Laguna State Polytechnic University Santa Cruz, Laguna (main campus) College of Nursing

LONDONIO, SHARAH RUTH U. BSN III-1 MRS. BUNDALIAN

FOOD ALLERGY
IgE-mediated food allergy, a type I hypersensitivity reactions, occurs in 6% to 8% of children and about 2% of the adult population (Beyer & Tueber, 2004), it is thought to occur in people who have a genetic predisposition combined with exposure to allergens early in life through the gastrointestinal or respiratory tract or nasal mucosa (Long 2002). Researchrs have also identified a second type of allergy, a non-IgEmediated syndrome in which T cells paly a major role (Eigenmann & Frossard 2003). Almost any food can cause allergic symptoms. Any food can contain an allergen that results in anaphylaxis. The most common offenders are seafood ( lobster, shrimp, crab, clams, fish). Legumes ( peanuts, peas, beans, licorice), seeds (sesame, cotton seed, caraway, mustard, flaxseed, sunflower seeds), tree nuts, berries, egg white, buckwheat, milk, and chocolate. Peanut and tree nut (eg, cashew, wanut) allergies are responsible for most severe food allergy reactions. Incidence and Prevalence In more that 70% of children with peanut allergy, symptoms develop at their first known exposure, suggesting unknown exposure through breast milk or another source (Al-Muhsen et al., 2003). Food allergies are the cause of 150 deaths per year in the United States (Tierney et al., 2005).

Clinical manifestations: Classic Allergic Sysmptoms Urticaria Dermatitis Wheezing Cough Laryngeal edema Angiodema

Gastrointestinal Symptoms Itching Swelling of Lips,tongue, and palate Abdominal pain Nausea Cramps Vomiting Diarrhea

Symptoms of allergies vary from person to person. The amount of food needed to trigger a reaction also varies from person to person. Diagnosis White Blood cell (WBC) count with differential can detect high levels of circulating eosinophils. Normally, eosinophils constitute a very small percentage (1% to 4%) of the total WBCs. Eosinophila, howver, is often present in clients with type 1 hypersensitivity. Radioallergosorbent test (RAST) measures the amount of IgE directed toward specific allergens. Test results are compared with control values and used to identify hypersensitivities. RAST poses no risk for an anaphylactic reaction. It is particularly useful in detecting allergies to some occupational chemicals and toxic allergens. (Goldsby, 2003). Complement assay is also useful in etecting immune complex disorders. In these disordes, complement is, in effect, used up by the development of antigen- antibody complexes. Decreased levels are seen on examination. Both total complement level and amounts of individual components of the complement cascade can be determined.

Skin tests are also used to determine causes of hypersensitivity reactions. These tests are used to identify specific allergens to which a person may be sensitive. Allergens for testing are selected according to the clients history. Test solutions made from extracts of ingested foods intradermal testing. (Tierney et al., 2005). If the large-dose intradermal test were initially made,

individuals highly allergic to substance would be at increased risk for an anaphylactic reaction. Intradermal: a small amount (just enough to create a wheal) of allergen extract at a 1:500 or 1:1000 dilution is injected on the forearm or intrascapular area. If several allergens are being tested, injections are spaced 0.25 to 0.5 apart. As control measures, plain diluent (negative control) and histamine (positive control) are also injected. If there is no response to a particular allergen at 12 to 20 minutes, the test is negative. The appearance of a wheal and erythema, with a wheal diameter at least 5mm greater than that produced by the control, indicates a positive response. Food allergy testing is performed when a food allergy is suspected but the source or implicated food item has not been clearly identified. Food allergy symptoms are typically demonstrated within hours of eating. Initially, the client is asked to keep a diary of foods consumed and allergic responses for a week. An elimination diet is ten prescribed. The diet excludes most common food allergens and all suspected foods for 1 week. An elimination diet is then prescribed. The diet excludes most common food allergens and all suspected foods for 1 week. Any food that may contain allergens I combination, such as breads, are also eliminated. If symptoms do not improve, a different variation of the elimination diet is prescribed. If symptoms are relievd, foods are reintroduced to the diet one at a time until symptoms recur, indicating allergy to that food.

Medical Management Therapy for food hypersensitivity includes elimination of the food responsible for the hypersensitivity. Pharmacologic therapy is necessary for patients who canot avoid exposure to offending foods and for patients with multiple food sensitivities not response to avoidance measures. Medication therapy includes: Antihistamine Major class of drugs used in treating the symptoms of hypersensitivity responses, type 1 in particularly. They are also useful to some extent in relieving manifestations (such as uticaria) of some type II and type III reactions. Antihistamines block H1-histamine receptors, acting as a competitive antagonist to histamine, but they do noy affect the production or release of histamine. The prototype antihistamine is dipenhydramine (Benadryl). It and other antihistamine alleviate the systemic effects of histamine such as uticaria and angioedema. They are also useful in relieving allergic rhinitis, although they are not effective in all clients. Antihistamines are available in both prescription and non-prescription preparations. The preferred route of administration is oral, although dipenhydramine and others can be given parenterally, particularly when immediate action is needed, as in anaphylaxis. They also dry respiratory secretions through an

