Concerns about \"when to use the EpiPen\"

Author:
Publish date:

My daughter was recently prescribed an EpiPen, Jr. for her PA (my son is also PA). The PA manifests itself differently in both children. For my son, if he were exposed to peanuts, he would start wheezing pretty badly fairly quickly and require the EpiPen and a trip to the hospital, no doubt, and that all sits perfectly well with me.

My concern centers around what the allergist told me about my daughter, and I'm just not as certain about the use of the EpiPen with her as with him.

My daughter gets a rash from her PA. She's only been exposed twice that I know of, and the rash went away pretty quickly with Benadryl and washing the effected area. Her skin prick test was the same as my son's, as in 4++, and we decided not to do the blood testing at this time (she'll be 2 on Friday). The allergist said that if she is ever exposed to peanuts again and gets a rash that I absolutely MUST give her the EpiPen and rush her to the hospital. She was actually mad at me that I didn't give her my son's (adult sized) EpiPen when she had the rash last time, BEFORE she was diagnosed. I told her I didn't think her reaction warranted such intense action, as it didn't appear to affect her breathing or anything else and went away with the Benadryl and bath.

I don't think I did the wrong thing and I'm not sure I agree with the allergist that I need to necessarily react so ferociously to what could be (or has been) a controllable situation. Is this a situation where, IF it happens again (she is exposed to peanuts, that is), I should follow my own instincts, or just give her the EpiPen for a mild reaction and rush her to the hospital anyway?

I know we never really know what the severity of the allergic reaction is going to be, and I also know that next time could be "the time" for anaphalactic shock, but I was really quite taken aback by her vehemence about it and it really made me feel pretty stupid. (I didn't give her the EpiPen last time because she's so tiny compared to my giant, monstrous son and I was afraid it would be way too big a dose for her, but I was given the third degree for not giving it to her anyway!)

And the really funny (or sick, however you prefer) thing about all this is that we pretty much discovered her peanut allergy while she was in the hospital for infected lymph nodes, and even though I pointed the rash out to the doctors (who gave her the peanut butter crackers, by the way!), they did and said nothing nor attempted to treat it or check for allergies to medication or anything!

I overreact about so much with my children, that this really is just a, 'I wanna know I'm not overreacting AGAIN if I do this' kinda situation.

Thoughts? Thanks! ~Melanie

On Nov 6, 2002

I am not sure of the right answer, but I do not get such coaching for "ferocious" intervention, as you call it, from my allergist. I belive him to be well reputed in the area, affiliated with Bostn Children's hospital. He tends to soothe my fears and anxieties and try to give some balance to my anxiety, as opposed to being full of caution. My instruction consisted basically of avoidance diet, with some education on label, watching an instructional video, and recieving hands on instruction in the epipen. We, too have only had rashy/eye itching reactions, and I did not ask if that would require an epipen in the future. I go by the general consensus on the board, which is 2 systems involved, or respiratory symptoms alone. Not sure if that is accurate, and luckily we have been reaction free.

My dd has had hives, and it was unclear exactly why, but I suspected a lotion and not PA. Benadryl wiped them out within an hour or so. I really do not know what to tell you, but I got more the feeling to observe my child. I guess I fell like I would know if she was "just not right" and go for it rather than wait. I think it is so hard to know when our kids have never had a strong reaction. It is really hard what to tell teachers to do. But I am so glad she has not had any big reactions! becca

On Nov 6, 2002

I'm not sure there is a "right" answer, but I will share what our allergist told us when we had our first visit after our daughter's reaction. He said that if we see any signs of swelling -- tongue, lips, face -- we should give the epipen. He was saying, I think, that this would be the sign of an anaphylactic reaction. If she really, really, really only had hives, give Benadryl. We have never had to put this advice into practice, luckily, since she has only had the one reaction. But I have to say that I would react more like you have than how your allergist is telling you to react.

That said, I don't think you could ever be faulted for giving the epipen even if it turned out not to be warranted. Better safe than sorry.

