How is anaphylaxis handled in the hospital ?

Posted on: Thu, 08/03/2000 - 8:28pm
VeesDad's picture
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So we've been told to use the EpiPen if needed and call 911 or go to the closest hospital (thankfully haven't had to do this yet).

Since the epi-pen only lasts 10-15 minutes, I am curious to know what exactly do they do at the hospital to subdue the reaction and get everything back under control? How long do you have to stay there afterwards?

Posted on: Thu, 08/03/2000 - 9:15pm
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My son has never needed more than one dose of epi. The first one has done the trick. They just will make you wait for a couple of hours to make sure the reaction does not return and that there is no adverse reaction to the epi. We only ended up in the ER once and at the time I didn't know as much as I do now. My mistake was not calling our allergist so that he could direct the care. The first ER Dr. didn't administer the epi right away. She instead tried Zantac and then steroids. When another Dr. was called in for an opinion, he immediately order the epi right into a vein. That stopped the reaction and after about 3 hours, we were ready go. I assume if the reaction had continued they would have administered the epi again.

Posted on: Thu, 08/03/2000 - 10:31pm
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My son had his anaphylactic reaction before we had the epi-pen. When we got to the ER the Dr. determined it was anaphylaxis and gave him a shot (we had given him benadryl before we left). We had to stick around the hospital for a couple hours for him to be monitored. My son was only 18 mos old at the time. The shot did make him very "jittery" and "shaky". He was still pretty wound up after we got home.

Posted on: Thu, 08/03/2000 - 11:47pm
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My daughter was 2 when she had her anaphylactic reaction. In my case, I had the Epi, but wasn't sure when to administer it. She ended up vomiting which reintroduced the pnut into her system, and she reacted all over again. When I got to the hospital, her face was 3x the size it normally is. After the doctor 'chewed' me out for not using the Epi, they finally treated her with a shot of Benadryl, a shot of Epi, and she had to drink some Prednisone. She immediately went to sleep, and we had to stay there for about 3 hours. The ER dr. told us we had to watch her carefully through the night for any re-reaction. Since it was already 3 in the morning, I insisted she stay there overnight, because I felt very nervous about taking her home. They wouldn't keep her, and I literally watched her like a hawk the whole night. Every time she sighed, or moved, I panicked! Luckily, she was fine. I think if the ER dr. is that concerned about a re-reaction, they should keep the child in the hospital for observation. I know as far as insurances go, that may not be possible, but each case should be evaluated. If she had stayed, I think I would have been stronger knowing help was right there if needed.

Posted on: Fri, 08/04/2000 - 7:19am
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Anonymous (not verified)

My son has had two anaphylactic reactions. The first time, he was administered the Epi-pen at the local medical centre, given Benadryl and then watched closely for an hour. The 2nd time, we administered the Epi-pen but did not know that you were supposed to go to the hospital immediately thereafter. Twenty minutes later, he started to "go" again. If I had had a 2nd Epi-pen at that time, I would have given him another shot. However, I didn't. We got him to the hospital where he was given the Epi-pen again, some Benadryl and we spent the whole night in intensive care (his reaction was all encompassing as far as the symptoms of anaphylactic shock) because a reaction can occur again up to 8 hours after the initial reaction. This was from merely touching a rice krispie square with pb in it to his lips - it did not enter his mouth, he did not take a bite out of it. When we left the hospital, we were given a prescription for Pediapred (kid's prednisone) for him to take for a week. Now, fortunately, we know what to do. His school has 2 Epi-pens with the instruction that they are to administer the 2nd one if he has a reaction, 20 minutes after the 1st one if an ambulance has not arrived. This was my experience with it and I would not wish it upon anyone, especially my dear child! Best wishes, and welcome!
------------------

Posted on: Sat, 08/05/2000 - 5:48pm
VeesDad's picture
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PattyR,
You mention that they injected the EPi into a vein .. I was just reading the insert that comes in the EpiPen package and it strictly warns against intra-vascular injection since there is possibility of causing cerebral haemmorhaege (sp?) .. Were you aware of this risk when the incident happened?

