Megan Lewis, MSN, CRNP: Thank you so much for joining us today. I am thrilled you are here to hear from myself and two other experts in the field of allergy. Two of our allergy nurses, Sabrina Cinti and Megan Valentino, will speak about different parts learning your new anaphylaxis plan. My name's Megan Lewis. I'm a nurse practitioner in the allergy department.

Let's see, we have nothing to disclose. That is the beautiful Buerger building if you don't come to the city. That is where we see patients in Philadelphia. So the objectives for what we'll talk about today are preparedness, we'll go through signs and symptoms of anaphylaxis, and the new treatment algorithm that we want everyone to feel comfortable with.

So the first part of being prepared, why are we making this change? Why is this even something to talk about? The joint task force for practice parameters, periodically they review practice parameters for the best care of anaphylaxis and other allergic conditions. And it had representation from major national allergy societies.

And together they felt these changes were really important. One of which was getting rid of diphenhydramine or Benadryl and replacing it with a newer, not really newer, but it's a second generation antihistamine, Zyrtec or cetirizine, which you'll hear about more in the next presentation.

There's also an individualized approach using shared decision making with your team about going to the emergency room after reacting. And lastly, there's some new medications available for treating anaphylaxis, which is the nasal spray epinephrine. So you're told to avoid your allergen, and I just wanted to highlight this study that avoiding it isn't so easy.

We feel how hard this is for families. This just highlights three different groups. In a study of teenagers with food allergy, only 16% of them followed self-care behaviors and all they had to do was carry epinephrine and read labels. Only 16%. In a study of college students, only 35% of them carried epinephrine with them.

And only half of that 35% had it with them at all times. So even getting older, then if parents in a voluntary survey. So this survey went out to families and they voluntarily responded. Of a hundred parents, almost half of them engaged in some type of behavior that put the child at risk. They talked about cost being a barrier, because they didn't have time to read the label or they got confused about what to avoid. So avoiding it isn't easy, and if you haven't experienced anaphylaxis, we just want you to feel prepared and comfortable for if that was to occur. You should use epinephrine unless there's mild symptoms.

In kids epinephrine, will never hurt you. It will only ever help. And it is the only drug that will stop an allergic reaction. And then in the past, we always said to proceed safely to the emergency room if you've had a reaction where you've needed to use epinephrine. And the reason we wanted you to go to the emergency room was because of the severity of the reaction, not because you used epinephrine.

Epinephrine works almost immediately, but it also wears off really quickly. And so if you needed additional support, you could be treated in the ER. This new guideline talks about talking with your allergy provider about whether or not you need to go to the emergency room after a reaction, and that's really an individualized discussion with your allergist.

Just a little bit of information about epinephrine just to make you feel really comfortable and confident with it. Albuterol is a beta two agonist, if you've ever heard that term, and it helps with one receptor. So often if somebody's coughing after they've had a reaction, people might wanna lean to use their albuterol.

Albuterol is helpful but it only works on one area. It will bronchodilate or open up your airways, but epinephrine is able to stop that allergic cascade and all the things that cause you to itch and sneeze and wheeze and get inflamed. Epinephrine works on all four of these receptors and so it's just important to remember epinephrine should be given first.

You could use albuterol second. And just to help reduce your worries about epinephrine, if you had to pick the size of a coin that was the length of the needle of an EpiPen, some people think it's gonna be that huge one, but this allergist actually who practices in Ohio did a great job on social media and he bent an autoinjector just to show how small that needle is.

And I show you that just to help reduce fear around using your EpiPen and that it's smaller than any vaccine or any shot that your child has gotten. There's been some great clinical trials. There's two nasal sprays that were in clinical trials. One is still in clinical trials, and then a sublingual strip that would go under the tongue.

So we're excited to hear news from that. And then in the fall of this past year of 2024, nephi is nasal spray epinephrine. There's two strengths available based on your child's weight. The lesser strength is available, if you're four years of age and 33 pounds. It would be an option for your child. So something to talk about with your allergy provider.

And now please stay tuned for the next part of this talk on the new anaphylaxis plan.

Sabrina Cinti, BSN, RN: Hi everyone. My name's Sabrina. I am an allergy nurse with the Children's Hospital of Philadelphia. I have been an allergy nurse with CHOP since 2022. So we'll be talking about the new anaphylaxis plan and just why we've made some changes. As far as our anaphylaxis plan goes, the new version does have two different versions based off of your child's age.

So there's one for those under three, and one for those over three. Next slide.

So you'll see here this is what the old plan looked like. You know, it's a little bit busy, there's not very much color, kind of hard to read. And the new plan, we've made it a little bit easier to break down, where we break down mild symptoms, severe symptoms, and then we have a plan in place depending on what you've discussed with your allergist as far as needing to go to the emergency room and such.

