MODIFICATIONS FOR PAEDIATRIC ALLERGY SERVICES DURING COVID-19 PANDEMIC

MODIFICATIONS FOR PAEDIATRIC  

ALLERGY SERVICES DURING COVID-19 PANDEMIC

Introduction

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) is highly contagious and spreading pandemically. The disease it causes is ‘Coronavirus disease 2019’ (Covid-19) ref. 1, Whilst vaccine development is underway, it is unlikely to be available in 2020.

Emergency social distancing aims to reduce transmission. Many hospitals are recommending that telephone or virtual consultations on platforms such as Skype (telehealth), should replace face-to face consultations, and day ward appointments are either reduced or stopped.

Most Paediatric allergy services are elective and can be managed without face to face interaction or deferred for short periods of time. During periods of social distancing, telephone consultations reduce exposure of patients and staff to potentially infected patients. Telehealth will become central to delivering allergy services during the SARS-CoV2 pandemic and most likely, for some period beyond. Many patients with allergic conditions are generally healthy, albeit with other allergic comorbidities. Telehealth is an excellent tool for less severe and stable conditions. Most consultations can be conducted this way with no serious untoward effects. With the exception of patients on immunotherapy or patients with severe asthma, there is limited need for face to face consultations, until the pandemic subsides.

We have made condition specific recommendations for temporarily adjusting paediatric allergy activity and prioritising patients. These recommendations are made on the understanding that normal services will eventually resume. They represent contingency planning for prioritisation of staff, space and patients. These suggestions for prioritisation of patients and services aim to provide a logical approach to mitigate risk to medical and nursing staff and patients. They aim to help guide decision making when physicians are forced to reduce services or change the way they deliver care. Clinical environments may vary and the decision to enact any of these measures remains subject to the judgement of the clinician and their healthcare team.

These recommendations are adapted from M.S.Shaker et al. AAAAI Special article 2020; COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic (ref. 2), as applied to a UK paediatric clinical service.

Service adjustment for food allergy (including EoE, FPIES, proctocolitis)

Most new patient appointments and routine follow-up visits can be handled by telephone consultations to provide diagnosis, advice about management and to make adjustments to medication. Allergy testing can be deferred. Most food challenges can be deferred until the pandemic subsides, unless there is a critical nutritional need for the introduction of a key nutrient.

Where possible, dieticians should contact patients on multiple food exclusions to establish if food shortages are causing concern. This may require prescription of additional vitamins, supplements or milk formulas.

Defer initiation and updosing of food immunotherapy. All patients should be held at their current dose until normal services resume.

Food challenges

The following food challenges should be deferred and supportive introduction at home considered:

• All baked milk and baked egg challenges
• Supervised feeds in children not sensitised to the food and who have never eaten the food
• Introduction of a food in a sensitised child, who has never eaten the food (with the exception of sesame seed, where 80% of challenges are positive)
• Re-introduction of food being avoided for EoE
• Re-introduction of food being avoided for eczema
• Re-introduction for outgrown IgE mediated food allergy
• Re-introduction for outgrown FPIES

The following food challenges should be prioritised in a hospital setting:

• Milk / soya / hydrolysate introduction in an infant with a critical nutritional need for this to be introduced and where it would be unsafe for the parent / carer to do the introduction at home. E.g. milk / soya FPIES.

Service adjustment for idiopathic anaphylaxis

These consultations can be conducted over the telephone. Assessment of new patients and patients with recurrent idiopathic anaphylaxis should be prioritised with laboratory and specific IgE allergy testing as appropriate.

Service adjustment for allergic rhinitis

Consultations for the diagnosis and management of patients with allergic rhinitis can be conducted via the telephone. It may be prudent to postpone skin testing to inhalant allergens or offer specific IgE testing as an alternative. Patients should be given advice about allergen avoidance and administration of medication.

Immunotherapy

For children with allergic rhinitis, immunotherapy (both SLIT and SCIT) should not be initiated unless there are exceptional circumstances (e.g. unavoidable exposure to a trigger resulting in anaphylaxis).

For children on conventional subcutaneous immunotherapy, consider schedule modification eg. widening the interval between updosing injections to every 2 weeks or every 6 weeks during maintenance.

For children on preseasonal subcutaneous immunotherapy, consider suspending treatment until the pandemic measures have lifted, unless there is unavoidable exposure to a trigger resulting in anaphylaxis.

Children already started on sublingual immunotherapy should continue their treatment with review via telephone consultation.

Service adjustment for asthma

From the currently available information, COVID-19 infection appears to be milder in children, including children with asthma. Physicians should continue to manage asthma according to existing asthma guidelines, ensuring that children with asthma have their condition under optimal control.

• Most mild-moderate and well controlled asthma can be manged by telephone consultations
• Beware unstable asthma in a patient with poor perception of dyspnoea
• Do not ‘step down’ preventer medication during the COVID-19 pandemic, unless this is clearly favourable for an individual patient.
• Prioritise care for children with asthma who have required ED care or been hospitalised with an exacerbation within the last 6 months, have received 2 or more courses of oral steroids in the last 6 months or who have required one or more dose escalation / additions of preventer medication in the last 6 months.

Service adjustment for allergic skin disease (eczema, urticaria, angioedema)

The majority of these consultations can be conducted via the telephone. Transmission of digital images (e.g. from a mobile phone to a secure e.mail address) can help visualise a rash.

• Appointments for urticaria / mild angioedema / eczema can be conducted over the telephone. Laboratory and / or allergy testing can be postponed and advice about management offered.
• Follow-up appointments for patients with established and well controlled hereditary angioedema should be managed by telephone.
• Acute episodes of hereditary angioedema in known patients, should be managed in emergency care as appropriate.
• New patient appointments for children with severe / suspected angioedema, particularly pharyngeal / laryngeal, abdominal or genital, requiring work-up for hereditary angioedema should be prioritised. Much of the consultation can be conducted by telephone, with phlebotomy as appropriate.

Service adjustment for drug allergy

• De-labelling drug challenges, where there is no immediate plan for administration of the given drug within the next 30 days, should be deferred.
• Patients where there is an urgent or critical need for drug allergy delabelling, challenge or desensitisation, should be prioritised.

Service adjustment for venom allergy

Venom immunotherapy should not be initiated. Patients on maintenance venom immunotherapy can be spaced to every 2-3 months, if they have been on maintenance for at least a year.

Prioritising Cases

In the current scenario of limited resource and likewise, when services start to normalise, priority access should be given to the following groups of patients:

• Patients with food allergy and co-morbid poorly controlled asthma
• Patients with a history of anaphylaxis
• Patients with severe, early onset eczema where early food introduction may prevent food allergy or food allergy may be contributing to the severity of eczema
• Patients with faltering growth where allergic co-morbidity is contributing

Acknowledgements

The BSACI would like to thank Dr Susan Leech, Professor Adam Fox and Heidi Ball for help with the production of this document. 24^th March 2020

References

1. Del Rio C, Malani PN. COVID-19 New insights on a rapidly changing epidemic. JAMA 2020

2. M.S.Shaker et al. AAAAI Special article 2020; COVID-19: Pandemic Contingency Planning for the Allergy and Immunology Clinic