Posted on: Sun, 08/06/2000 - 4:05am
sandi's picture
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My 5yo Pa son has had 3 severe reactions. The first severe one began after biting into and then immediately spitting out PB. i gave him Benadryl immediately, within 15 minutes he had a rash on his face. I began to drive to the Dr office and he became lethargic and had audible wheezing---I had the epi pen in hand ready to give when we got to the Dr office. He was given the epi and more Benadryl and w/in approx a minute he made a turn around. He said Mom lets go !! We of course stayed another hour w/ orders to watch him close for rebound reaction. THe second reaction occured after biting into a cookie that had been siiting next to a pb cookie. His syptoms began with nausea , no rash, no wheezing, I had a gut feeling things were well on there way to a full blown reaction and administered Benadryl and we took off to The childrens hospital ER. when we got there he was still only complaining of nausea, and the Er staff wasn.t worried, even though I had warned them of how fast he reacted the last time. They told me to have a seat and it was then that Sawyer began w/ resp difficulty, I can't tell you how fast we were escorted to the trauma room an IV was placed and they gave him IV Benadryl, no epi. we stayed that visit approx 4 hours, w/ discharge orders to stay away from peanuts---NO DUH!!! The 3rd and hopefully last time he ate a sweet tart candy off the hands of my neice whohad had pb for lunch and he started W/ in 10 minutes w/ resp difficulty I administered the epi ,called 911 and had the fire dept and EMs at my house in 5 minutes. By the time they got there he was breathing fine but I had him transported to the hospital anyway and they observed him and sent him home after3hours, no steroids prescribed only orders to cont Benadrly every 4 hours for the next 24 hours and again to stay away from Peanuts--Like we weren't???? I have learned that this little guys reactions are becoming much quicker as expected and I don't hesitate to give him the epi and have EMS transport.

Posted on: Sun, 08/06/2000 - 11:35am
PattyR's picture
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VeesDad,
I believe what you say and have to assume that I may be mistaken. I need to look into it more and see if I can track down the truth but you have me wondering. Thanks for the info. When they gave him the epi it was in a syringe rather than the epipen auto injector. Could that be the difference?
[This message has been edited by PattyR (edited August 06, 2000).]

Posted on: Sun, 08/06/2000 - 12:49pm
Vanessa's picture
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Joined: 06/28/2000 - 09:00

I had to administer the epi-pen to my daughter for the first time last month I took her directly to ER afterwards and they kept her over night to watch her. My ped. allergist told me that if and when I had to use epi to go directly to ER and if they try to tell you're free to go home, if it hasn't been 3 hours then tell them you're staying or go wait in the car. I really was releived that they kept her, I was scared to death.

Posted on: Sun, 08/06/2000 - 1:09pm
tkiaml's picture
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Joined: 06/18/2000 - 09:00

Before I knew about my sons allergies and before having the Epipen he had a severe reaction to wheat in a cracker. (hives from head to toe,flushing head to toe, wheezing, coughing, excess mucus, swollen face and vomitted in ER.) When I got to the hospital..trying to remain calm... I told the nurse I thought he was reacting to a cracker I had given him. They took name, insurance info., and then had me take him to the back. The took his pulse and pulsox (sp?) and then left the room. A nurse come back in and said the Dr. ordered a shot. I think it was steroid but may have been adrenaline...He was already acting like he felt better right after the shot. I waited by myself with him for about 5 min. and then the respiratory nurse gave him a breathing treatment. He was acting much better and the wheezing had stopped. He wanted to nurse and after about 5 min. he vomited everywhere...Allergist later said it could've been the shot that caused upset stomach....The doctor came in and didn't seem too concerned about the vomit. He said he was doing fine and that his blood pressure was fine from the start. He was free to go but I was told to avoid crackers! DUH! Mind you, I was probably there for about 1 hour tops! My 5 1/2 month old son was still flushed some and covered in hives. Noone ever said anything about a second reaction. I even questioned whether he should stay or not. Everyone acted like it wasn't necessary so I trusted them. I know better now...stand your ground!!! Fortunately, he didn't have a second reaction.His hives faded after about 3 hours.
tkiaml