Next slide.

On both plans, there was information about how to use epinephrine based off of the different types of EpiPens or epinephrine injectors that are available. The new version has included the nasal epinephrine spray, so that's helpful. Just in case anybody who isn't you, isn't familiar with how to give it, they have instructions listed.

Next slide.

Like we talked about, the appearance is a little bit different. So that is something just to keep in mind, as well as based on your child's history, you might not need to go to the emergency room or call 911 if you use epinephrine. So just be sure when you come in for your yearly visits that you're discussing with your provider the guidelines for your specific case.

Some things to consider would be if there's a history of severe reaction, a history of needing multiple doses of epinephrine, and how far away you are from a medical facility. Like we talked about, there are also age specific symptom descriptions, which we'll go over.

And then epi, the nasal epinephrine is now included in directions as well.

So some tips to navigate the differences, you wanna consider taking a screenshot just so that you can have that on your phone as well as favoriting it so it's quick, easy access for you. You can print it from your, MyCHOP account with color. I know they don't always print in color in the office, but they always get sent to you as well. So if you have access to MyCHOP, you can print it in color. And then just make sure you're reviewing the newer versions with your family members and anyone who's in care of your child. Some other helpful tips are to laminate a copy and keep it posted on your fridge or your kitchen cabinet just for quick access and you can just review it anytime you're grabbing a snack from the fridge.

And then practice training with your EpiPen. Every time you change your smoke detector batteries, that's just a good, helpful hint just so that it's always on a timeline and you can make sure you're practicing and that everyone knows how to use it.

Next slide, perfect. So on our previous anaphylaxis plan, we had the mild symptoms and the severe symptoms all grouped into just one section. The newer plan breaks that down a little bit, but you know, it's a little bit easier to read on the newer plan, so we can look at that now. Perfect. On the new plan, mild symptoms are listed as their own section. So just to review those with you, if your child were to have a few hives, some mild itching, lip swelling, itchy runny nose, sneezing, mild nausea, discomfort, or just threw up one time, those would all be considered mild symptoms. And then in the next section, Meg is gonna go over how to treat with those things, but we'll just review the symptoms for now.

Some differences now, like we talked about with the multiple anaphylaxis plans based off your age, for children under three severe symptoms would include shortness of breath, wheezing, coughing, a barky cough or nasal flaring, which is when their nose opens really wide when they breathe. Skin, that would be like many hives all over the body, if they have a widespread red, purple, or gray color, or a patchy lacy appearance. For heart symptoms, that's anything fainting, weak pulse, dizziness, if they're pale, they're difficult to wake, floppy, if they're having any like bluish gray tint to their skin, lips, nails, or feet. Eyes and ears, some common symptoms for that would be like eye rubbing, if they're pulling, at their ears, or putting their fingers in their ears. For mouth symptoms, that could be visible, swelling of the tongue. Some other common symptoms are tongue tugging, or thrusting, as well as drooling.

Keep in mind some kids do drool a lot. That doesn't necessarily mean it's an allergic reaction, but just keep in mind all the symptoms that you could see. For throat symptoms, that's like tight horse, if they're having trouble, breath or swallowing, high pitched breathing sounds, neck tugging. For any like stomach symptoms, that would be like ongoing vomiting.

So multiple episodes of that or diarrhea. And then some behavioral changes you could see are crankiness, inconsolable crying, if they're subdued or less active, or if they're withdrawn or clingy. Now for over three, it's a lot of the same symptoms. So you're still gonna look out for that shortness of breath, wheezing, coughing, visible swelling of the tongue, tight hoarseness, or if they're having trouble swallowing. Many hives all over the body.

The one difference is that the older kids sometimes verbalized feeling something bad is about to happen, or they're very confused or agitated. So that's just something to keep an eye out for in the older population.

So Meg's gonna talk about treatment and resources now regarding the anaphylaxis plan.

Megan Valentino, BSN, RN: Hi, my name's Megan Valentino, and I'm a nurse here at the Children's Hospital of Philadelphia in the allergy department. I've been a nurse here for 25 years, and 17 of those years I've spent with the allergy department. So today I just wanted to talk to you a bit about treatment of anaphylaxis and allergic reactions related to food allergies and some resources that we have here that we can offer you.

So recently our anaphylaxis plan has been updated to reflect the current guidelines. Previously on the old anaphylaxis plan, it was recommended that you treat a mild reaction, which would include hives or maybe a little mild skin swelling, with Benadryl. In the past few years, the recommendation has changed to treat these reactions with Zyrtec or the generic form being cetirizine.

