Oral Food Challenge Testing in the Paediatric Day Stay Unit



Canberra Hospital and Health ServicesClinical Guideline Oral Food Challenge Testing in the Paediatric Day Stay Unit (Infants, Children and Adolescents)Contents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc508360526 \h 1Guideline Statement PAGEREF _Toc508360527 \h 2Scope PAGEREF _Toc508360528 \h 2Section 1 – Referrals and Booking PAGEREF _Toc508360529 \h 2Section 2 – Assessment prior to commencement of testing PAGEREF _Toc508360530 \h 3Section 3 – Safety PAGEREF _Toc508360531 \h 4Section 4 – Testing PAGEREF _Toc508360532 \h 5Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc508360533 \h 5References PAGEREF _Toc508360534 \h 6Search Terms PAGEREF _Toc508360535 \h 6Guideline StatementBackgroundOral Food Challenge (OFC) is performed under medical supervision in order to confirm or disprove a current diagnosis of food allergy (or other adverse reaction to food). The need to perform an oral food challenge is based on patient history, age, time since last reaction, characteristics of previous adverse food reaction, the results of allergen-specific allergy testing (skin prick tests or serum food-specific IgE testing) along with importance of the food to the patient because of nutritional value, ethnicity and anxiety related to potential risk of life threatening mon foods tested include peanuts, tree nuts (for example, cashews, macadamias, hazelnuts), wheat, dairy, egg, soy, fruits, fish and shellfish. Key ObjectiveThat OFC for infants, children and adolescents is carried out in a safe manner.Alerts During the OFC, there is a risk of an allergic reaction/anaphylaxis. Anaphylaxis is a severe allergic reaction which can manifest in more than one organ system. Anaphylaxis is a medical emergency and therefore requires immediate medical management. Refer to Management of Anaphylaxis in Adults and Children Clinical Guideline.Back to Table of ContentsScopeThis guideline pertains to the management of OFCs for infants, children and adolescents in the Paediatric Day Stay Unit (PDSU) at Canberra Hospital and Health Service (CHHS). Local escalation policies, such as the Paediatric Early Warning Score (PEWS), should be used in conjunction with this guideline.This clinical guideline applies to CHHS staff working within their scope of practice: Medical OfficersRegistered nurses, registered midwives, and enrolled nurses Back to Table of ContentsSection 1 – Referrals and BookingReferrals:Referrals are made by an Immunologist, with all patients admitted under the care of a Paediatrician and the referring Immunologist. Each child will be assessed by the Paediatric Registrar prior to commencement of the challenge, midway during the challenge and at completion of the testing or as requested by the Registered Nurse. The test will be performed according to the protocol. The Immunology Dietitian attends prior to the challenge to confirm diet and food allergy?history. They return at the end of the challenge to counsel families on reintroduction of the food into the child’s diet or advice on further food avoidance. BookingRequest for OFC will be received by PDSU in writing from the immunologist or paediatrician outlining the specific protocol, patient history and risk assessment Risk Assessment: Children will be assessed by the immunologist for risk of adverse reaction, based on the presence or absence of serious allergic reactions in the past and the presence of regular asthma requiring a preventer drug, or other factors considered by the referring specialist or supervising paediatrician to convey a higher risk. Any child classified as high risk will require an intravenous cannula prior to commencement of the test. Children assessed as being high risk will not usually have an OFC performed in PDSU, rather, Paediatric High Dependency, ICU, or a tertiary paediatric centre may be considered.A maximum of one patient to be booked on any day and no more than one food tested per booking The Day Stay Nurse will contact the family to arrange admission and advise of food that may need to be provided, e.g. M&Ms for peanut challenge, cake for egg challenge, and any other food that the child may need for the entire day. The children are not routinely required to fast prior to testing. For children requiring cannulation it is recommended that local Anaesthetic Cream (LAC) be collected from PDSU prior to admission and applied before leaving home on the day of the OFC.The patient will be asked to arrive by 0830 hrs to allow the OFC testing to commence by 0900 hrs. This is to allow for cannulation if required, testing time and 3 - 4 hour post-test observation time to be completed within business hours. The Dietitian will provide the specific food challenge protocol to the nursing staff and also give a copy to the parent and child. Back to Table of Contents Section 2 – Assessment prior to commencement of testingPatients must be in good health i.e. no fever, current illness or reported symptoms that may interfere with the child’s ability to complete the challengeIf present, asthma should be well controlled in the 2 weeks prior to challenge.Obtain and record baseline vital signs on observations chart as per the Vital Signs and Early Warning Scores Procedure including PEWS and weight Obtain weightAssess child for signs of active allergic disease, i.e.: asthma, allergic rhinitis, eczema that may result in inaccurate interpretation of resultsObtain medication history to ensure that they have not taken