Posted on: Mon, 08/07/2000 - 10:45pm
tkiaml's picture
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Hi everyone! I brought this one back to the top because I was hoping to find out more about specific situations of how the hospital personnel handled your child's case. I know others have given some of this info. on other threads but wondered if others have had experiences in which it seems the hospital didn't really seem to recognize the importance of acting quickly and observing the patient for secondary reactions. Hope you don't mind that I brought it to the top. thanks! tkiaml

Posted on: Tue, 08/08/2000 - 1:00am
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Joined: 05/28/2009 - 16:42

My one emergency room visit was horrible! My son was eating lunch (something he had eaten numerous times), and all of a sudden he vomitted and broke out in hives. We immediately gave him a dose of Benadryl. Soon afterwards he started drooling really bad - everything around him was soaked, and he seemed to be breathing harder. (He also has asthma, so t is sometimes hard to tell if is that or a reaction.) I called the pediatrician, and he told me to go to the emergency room. Since I only live 10 minutes away and have the epi-pen, we decided to drive ourselves as it would be quicker. The nurse said that he was fine. My son started crying because he was tired and scared, but the doctor wouldn't see us until he stopped crying. She said that he was perfectly okay, that we obviously didn't think it was serious because we didn't call 911. She said that he was drooling because he was getting his molars (which he already had), and she didn't seem to know much about allergies. She also said that we only got to see her because we were scared. There was absolutely no concern about my son's life. One of my friends mother's is a nurse so we spent a couple of hours with her - just in case. My son was okay, but I am very concerned now if he has another reaction.

Posted on: Tue, 08/08/2000 - 2:49am
jrizos's picture
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Joined: 05/30/2000 - 09:00

The care you recieved was inadequate and I think you should write a letter to your hospital and demand a reply. You should write a letter to your doctor. I am sure all of us have had bad experiences myself included. The nursing shortage does not help. You could find out if she was a fill in or fully trained to work in the E.R. Goodluck.

Posted on: Tue, 08/08/2000 - 6:44am
tkiaml's picture
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And I thought my experience was bad!!!!! tkiaml