On Nov 6, 2002

Is the rash all over her body (generalized) or just in one area (localized)? I think a rash all over is considered a more serious reaction.

I thought this F.A.S.T. poster from Canada was interesting summary of serious symptoms that might require an epi-pen:

[url="http://www.safe4kids.ca/images/Safe_poster_english.jpg"]http://www.safe4kids.ca/images/Safe_poster_english.jpg[/url]

On Nov 7, 2002

[quote]Originally posted by dmbb: [B]Is the rash all over her body (generalized) or just in one area (localized)?

Thanks for the link to the poster and for the responses! So far, the two rashes I've seen have been localised to only contacted skin on her face and no where else on her body and no other symptoms of any kind (respiratory, gaseous, tongue swelling, etc.) ~Melanie

On Nov 7, 2002

I`m with Becca. When my daughter had a few hives, swelling around the eyes, and wheezing I used the Epipen. When my daughter had only wheezing (mild), I gave her a nebulizer, and she was fine after so I didn`t use the Epi. Both times our allergist said I did the right thing. I would have used the Epi on the second reaction if the wheezing were more severe or if the nebulizer didn`t take care of it or if she had had any other organs involved.

On Nov 7, 2002

Carefulmom, and all, Dr. Young addressed this very issue last night at his talk. He really agreed it is a tough call sometimes, but best to err on the side of using the epipen. Delaying can have tragic consequences, and you can never be faulted for choosing to use it in a questionable situation. He was pretty calm about it, though. However, the bottom line is that deaths result from delaying treatment with epinephrine. He did say often hives can be just a skin thing and not anaphylaxis and there is no absolute instruction he can give. He said consider them over time. Are there just a few, and not alot more over time, or are they spreading rapidly in minutes down the trunk, and such.

He also specifically addressed the confusing issue with kids with asthma. If they just ate and they are wheezing, he says it is likely the food, and it could be anaphylaxis, and to give epi first, then the inhalers or pufferes if they need more help. If a child is wheezing due to swelling, the puffers, etc. are not going to get to the lungs anyway.

So it is key to determine if the wheezing might truly be from eating(if they just ate) an allergen. We do not have asthma, but I can imagine it could be very confusing.

My friend's kids have asthma, but no known food allergies. Her dd had a heck of an attack(in my opinion, though her mom was not too worried [img]http://uumor.pair.com/nutalle2/peanutallergy/eek.gif[/img] ) while eating a sandwich at my house. I have a cat. Now, if there were some food allergic history, environmental allergic history, and she was eating, away from home, how would you ever know which was causing it??? I guess then you would err on the cautious side and give the epi? Fresh air did it for her, thank God(forgot inhalers!)

Just passing along info from the lecture last night as I understood it. Not questioning your advice in your situation. becca

[This message has been edited by becca (edited November 07, 2002).]

On Nov 7, 2002

Becca, I would have thought in advance that any time my daughter had wheezing as a food allergy reaction, that I would use the Epipen. But in fact when it happened, her wheezing was so extremely mild, that it just seemed totally unnecessary. Half the parents I know wouldn`t have even noticed such mild wheezing; the school nurse who heard the story later commented that if it had happened at school probably the teacher wouldn`t have even noticed because it was so mild. She responded great to the nebulizer, and although she is seven she didn`t even know she was having a reaction because she felt completely fine. Her allergist agreed with what I did, although prior to this I would have thought that the Epipen should be used if the child is wheezing. I guess it is one of those "you had to be there" things. If her wheezing had been anything more than mild, I think the Epi should be used. While doing the nebulizer if she had gotten worse or if she had developed any other symptoms I would have used the Epi.

On Nov 7, 2002

Carefulmom, I just want to be clear, I was not questioning what you did! I had a dd *covered* in hives over the course of 5 mins. I gave her Benadryl, and they cooled down quickly. Later she had some diarrhea. In hindsight, after last night's lecture, I woonder if she ate something PN contaminated? Or reacted to a new thing. Or I think she might have had a roseaola episode, and some complicated reaction to sunscreen because of the rash already there.