anticholinergic effect. Their use is limited by their side effects, especially drowsiness and dry mouth. Antihistamines are not effective in relieving asthmatic responses to allergens and may actually woren symptoms by their drying effect on respiratory secretions. Antihistamines are often combined with a sympathomimetic agent such as pseudoepinephrine to improve their decongestant activity and counteract their sedative effect. Parenteral epinephrine an adrenergic agonist (sympathomimetic) drug that has both vasoconstricting and bronchodilating effects. These qualities, combined with its rapid action, make epinephrine ideal for treating an anaphylactic reaction. For mild reactions with wheezing, pruritus, uticaria, and angioedema, a subcutaneous injection of 0.3 to 0.5 mL of 1:1000 epinephrine is generally sufficient. For clients with Corticosteroids Cromolyn sodium Another essential aspect of management is teaching patients and family members how to recognize and manage the early stages of an acute anaphylactic reaction. Many food allergies disappear with time, particularly in children. About one third of proven allergies disappear in 1 to 2 years if the patient carefully avoids the offending food. However, peanut allergy has been reported to persist throughout adulthood in some people. (Beyer & Teuber, 2004). Assessment Collect the following data through the health history and physical examination. Health history: risk factors, hypersensitivities, reaction, type of treatment for hypersensitivity reactions; allergy skin testing; asthama, hay fever, or dermatitis. Physical assessment: mucous membrane of nose and mouth, skin lesions or rashes, eyes (tearing and redness), respiratory rate, and adventitious breath sounds.

Nursing diagnosis and Interventions Priority nursing diagnoses will vary according to the type of hypersensitivity reaction experienced by the client. Because nurses most likely to become involved with a client experiencing a type I or II response, this section focuses on diagnoses for these clients. Airway, breathing, and circulation (the ABCs) are of greatest importance for the client with an anaphylactic reaction. Ineffective Airway Clearance The airway maybe obstructed due to facial angioedema, bronchospasm, or laryngeal edema. Establishing and maintaining a patent aiway is a highest priority.

Administer oxygen per nasal cannula at a rate of 2 to 4 L/min. Apply oxygen emergently and obtain a physician oreder for oxygen administration. This increases the alveolar oxygen and its availability to cells of the body. Assess respiratory rate and pattern, level of consciosness and anxiety, nasal flaring, use of accessory muscles of respiration, chest wall movement, audicle stridor, palapate for respiratory excursion; auscultate lung sounds and any adventitious sounds, such as wheezes. Extreme anxiety or agitation, nasal flaring, stridor, and diminished lung sounds indicate air huner and possible airway obstruction, necessitating immediate intervention. Insert a nasopharyngeal or oropharyngeal airway, and arrange for immediate intubation as indicated. Ensuring an adequate airway is vital to preserve life. Administer subcutaneous epinephrine 1: 1000, 0.3 to 0.5 mL, as prescribed. This may be repeated in 20 to 30 minutes if necessary. Administer parenteral diphenhydramine (deep intramuscular or intravenous) as prescribed. Epinephrine is a potent vasoconstrictor and bronchodilator, counteracting the effects of histamine. Dipenhydramine is an antihistamine that blocks histamine receptors and their effect. These medications can be effective in rapidly reversing manifestations of anaphylaxis. Provide client reassurance. Hypoxemia and air hunger are terrifying for the client. Anxiety can impair the clients ability to cooperate with treatment and can increase the respiratory rate, making breathing less effective.

Decreased Cardiac Output Peripheral vasodilation and increased capillary permeability from the release of antihistamine can siginificantly impair cardiac output. When it falls to the degree that tissue perfusion becomes impaired and hypoxia results, a state of anaphylactic shock exixts. Monitor vital signs frequently, noting fal in blood pressure, decreasing pulse pressure, tachycardia, and tachypnea. These vital sign changes may indicate shock. Assess skin color, temperature, capillary refill, edema, and other indicators of peripheral perfusion. As cardiac output falls, peripheral vessels constrict and tissue perfusion is imapaired. Monitor level of consciousness. A change in level of consciousness (lethargy, apprehension, or agitation) is often the first indicator of decreased cardiac output. Insert one or more large-bore (18 gauge or larger) intravenous catheters. It is important to insert intravenous catheters as soon as possible to provide sites for rapid fluid replacement.

Administer warmed intravenous solutions of lactated Ringers or normal saline, as prescribed. These isotonic help maintain intravascular volume. Warmed solutions are used to prevent hypothermia from the rapid administration of large amounts of fluid at room temperature (about 70 degree F, or 21.1 degree C). Insert an indwelling catheter, and monitor urinary output frequently. As the cardiac output drops, the glomelural filtration rate (GFR) falls. With an output less than 30 mL/h, the client is at risk for acute renal failure from ischemia. Once breathing is established, place the client flat with legs elevated. This position enhances perfusion of the central organs, such as the brain, heart and kidneys.

Nursing Management The patient is instructed about the importance of carefully assessing foods prepared by others for obvious as well as hidden sources of food allergens and of avoiding locations and facilities where those allergens are likely to be present. Teach the patient about the importance of careful reading of food labels and monitoring the preparation of food by others to be sure that exposure to even minute amounts of allergenic foods is avoided. The patient and family must be knowledgeable about early sings and symptoms of allergic reactions and must be proficient in emergency administration of epinephrine if a reaction occurs. The nurse also advises the patient to wear a medical alert bracelet or to carry identification and emergency equipment at all times. Patients food allergies should be noted on their medical records, because there may be risk of allergic reactions not only to food but also to some medications containing similar substances (Karch & Karch, 2003). Pregnant women and those who are breastfeeding are instructed to avoid eating peanuts or food conataining peanuts to minimize the risk of peanut allergy in their children. (Sheetz & Mclntyre, 2005).