Posted on: Wed, 08/09/2000 - 8:31am
Kathryn's picture
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Some of you may remember that I am a librarian/researcher. I found this somewhat technical article outlining the treatment of anaphylaxis at a hospital emergency room. It is from Consultant, April 1998 v38 i4 p851(9). It is titled Allergic reactions: 10 questions physicians often ask. It is by John F. O'Brien. I am picking it up in the middle of the article at the question that is relevant to this discussion.
I quote: "What is the current treatment protocol for hypersensitivity reactions? {question asked by doctors} The most useful agents for treating anaphylaxis are oxygen, epinephrine, and fluids.
Oxygen. The final common pathway of anaphylactic death is tissue hypoxia. Therefore, oxygenation and perfusion are critical. Give patients supplemental oxygen if any evidence of hypoxia exists. Monitor oxygen saturation (by arterial blood gas measurement or pulse oximetry); however, be aware that pulse oximetry may not be accurate in patients with severe hypoperfusion.
Endotracheal intubation with 100% oxygen may be required if the response to therapy is not rapid. Orotracheal intubation is usually best; the nasotracheal route may be difficult because of severe mucosal airway edema.
Epinephrine. A potent [Alpha]- and [Beta]-agonist, epinephrine is the drug of choice for severe reactions. Although severe hypertension and coronary artery disease are relative contraindications, especially in older patients, the bottom line is that there are no absolute contraindications in an anaphylactic emergency.
The dose and route of administration of epinephrine depend on the severity of the reaction:
* For a mild to moderate reaction, give 0.01 mg/kg (up to 0.3 to 0.5 mg) SC or IM.
* For a severe reaction, give 1 mL of 1:10,000 solution IV. Repeat the dose after 2 to 3 minutes if needed. Depending on the response, titrate the dose carefully (up to 5 mL may be given). You can also administer epinephrine intratracheally; however, this route may make titration difficult. If the patient is intubated, consider doubling the intratracheal dose. Use caution, since this drug is fairly well absorbed.
Once the symptoms are controlled, start an epinephrine drip (1 mg in 250 mL of 5% dextrose in water). Titrate the drip according to the signs and symptoms.
ECG monitoring for possible cardiac arrhythmias and hemodynamic monitoring for blood pressure control are required during epinephrine therapy. Inhaled epinephrine can be useful in patients who have severe laryngeal edema.
Barach and colleagues[9] studied patients with anaphylaxis who received intravenous epinephrine. The investigators reduced the dose to the point at which the anaphylactic symptoms just barely recurred. They found that 8 to 12 [[micro]gram]/min (or 2 to 3 mL) of epinephrine drip was sufficient to control symptoms in most patients with anaphylaxis.
While higher doses of epinephrine may be required to improve symptoms, low doses usually control them. Disaster may occur if too much is given. One milligram of epinephrine is a supraphysiologic dose as well as a tremendous pharmacologic dose.
Volume expanders. Leaking capillaries and venules are a prominent problem in patients with hypersensitivity reactions. Fluid shifts from the intravascular to the interstitial space.
Use crystalloids rather than colloids, since the latter are likely to leak out of vessels. In severe hypersensitivity reactions, several liters of isotonic saline or lactated Ringer's solution may be required to replenish intravascular volume. Avoid hypo-osmolar agents because they do not adequately restore volume. Also avoid dextrose-containing solutions because they can produce an osmotic diuresis in patients with high glucose levels.
Be aggressive in hemodynamic monitoring. Insert a pulmonary artery catheter if required. Urine production monitoring is also important in patients with severe reactions.
Antihistamines. These agents are effective in mild allergic reactions; however, they are inadequate in severe anaphylaxis because mediators that are much more potent than histamine are also involved. In a severe reaction, the role of antihistamines is adjunctive.
Commonly used [H.sub.1] antagonists are diphenhydramine and hydroxyzine (both are given at a starting dose of 1 mg/kg). Intravenous hydroxyzine is not recommended. Nonsedating antihistamines, including astemizole, cetirizine, and loratadine, may also be used for mild allergic reactions. Cetirizine and loratadine have much less cardiac toxicity than astemizole.
[H.sub.2] antagonists are useful in managing mild allergic reactions. The recommended dose of cimetidine in this setting is 300 mg IV. Cases have been reported of patients whose condition failed to improve after receiving epinephrine and diphenhydramine but who responded to cimetidine.[10]
Other drugs. Agents that may be useful in treating hypersensitivity reactions include:
* A mixture of helium and oxygen in patients with respiratory problems, because it decreases airway turbulence and reduces the work of breathing.
* Inhalational sympathomimetics (such as albuterol and metaproterenol).
* Other parenteral sympathomimetic agents (examples include dopamine and norepinephrine).
Under what circumstances would yea use corticosteroids to treat a hypersensitivity reaction?
6 Give corticosteroids to patients with severe laryngeal edema, bronchospasm, or hypotension. Consider administering them to patients with mild allergic reactions, such as urticaria.
Corticosteroids have a delayed therapeutic effect; they are not effective until 4 to 6 hours after dosing. Corticosteroids may attenuate the late-onset component of hypersensitivity reactions, but this remains unproven.
For most hypersensitivity reactions, a dosage of 1 to 2 mg/kg/d of prednisone for 4 or 5 days is usually appropriate. This regimen generally does not require tapering. Consider tapering if the patient has received corticosteroid therapy in the recent past or if you plan to continue therapy for more than 2 weeks. When given as short-term therapy, prednisone has fairly benign effects.
Pollack and Romano[11] examined the role of prednisone for simple urticaria of less than 24 hours' duration. To avoid adverse reactions from the corticosteroid, persons with diabetes mellitus or ulcer disease were excluded. Twenty-four patients received prednisone (20 mg bid) for 4 days, and 19 received placebo. All patients received hydroxyzine as needed for itching. At 2 and at 5 days, itching was much less severe in the patients who received prednisone.
What is the recommended treatment for a hypersensitivity reaction in a patient receiving [Beta]-blocker therapy?
7 Standard therapy for allergic reactions can be ineffective in patients who are receiving [Beta]-blockers. Such patients can have marked hypotension and bradycardia during a hypersensitivity reaction.
Glucagon and the anticholinergics atropine and ipratropium are particularly effective in this setting. Glucagon lowers intracellular cyclic guanosine monophosphate (cGMP) levels and inhibits mediator release. Give 1 mg IV, and repeat or increase the dose as needed. Since nausea and vomiting are common side effects of glucagon therapy, pretreatment with antiemetics is reasonable.
The anticholinergics also decrease intracellular cGMP levels. When delivered as inhalation therapy, they are useful for treating bronchospasm. Ipratropium may be particularly helpful in patients with bronchospasm.
Which patients with hypersensitivity reactions should I hospitalize?
8 Admit all patients with severe reactions - including airway angioedema; bronchospasm; hypoperfusion; and cardiac problems, such as serious arrhythmias or congestive heart failure - that do not resolve promptly with therapy. Also hospitalize persons with a significant allergic reaction who:
* Are receiving [Beta]-blocker therapy.
* Have a history of severe late-phase reactions.
* Have an inadequate support system at home.
Observe patients who have reactions associated with systemic toxicity for at least 4 to 6 hours (Box III). When patients are discharged, prescribe an [H.sub.1] and/or an [H.sub.2] antagonist for at least 24 to 48 hours. For most patients, 5 mg/kg/d of diphenhydramine is appropriate. Consider corticosteroids (1 mg/kg/d for a few days) to modify the inflammatory component of the allergic reaction. If the patient has significant wheezing, consider a [Beta]-agonist metered-dose inhaler.
[Diphenhydramine mentioned above is the generic name for Benadryl.]
I found this article searching an Infotrac database of medical articles that is widely available in the US and Canada in public libraries. It is called Health Reference Center. Ask your local librarian for more information.
[This message has been edited by Kathryn (edited August 09, 2000).]