any medications known to interfere with test results, e.g. steroids, beta agonists Alert: It is recommended that no antihistamines have been taken for a period of 3 days prior to challenge. This is communicated in a letter to families, and by a senior nurse who counsels the parent at the time of scheduling the appointment.Obtain a thorough description of any previous adverse reactionFull explanation of food challenge procedure is provided to the parent and child including the early signs of an adverse reaction. Copy of challenge protocol given to parent by Dietitian, and advice on any other food that is able to be eaten during and after the testing.Obtain verbal consent.Back to Table of Contents Section 3 – SafetyEach child will be allocated a named staff member to be responsible throughout the challenge for administration of the protocol and for observationThe test will be carried out in an area that allows for constant observation by staff and easy access to emergency equipment, whilst allowing a relaxed environment for playReinforce signs and symptoms of adverse reaction to parent/carer and instruct them to report any concerns to staff immediately, i.e. wheeze, vomiting, rash or hives, abdominal pain, swelling or tingling inside the mouthOrientate parent to nurse call button and emergency call buttonRefer to the Management of Anaphylaxis in Adults and Children Clinical Guideline, Sections 2 and 3 for information on clinical symptoms and signs of acute allergic reaction, and the emergency management of anaphylaxisPaediatric Registrar to order dose of Adrenaline in accordance with patient’s weight on medication chart. Dose is Intarmuscular Injection (IMI) 0.01mg/kg/dose, up to a maximum of 0.3mg Ensure that loratadine syrup, prednisolone syrup and salbutamol inhaler (MDI )with spacer and mask, and a nebuliser are also available as treatment options for potential allergic reactions. Ensure emergency resuscitation equipment is in place and checked. i.e. oxygen, bag and mask, suction, oxygen saturation monitor, Broselow trolleyVital signs will be monitored hourly, or more frequently if signs of adverse reaction occurEach child will be required to stay in the ward for a minimum period of 3 hours after the last dose to observe for delayed reaction. If an adverse reaction occurs the stay is increased to 4 hours or as advised by the paediatrician or immunologistBack to Table of Contents Section 4 – TestingAs above, the tests will be performed in accordance with the protocols provided by the Immunologist or Dietitian. Doses are usually administered at 20 - 30 minutely intervals at increasing strength and amounts, or as per protocol. Progress will be recorded on the Food Challenge Symptom Chart simultaneously, including any adverse reactions and vital signs. Note: Food contact to the skin around the lips and mouth may cause minor redness, spots or swelling that is not indicative of a systemic reaction and can be ignored. To avoid this it is advised to quickly wipe the mouth with a clean cloth to remove residue from the skin and lips. Discourage the child from licking the lips or holding food in the mouth that may spread to the skin. If no adverse reaction occurs after 30 minutes from a dose, or period stated in protocol, proceed to the next dose. Adverse Reaction Refer to the Management of Anaphylaxis in Adults and Children Clinical Guideline Sections 2 and 3 for information on clinical symptoms and signs of acute allergic reaction, and the emergency management of anaphylaxisThe Paediatrician and Dietitian are to be informed of any adverse reaction. The referring immunologist should also be contacted if concerns or queries arise.Test completionPatients are required to stay in the ward under observation for a minimum period of 3 hours after the last test dose in the absence of any adverse reaction. If an adverse reaction has occurred the length of observation time will be extended. The Nursing staff will notify the Dietitian of the test completion. The Dietitian will perform the end of test assessment; provide initial advice to the parent and forward test results to the referring Paediatrician or Immunologist who will then provide comprehensive interpretation and advice to the family.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesConsent to Treatment PolicyProcedures:Vital Signs and Early Warning Scores ProcedureGuidelines Management of Anaphylaxis in Adults and ChildrenBack to Table of ContentsReferences Australasian Society of Clinical Immunology and Allergy (ASCIA), Internet [accessed November 2017] Available from: Norwak-Wegrzyn, A. et al, (2009)Work Group Report: Oral food challenge testing, J Allergy and Clinical Immunology, Vol 123, No 6, 365- 383Osborne NJ, Koplin JJ et al. (2010). ‘The Health nuts population-based study of paediatric food allergy: validity, safety and acceptability. Clinical and Experimental Allergy 40(10): 1516-1522Skypala, I and Venter, C. (2009) Food Hypersensitivity: Diagnosing and managing food allergies and intolerance, Wiley-Blackwell.Back to Table of ContentsSearch Terms Allergen, allergy, allergic, anaphylaxis, food, intolerance, food challengeDisclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 24/01/2018Complete ReviewKaren Faichney, A/g ED, WY&CCHHS Policy CommitteeThis document supersedes the following: Document NumberDocument Name12/065Paediatrics – Oral Food Challenge Testing in the Paediatric Day Stay Unit ................
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