This is now the preferred method of treatment because Zyrtec works just as quickly as the Benadryl and has less side effects. If at any time your child develops more severe symptoms or is having an anaphylactic reaction, you would immediately administer your epinephrine autoinjector into the outer portion of the thigh, just as you are instructed in clinic. You can now also treat an anaphylactic reaction with nephi, the intranasal epinephrine, and you do one spray into the nostril. If you're treating anaphylaxis and your child can still swallow, it is reasonable to also give a dose of cetirizine. And if they're asthmatic and you have albuterol on hand and they're having some trouble breathing, this would be a good time to also give them the albuterol.

It also notes there, to arrange transport to the emergency room or the physician's office. But these guidelines changed over the summer and we will discuss them shortly.

So this is a copy of the flow chart that is on our new anaphylaxis plan that just came out this summer. This flow chart helps us decide what to do and how to treat our child with this whole watch and wait. So if your child is experiencing anaphylaxis and you give epinephrine, if you are comfortable watching them at home, they are getting better, which means no new symptoms are appearing and the symptoms that they were have are starting to resolve within the first few minutes, you have a second dose of epi on hand, you do not have to call 911 or go to the emergency room. You can stay at home and watch your child. The times in which you would call 911 and go to the emergency department is if the symptoms are continuing.

Say you give the epinephrine, the symptoms are not resolving, or new symptoms are coming up. If any point in time you don't feel comfortable, watching them at home, or you don't have a second dose of epi on hand, these are the times that you would call 911 and go to the emergency room. Another time that I'd like to advise children to still call 911 is for our teenagers, say our high schoolers or college kids that are out with their friends and there's no adult around to help monitor them.

I would still instruct them to treat with the epinephrine and still call 911 and head to the emergency room. If anyone, if they're ever experiencing any heart symptoms such as feeling lightheaded or dizzy, or if two doses of epinephrine have been given, you want to lie your child on their back and raise their legs in the air.

If they're experiencing any trouble breathing or they tend to sometimes feel sick to their stomach, it's okay for them to sit up in a comfortable in which, in a position in which they feel more comfortable in or lie on their side. Again, if your child's asthmatic and you have albuterol on hand, now would be a good time to give them their rescue inhaler.

And you can also treat with an antihistamine, if they're able to swallow.

So just a few reminders, even though we now have this watch and wait recommendations for any allergic reaction, you just wanna follow up with your allergy provider. It's a good idea to consider taking a screenshot of the new anaphylaxis plan and saving it to your favorites so you have a quick access on your phone if you need it.

The version that you get in the office is all black and white and not very friendly to the eye. But if you pull it up on MyCHOP, it's all color coded and looks very easy to read and navigate. You wanna review this new version with your family members and those close to your child. And again, I just wanna reiterate, if you give epinephrine and you still, if you don't feel comfortable staying at home, it is never wrong to go to the emergency department.

Another thing that is good, is you can always laminate a copy, keep it on posted in your refrigerator, that way if anybody's there helping take care of your child, just quick access. Practice training with your epi device every time you change your smoke batteries, or smoke detector batteries, this is a good time to do it.

Sometimes with those refills, they come at the start of school with school forums and all of that, and it's just a busy time of year.

So now we can just go over a few resources that we have to offer you here. Oral Food Challenges, CHOP's program, is one of the largest in the country. We tend to recommend these when we think that your child has outgrown an allergy. When testing is decreasing and showing encouraging results, we'd like to find out if we can safely get the food back into the child's diet to help expand their nutrition.

At a food challenge, your child will be given small, increasing amounts of the food and monitored very closely for an allergic reaction. To learn more about this, you can check out the link below.

We also offer our multi food OIT program. It's was a protocol that was developed to desensitize children to, up to five foods at once. And we start at any age. You must be a current CHOP allergy patient and have all other allergic conditions under control, such as asthma and eczema. The goal of this program is to low dose oral immunotherapy to protect against accidental exposures.

So there's different goals for different foods and families, such as milk and egg versus peanut. And there can be more information found at the link below.

So finally, just to reiterate, we have food challenges and this is the way that you can get and contact them with them via email or the link here, the Oral Immunotherapy Program. We have a wonderful food allergy bravery program that helps parents and children work through some of the anxiety that can develop around food allergies.

And we have a new and exciting clinical trials and research interest that come up all the time. Again, you need to be a current ChOP patient in order to be eligible for any of these. So you just wanna make sure you say up to date, with your follow up visits with your provider.

So our goal here in the allergy department is firstly to keep everyone safe and to make sure none of our children feel isolated. We really want our kids to feel like they can participate in all activities and just feel like all the other kids out there. Sometimes this requires creativity, but it really can be done, and we look forward to working with you guys just to help you feel educated and prepared, so this can happen. Some other guidelines as far as school, are the voluntary management of food allergies, and again, the link is below.

I'd like to thank you for your time.