Posted on: Wed, 08/09/2000 - 12:56pm
tkiaml's picture
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Kathryn- Thank you for this information. I found it very interesting. I really believe my son's reaction should have been handled differently...I don't think they should have sent me home with him so soon and I think I should have been warned of secondary reactions. I certainly hope I'm not in the situation again in which I must seek emergency help (although I wouldn't hesitate if necessary) but if I am I will insist(hopefully without having to become rude) that my child's care be monitored much better. I would definitely question myself as to whether I like how things are being handled and act on any concerns. I think they did have me give my son Benadryl every 4-6 hrs. for the rest of the day. But it seems that from what I have read above that perhaps he should have been admitted and observed (his airways were definitely affected, many other symptoms of anaphy. to o!) especially since he has asthma anyway!
Thanks again for the info.! By the way he was only 5 and 1/2 months old at the time. He is now 18 months and has had some reactions that I was not too sure how to handle but none quite as bad as that incident. tkiaml

Posted on: Thu, 08/10/2000 - 2:42am
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Joined: 08/10/2000 - 09:00

I've had all of that done, plus one that wasn't mentioned. I had an iv that pumped blood out of my body and into a unit that purified the blood. The doctors were concerned that the ingestion had occured from stomach lining to bloodstream, and they thought I might go into cardiac arrest. I'm not sure if this is common practice, but it sounded like a good idea to me at the time. Also, My last few Emergency room visits averaged 6 hours.

