I just saw this.

http://www.asthmaallergieschildren.com/2013/01/12/auvi-q%E2%84%A2%E2%80%94thoughts-about-the-new-autoinjector/

QuoteThe program began with a talk by Dr. John Oppenheimer, formerly of National Jewish in Denver and currently in private practice in New Jersey as well as Clinical Professor of Medicine at the University of Medicine and Dentistry of New Jersey and Associate Editor of the Annals of Allergy, Asthma & Immunology.

Several things he said stood out. One was to cite a subject we have written about here—the misunderstanding of anaphylaxis by emergency department doctors. A second was the remarkable growth of exercise-induced anaphylaxis. A third was that he specifically cautions against administration of Benadryl as a first resort because the sedative effects can mask the onset of more serious symptoms like plunging blood pressure. And finally his observation that allergy practice frequently seems more like a matter of "risk management" than a healing art, or words to that effect. I hope to get Dr. Oppenheimer to write for us soon.

I like that one too lakeswimr.  I've never seen it, but it is very similar to what my son's new school set in his IHP.  He's had an IHP since kindergarten, but none of the other schools had anything like that.

Did the allergist give you a written emergency plan?  He or she should have and if not I'd request one asap so you don't have to guess when to epi.  The symptoms you described are listed on our plan as time to epi. 

I think the FAAN emergency plan is a good example if you don't yet have a written plan.  Our plan is a bit different than the FAAN one but I don't have it scanned so can't show it to you.  Here is a link to the FAAN plan. 

http://www.foodallergy.org/files/FAAP.pdf

I like it much better than the grading chart. 

Yup-- what she said!

That grading chart is really helpful-- especially since some of the most serious presentations are not always overt/obviously 'allergic' and not just something else going on. 

We're really glad that you found us, Rae. 

Yes, that would definitely be an epi situation in our house also.  It being his first reaction like that, it's hard to know until after the fact that you should have used the epi.  The important thing is that your son is fine and that if it happens again, then you know it's an epi.

Yes, I have not heard Benadryl can increase chances of causing a biphasic reaction by itself.  It can increase the chance a person delays epi administration and the chance a person doesn't give the epi at all, thereby increasing the chance of a fatality. 

I also wonder, if your child just got minor hives from eating nuts or if the reaction was more extensive.  Do you have a written emergency plan?  Did you follow it? 

My son's allergist knowns I failed to give the epi when I should have and he never threatened me.  I think that's extreme.  He did tell me to imagine how I would never forgive myself if the worst happened and I hadn't given it, though, and I think that was entirely appropriate for him to say to me. 

Modified after I actually read posts, lol.

Would the following statement be a fair and accurate interpretation of this doctor's orders:

Late or delayed administration of epinephrine, or lack of administration contributes to likelihood of mortality.

instead of

Administration of Benadryl directly increases mortality.

Yeah, I would think firstly that his absolutism here is pretty suspicious.

The evidence (as Boo and Lakeswimr have both noted) just isn't that clear on the subject.

What is clear is that he isn't giving you much respect as a patient-- and I'd consider his (severe?) dressing down of you over this to be both largely unwarranted* and fairly disrespectful in terms of your patient-doctor relationship.  He's bullying you, not "convincing" you.  There's a difference.

On the other hand, if this is an ALLERGIST, think twice before ditching him because too few allergists understand the relative importance of epinephrine and the relative severity/seriousness of food allergy. 


* assuming that "just hives" is completely accurate as a description of the reaction-- if there were OTHER symptoms, then no, his analysis may have been justified.  See that anaphylaxis grading chart.

I have looked for information on this for years. This is the only study I've ever seen that tried to evaluate whether H1 blockers cause harm or poorer outcomes:

http://www.ncbi.nlm.nih.gov/pubmed/17253584

As you can see from their review, there's no real evidence either way. Standards are different across different countries. As many physicians swear that H1 blocking can diminish the effects of anaphylaxis (in some cases - and that's an important caveat) as believe it can mask the build-up of anaphylaxis.

I would be skeptical of any doctor who tells me he had two fatalities in his practice from anaphylaxis. I have also not heard of a trial involving food allergies. And, since I've been looking for that research for years, if he has it, I would love to see it.

His take-away is a good one: you should be using an Epi for a walnut reaction. However, IMO his methods are suspect.

Here is an older thread about Benadryl vs epi that might be helpful.

Bendaryl vs. Epi ... help!

My son's allergist is opposed to giving Benadryl for a food allergic reaction because he says it can mask a reaction getting worse than it has no life saving capabilities.  So, it might hide some of the early signs that a reaction is spreading and is now systemic.  Then, suddenly the reaction pops out over the Benadryl and people can be caught unprepared.  Our emergency plan is to watch for the signs of anaphylaxis and if they occur, epi, benadryl, 911 and ER via ambulance.  I have talked about this elsewhere with a lot of other FA people and it seems about half of allergists agree with my son's allergist and the other half advise Benadryl for minor reactions.  However, support for my allergist's way of thinking seems to be growing and a growing number of allergists are even removing Benadryl from emergency plans altogether.  There have certainly been food allergy fatalities in cases where people gave Benadryl for what they thought was a minor reaction and did not give the epi pen.  Benadryl has been shown to have no life saving capabilities.  It does not thread the part of a reaction that has the potential to become life threatening.  It so for comfort only.  I think giving it can make a person feel they are "doing something" but in reality it isn't going to stop a reaction that is going to progress and become life threatening.  It can make people delay giving the epi pen and do the whole, 'watch and wait' thing.  (BTDT myself.) 

I can believe what your allergist is saying.  I read something yesterday on a different food allergy related topic and I remember thinking last night that apparently all FA related stories do not make it into the news since I hadn't heard of this topic in news stories but it was in this other article at another site. 

Our allergist (if fact the last 2 allergists) have advised to use benedryl if the reaction is only hives.  Anything beyond/or in place of a hive (my DS usually doesn't get hives) is an epi.


Just curious, is the doctor a pediatrician or an allergist?  Is it possible he's trying to "scare" you into the seriousness of the situation?

I've never heard this either; I do know that Benadryl alone won't stop an anaphylactic reaction so it's always better to epi if there's any question as to severity of reaction.  But I've always heard that administration of Benadryl after epi is pretty standard.

And welcome!  Sorry you had to find us this way.

Hello and welcome.  Sorry about your childs reaction.  I have not heard anything about that.  For minor reactions we use Benadryl, under dr. orders.  For anaphylaxis, epi.  But even once we got to the ER they gave him more Benadryl.  Whether he is right or wrong, I don't know that I would stay with a dr with that attitude.