It is so hard to know *what* it is sometimes, especially with very reactive skin or airways!! Your post just made me recall what the doctor said last night regarding the subject of when to give the epi-pen, and in consideration of hives and/or asthma. He also did say observe the child, and keep observing the child and it will progress, usually rapidly, if it is anaphylaxis.

You obviously did the right thing! becca

[This message has been edited by becca (edited November 08, 2002).]

On Nov 7, 2002

Me Cash, I have to say that I have never been told by any of the doctors that have seen Jesse re PA when/how/why to administer the Epi-pen. It's frightening actually if I add up the list of doctors. However.

From what I read in your post, I think you're doing the right thing. Why would you administer an Epi-pen for localized hives? This would be considered a hive-only reaction, wouldn't it? My understanding, and I certainly don't mind being corrected, is that an Epi-pen is used when you are having an anaphylactic reaction and there has to be more than one system in play for it to be considered anaphylactic.

You are aware of PA and the differences between your two children. I know that we are all *supposed* to trust our doctors, but what about those of us who have had doctors that told us nothing or doctors that actually told us something incorrect? I believe what your doctor told you was incorrect.

You have the understanding that the next reaction may possibly not be a hive only reaction and you are prepared to administer the Epi-pen Jr. should your daughter need it.

I say go with your gut instinct as HER MOM. Should she ever be exposed again, watch for anaphylaxis for the 24 hour period after (or so I have been advised HERE, not by a doctor - Jesse, his first anaphylactic reaction, they let us leave the doctor's office after 1 hour with NO instructions for follow-up [img]http://uumor.pair.com/nutalle2/peanutallergy/mad.gif[/img] ) and carry on accordingly. YOU know your child, you know her history of reactions and your son's as well, and trust yourself. Seriously.

It's just like how it's in most of our GUTS that our children have had their first PA reaction. Did we even know about PA? But somehow we knew. For me, I really trust my gut instinct when it comes to PA and actually most other health issues re the kids. And, I also trust the members here who have given me invaluable information that may one day save Jesse's life that NO doctor (and that includes a well respected allergist) has ever given me.

Best wishes! [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img]

------------------

On Nov 12, 2002

Hey Becca:

On the asthma side: my son is/was asthmatic. We thought for five years that it was environmental (pollen) related). We never thought for a second it was food allergies and he never had any kind of hives or rashes (except to Tide). When he got allergy tested, he tested negative for all the usual suspects (mites, pollens, molds, trees, etc..) and positive for peanuts, sage brush (which doesn't grow here) and mildly for cats and dogs.

Once we altered his diet in April 1.5 years ago, things finally changed for us. He has not wheezed once in 1.5 years. I still get his meds updated and have a nebulizer handy and, of course, EpiPens, but my son is not considered "asthmatic" anymore. He is considered "peanut allergic." He can run to his hearts content without any problems breathing. I am so happy that I got to ditch the whole regimine of peak flow meters, nebulizer treatments and inhalers on top of useless pills. He just needed a peanut free diet!

~Melanie

On Nov 12, 2002

Cindy:

Thank you for your response. I sometimes find it hard not to beat myself up with worry over these kids, and I usually have no problem following my own instincts, but our allergist really made me feel stupid. Thanks for some reinforcement in my self confidence and judgement circuits! [img]http://uumor.pair.com/nutalle2/peanutallergy/smile.gif[/img]

I really appreciate your response. ~Melanie

On Feb 1, 2003

Melanie

I know this is late coming in, but I just read this tonight and it helped me determine what I'll do next time, although some may not agree....

if the initial reaction was an anaphylactic reaction, epinephrine should be given immediately if accidental ingestion occurs, even before evidence of any reaction, and the patient taken to the emergency of the nearest hospital. If the initial reaction was hives only, accidental ingestion does not necessitate epinephrine at once, but an Epipen or Anakit should be on hand, and given if signs of anaphylaxis are observed.

If you want the site I got it from let me know, I couldn't copy exactly who it came from but was a very lengthy link in the LINKS section of this board.