Posted on: Mon, 08/14/2000 - 3:05pm
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Joined: 08/07/2000 - 09:00

1 1/2 weeks ago my stepson (son, if he reads this) had an anaphylaxis attack because of peanut oil. His entire body swelled to the point he now has stretch marks. He was unrecognizable to look at. When we got him to the local amblutory (sp?) care center they gave him two shots of epi among other things (Benadryl, Steroids etc.) They said he was stable BUT had to be LifeFlight him to the hospital. After finaly getting to the hospital (which is another story) he was kept for 48 hours just so they could watch him. We were told that because they had to literally shock his system with allergy medication, that his immune system had shut down. He could have a relapse any time within the next 30 to 60 days. Also, from now on, if he has any swelling or signs of an allergic reaction he is to have the epipen immediately. This allows him 30 minutes to get to the nearest ER. Any allergic reaction he has could be life threatening. I don't want to scare anyone but never second guess yourself when it comes to administering the epipens. If you think your child needs it, do it. You know your child better than anyone else.

Posted on: Tue, 08/15/2000 - 10:44pm
tkiaml's picture
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RMSDREAMS- So sorry to hear of the incident with your son. Since I received an epipen for both my PA children I have not used it. (I have had one for them for about 1 year) I have had a couple incidents in which I wasn't sure whether I should use it or not...the reactions went away on their own without complications. However, I often wonder what it will take to convince myself to go ahead... I know all the advice given on these boards and try to weigh them out with what I feel comnfortable with...but at the same time I don't want to have to learn from experience with something like this. I hope my instincts truly do kick in...from what everyone says I think they will but I do remind myself that it is better to err on the side of safety! Thanks for the info. tkiaml

Posted on: Sun, 10/01/2006 - 12:09pm
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Joined: 05/28/2009 - 16:42

My son has needed more than one epi-pen. Once I reach the hospital they put him on an IV just incase and they start giving him steriod shots.
I have started a program to remove peanut/nut products from vending machines in hospitals. Also a it has a continuing education class for ER staff. Please contact me if you would like more info.
It is called AACE- Allergy and Anaphylaxis Continuing Education.
Thank you!!!
------------------
Francey Westinghouse
No more Nuts allowed!

Posted on: Sun, 10/01/2006 - 11:32pm
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They Epi penned my son in the hallway while my DH was carrying him back to a room. He was bareley conscious. they gave him IV steroids and honestly I don't know what else they did to him.
We were in a room and there were literally about 10 doctors/nurses all around him and it is all a strange blur now. We stayed for 6 hours. After about 1 hour, DS was bouncing off the walls, starving to death. I remember asking if they could give him something to eat and saying I could get something from vending machine. That is when I got the May contains lesson.

Posted on: Sun, 10/01/2006 - 11:54pm
TRexFamily's picture
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My DD was 17 pounds when she had her ana rxn, so the Epi Jr was about twice the dose for her weight. We gave her the Epi Jr at home, along with liquid Benadryl (1 tsp) and albuterol.
At the ER, she got 2 nebulizer treatments, oxygen and a shot of oral steroids. We were there overnight, and she was on oral steroids and antihistamines at home for 5 days.

Posted on: Mon, 10/02/2006 - 5:31am
Kathryn's picture
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If you have a local public library that makes Gale's health reference database available then you can do a search and get the protocols for hospital treatment of anaphylaxis and research articles suggesting changes and improvements. I regularly review the medical journal articles in Health Reference Centre as these are the articles that emergency physicians and other medical personnel read and learn from. When I travel, I carry one of the articles that is a step by step outline of normal practice in anaphylactic emergency medicine. I carry it so that I am informed and so that if we are in a small non-teaching hospital, I have it available to share with staff. Check out the Health Reference Centre from Gale at your local library or through your local library website.

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