anaphylactic reaction--he just gets hives on his face with an exposure.  For instance, my IL's gave him a Sun Chip and he had hives for 2 days.  We gave him Benadryl and the hives went away slowly.  

He was given the EpiPen by his allergist at 9 months old, when we had him tested.  He had been getting bad rashes on his face since he had started solids, and there's a strong family history of food allergies (myself, my DH, my DD2).  He was tested for both igG and igE (patch and prick testing) and tested positive for anaphylaxis allergies to garlic, peanuts, cashews, and eggs.  The strongest reaction was to garlic; he had initially tested negative to peanuts but she poked him again for peanuts since he had gotten hives after DD shared a peanut butter cookie.  That time was +2.  He has 14 igG allergies.

Also, interestingly enough, he was diagnosed with pediatric epilepsy at 10 weeks of age.  He outgrew it completely by his 1st birthday.  His neurologist suggested that his epilepsy was related to his allergies, and that he was reacting to the proteins in my milk when I ate his allergens.  He said that anaphylaxis in infants is very hard to diagnose and is very unpredictable, but one way that it can present is with seizures.  We all found it very coincidental that he suddenly stopped having seizures at the same point in time that we had his allergies diagnosed and both he and I went on a strict diet.  

[sbgrace]

Ok. That changes the picture. He tested positive for both peanuts and cashew...deadly allergens. I would want an epi pen for that. I'm not sure what anaphylactic allergy to garlic based on testing is, though? I don't get that at all. They can't tell anaphylaxis from a skin prick. But I think he needs an epi pen.

Cashew (we have that...) is very deadly. It has cross contamination potential with sesame. Those sunchips undoubtedly had sesame cross contamination.

I'd want an epi pen. I think you need to talk to the allergist about when to use it. It is complicated with a young baby.

[an_aurora]

That's not my understanding at all.  I thought it's not the allergen that's important; it's the response to the allergen.  Yes, cashews and peanuts are deadly allergies, but that's because they are common ones.  A reaction to, say, pineapple or garlic or cinnamon or whatever could be just as deadly if the child reacts strongly to it.  

As far as testing, it's standard practice at our allergists office to have testing, and that's how they diagnosed his allergies and gave him an EpiPen.  They base the severity of the reaction on the severity of his reaction to the test.  For him, garlic is the strongest reaction (which has held true in real life) and while he reacted to the other pricks, those weren't as strong and could go either way--she said he could react to them with every exposure or he could be fine with one exposure and need his EpiPen with the next. 

All of this is so mind-boggling to me...I have several things that I react to (nuts and soy make my throat and face itch) but the only real reactions I have had were to antibiotics and then recently I was on steroids for a reaction I had to paper tape and/or chlorhexadine (they weren't sure which).

[sbgrace]

I'd be confused too in your place!

This is my thinking--he may have severe reactions to garlic, yes. My father in anaphylactic to a spice almost no one is allergic to at all. The thing is your child has shown no signs of anaphylaxis to garlic, right? He gets hives and has a big wheel on skin prick so clearly he's very allergic. I just don't understand why the allergist would say anaphylactic and want you to use an epi pen with exposure. You can't predict anaphylaxis with a skin prick. I'm just not following your allergist's thinking if he is thinking large garlic wheel without any history of anphylactic reaction meant he should be treated as anaphylactic to garlic. Maybe he did mean that. I've just never come across that thinking. I'm not allergist though! I think most allergists would prescribe an epi pen for a common anaphylaxis trigger allergy regardless of history--so I thought that was the allergist's thinking re: peanut and cashew. I think anyone with those allergies should have an epi pen regardless of reaction.

I really think you need to talk to the allergist again. I can't see giving an epi pen and taking an ambulance ride every time he has garlic when he's never shown signs of anaphylaxis to garlic. Maybe he did mean that though--if you can get clear on that and his reasoning it would help you in those situations I think. You don't know what to do and I wouldn't know either in your place! .

I'd imagine garlic is a lot like sesame in terms of difficult to avoid cross contamination and not labeled (ie spices...). If you think your child is ana to it I think you should likely call companies and make a list of safe (doesn't contain and isn't produced on lines with garlic) options and make sure family understands they can't feed him anything you don't provide or approve from the safe list. Even if he's not anaphylactic I'd want to prevent those hives.

[an_aurora]

Ok, that makes sense.  So he's allergic but not ana-allergic.  Good to know...I was thinking I was crazy, reading how you should give the Epi with a known exposure, but that would have just meant lots of unnecessary ambulance rides & ER visits.  So I will keep on with just giving Benadryl and watching him with exposure and keeping the EpiPen with us just in case.  

And thanks for the info about the sesame--I didn't know that.  He eats halvah with no issue, but I won't be giving him that again just in case.