HTH, Lana

On Feb 2, 2003

I was told by my allergist that I should use the epipen if my son has any reaction resulting from peanuts. He has only had one reaction (prior to knowing he was PA) which was hives only. Benedryl relieved the symptoms.

On Feb 3, 2003

There are some great links at the following Website on this topic.

[url="http://www.allerg.qc.ca/professinfo.htm"]http://www.allerg.qc.ca/professinfo.htm[/url]

[This message has been edited by Syd's Mom (edited February 03, 2003).]

On Feb 3, 2003

Below is an portion of a full study (unfortunately dealing with deaths of children who weren't given the epi-pen on time) The article was produced by the Canadian Paediatric Society (CPS)

Quote:

[b] "Characteristics of children at risk

In a case series, six young patients with fatal anaphylaxis after food ingestion and seven others with near-fatal anaphylaxis not only had a history of reactions to food but also had asthma and were highly allergic to many substances. Their parents or caregivers had failed to appreciate the potential seriousness of the food allergies. Four of the six fatal reactions occurred at school. Although self-injectable epinephrine had been prescribed for half of the children with fatal reactions, they did not have it available when they died. Many of the children had deceptively mild symptoms for 1 or more hours before breathing problems developed, yet none of them received epinephrine before severe respiratory symptoms developed. "

[/b]

How sad - each having mild symptoms that could have easily been treated with the epi-pen before respiratory symptoms developed. I'll be rethinking my use of the epi-pen on mild symptoms rather than waiting for the more serious breathing issues to develop.

The full article is available at Canadian Paediatric Society (CPS)link: [url="http://www.cps.ca/english/statements/AL/al94-01.htm"]http://www.cps.ca/english/statements/AL/al94-01.htm[/url]

[This message has been edited by Syd's Mom (edited February 03, 2003).]

On Feb 3, 2003

My problem with using the epi right away is our DS has so many other "minor" allergies. By far most of his reactions are simple, non life threatening ones. Just the other night he had a reaction at home, hives all over his chest, neck and wrists, watery eyes and runny nose. I was ready to inject him, but I knew he had not ingested any PN because our house is totally safe.

When we finally figured out it was from a wool jacket he had put on for dress-up, I was glad I hadn't injected him. If we had been out though I wouldn't be quite as confident about whether it was PN or not, and I probably would have injected him. I know it wouldn't hurt him, but if I'm injecting him I'm going to call 911 and spend the rest of the night in the ER.

I've said many times I won't hesitate to give the epi, but only if I know it is PN or it is anaphylactic. Anyone else in the same boat? What do you do?

------------------ Cynde

On Feb 3, 2003

I would always err on the side of caution and administer the epi-pen. I have read similar information as Syd's mom in that a lot of the people who die from PA were not administered the epi-pen within the first ten to fifteen minutes of the reaction starting. We were told once the hives start or you hear wheezing mild or not administer the epi. Better safe than sorry. And like you said PA is progressive, so the next time it might be worse.

On Feb 3, 2003

Cynde - I totally agree with you that mild symptoms at home can be confusing as to whether they are related to non-peanut allergies and at times treated differently (our house is 100% free of any cross contaminated items and totally peanut free) but now that we have frequent little visiting friends (who may have pb at home before coming over), I guess I'm second guessing mild symptoms now at home as well.

Syd is confirmed as airborne sensitive - just a whiff on someone elses breath has caused her eyes to swell over.

It's so hard when our kids also have allergies to other food items/ea's and asthma on top, and the symptoms of these other allergies, and the common cold and flu sometimes seem so similar - it can be just so confusing and worrysome.

Hoping the best for everyone having to handle this issue.

Warm regards,

[This message has been edited by Syd's Mom (edited February 03, 2003).]

On Feb 5, 2003

This is a difficult question to answer. If my DD gets hives only, she will get Benedryl. If she gets any 2 symptoms (different body functions) or any facial swelling,she will get the Epi-pen.

DD has had a bi-phasic anaphylactic reaction.

HTH Andrea

Related