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Primary Care Liaison

Insect allergy

  • The following covers recommended pre-referral treatment and investigations for children of all ages presenting with a suspected insect allergy.

    Initial work-up

    Symptoms

    The most common insects that cause allergic reactions are bees and wasps. In some circumstances, depending on the severity of the reaction, the nature of the insect and the age of the child, a course of desensitisation injections is indicated.

    An allergic reaction to an insect sting or bite may involve one or more of the following signs and symptoms:

    Mild allergic reaction

    • Swelling of lips, face or eyes.
    • Hives or welts.

    Moderate allergic reaction

    • Abdominal pain, vomiting.
    • Note: Abdominal symptoms are more likely to progress to a severe systemic allergic reaction in insect sting reactions than in food allergy reactions.

    Severe systemic allergic reaction (anaphylaxis)

    • Difficulty breathing.
    • Swelling of the tongue and/or throat.
    • Difficulty talking.
    • Hoarse voice, wheezing or persistent coughing.
    • Loss of consciousness and/or collapse.
    • Infants and young children appearing pale and floppy.

    Severe allergic reaction (anaphylaxis) will typically include multiple organ systems (eg. hives and respiratory symptoms).

    Taking a history

    • History of allergic reaction:
      • Stinging insect - circumstances, insect prevalence.
      • Nature of the bite or sting reaction
      • Presence of a stinger or recognisable insect - can the insect be identified? (Note:if the insect is killed, keep and bring to consultation for identification)
      • Previous and subsequent sting history and nature of reaction. 
      • History of atopy (eg. eczema/asthma).
      • Family history of allergies.
      • Relation of reaction to exercise.

    Diagnostics

    • Detection of allergen-specific IgE by RAST test to the insect venom of interest is only required if there is a history of systemic reaction (generalised hives, angiodema, vomiting, abdominal pain, respiratory or cardiovascular signs).
    • RAST test is not required for local reactions.
    • RAST test to Jack Jumper ant is only available through specialist paediatric centres as this is a research test at present (2011).
    • Skin testing to insect venom must only be performed by a specialist allergist.

    Interpretation of RAST test

    • Demonstration of allergen specific IgE by RAST does NOT necessarily indicate presence of clinical allergy.
    • Test results should be interpreted together with history.
    •  Positive allergen-specific IgE (RAST) in the presence of a clear history of allergic reaction confirms clinical allergy.
    • Refer patient to Allergy and Immunology specialist for further management and instruct patient to avoid the specified allergen.

    Pre-referral treatment

    Severe systemic reaction (anaphylaxis)

    Emergency management

    • Intramuscular Adrenaline (0.01mg/kg up to a max of 0.5mg) or Epi-pen. 
      • Children under 20kg - 0.15mg adrenaline (Epi-pen Junior).
      • Children and adults over 20kg - 0.3mg adrenaline (Epi-pen).
      • Oxygen
      • Steroids (consider 1mg/kg).
    • Lie child in supine position.
      • Left lateral if vomiting; 45 degrees if difficulty breathing.
    • Call ambulance
    • Antihistimine has not been demonstrated to be of benefit in acute management of anaphylaxis. It can be given after emergency management. However, even if the patient responds, they need monitoring in a suitable environment (ie. hospital for up to four hours post episode).
    • Always refer to the RCH Department of Allergy and Immunology.

    Follow-up management

    • Prescribe Epi-Pen / Epi-Pen junior.
    • In order to access authority funding for an epi-pen, discuss with an allergist, paediatrician or ED Consultant (by phone via RCH switchboard).
    • Educate on correct use of Epi-Pen.
    • Provide an Insect Sting Anaphylaxis Action Plan ( www.allergy.org.au)
    • Ensure any asthma is well controlled.
    • Educate on avoidance of allergen (eg wearing shoes in summer, avoiding settings where bees are highly prevalent).
    • Support parent in school/ day care communication.

    Mild-moderate reactions (including local reactions)

    • Antihistimine will alleviate symptoms of hives and itches but will not address anaphylaxis.
    • Loratidine (Claratyne) and certirizine (Zyrtec) are suitable for children and available in syrup form. 
    • Minimise risk of exposure. For example, for bee allergy, wear shoes when outdoors, wear long-sleeved, light coloured clothing, avoid perfumes, use ventilation systems in vehicles rather than open windows and avoid drinking from containers where you cannot see the contents (eg. cans).

    When to refer

    • ALWAYS refer confirmed or suspected anaphylaxis to the RCH Department of Allergy and Immunology. This is an URGENT REFERRAL.
      • Anaphylaxis to stinging insects is an indication for desensitisation
      • Note: Large local reactions and mild-moderate systemic reactions are NOT indications for desensitisation.
      • Arrange an Epi-Pen as a start.
      • History and RAST/ SPT  do not correspond -priority referral as further specialised testing (ie. challenge) may be needed.
    • When patient is identified as having a systemic reaction to insect venom.
      • When a diagnosis of Jack Jumper Ant allergy is suspected.
      • Note: RAST to JJA is currently only available as a research test (2011).

    Do not refer

    • For allergy screening if there is no clear history of allergic reaction - such referrals will be rejected.
    • When the family history is positive, in a healthy patient who does not have an allergic condition.

    Referral information needed

    The GP at first consultation is in the best position to get the most comprehensive information from parents on the details of an allergic reaction. Please collect and include in your referral as much detail as possible. It is increasingly difficult to collect this information later.

    Information needed

    • CLEARLY INDICATE if child has confirmed or suspected ANAPHYLAXIS. The referral will be triaged as urgent.
    • Date reaction(s) occurred.
    • Allergic reaction symptoms experienced -
      • Severe systemic reaction (anaphylaxis).
      • Difficulty breathing.
      • Swelling of the tongue or throat.
      • Difficulty talking.
      • Hoarse voice, wheezing or persistent coughing.
      • Loss of consciousness and/or collapse.
      • Young children appearing pale and floppy.
    • Moderate systemic reaction -
      • Abdominal pain, vomiting.
    • Mild-Moderate reaction -
      • Swelling of lips, face or eyes.
      • Hives or welts.
      • Local reaction.
    • Potential causes of reaction(s):
      • Insect -  WHAT INSECT?
      • When, where and how did the reaction(s) happen?
    • RAST results.
    • Treatment given and patient response.
    • Previous or subsequent exposure to allergen.

    Contact information

    Clinical advice -  Page the 'on-call' Consultant or Allergy and Immunology Fellow.

    (03) 9345 5522


    RCH Emergency Department:

    (03) 9345 6477


    Specialist Clinics

    (03) 9345 6180 

    referral guidelines)

    Victorian Statewide Referral Form (VSRF)


     

     


     


     





    Resources

    References

    Copyright and Disclaimer

    Copyright 2009, Royal Children's Hospital (RCH) Victoria, Australia. The RCH is not responsible in any way for application of the procedures or guidelines to patient care at your facility. They are guidelines only and your professional judgment must always prevail. Guidelines may not be reproduced without permission. RCH Kids Connect - Primary Care Liaison. www.rch.org.au/kidsconnect . These guidelines were developed by specialists at the Royal Children's Hospital and reviewed by general practitioners in Victoria. Last reviewed in April, 2012.