Case one:
Siobhan presents with her 12 month old baby who is allergic to egg protein. She has been told by her next door neighbour not to have Lucy immunised against measles as she might have an allergic reaction.

Further history

Siobhan advises you Lucy has had a runny nose and mild cough for the past 2 days but is otherwise well. You diagnose an upper respiratory tact infection (URTI).

Answer 1

A thorough history should be taken to determine if this is a true egg allergy. Symptoms suggestive of an anaphylactic reaction following ingestion of egg protein include:

• development of an urticarial rash
• angioedema
• onset of respiratory distress wheeze.

You confirm Siobhan has had a previous anaphylactic reaction to egg and required intramuscular adrenaline as part of her management.

Answer 2

No. MMR can safely be given to children with egg allergy. However, influenza vaccine is contraindicated in people who have an allergy to eggs.

Answer 3

Anaphylaxis following a routine immunisation is very rare with a recent paper quoting the incidence as 1:1 500 000 doses. Fainting or a vaso-vagal episode is common in adolescents and adults and less common in children. The immunisation provider must be able to distinguish between these conditions. Recipients of vaccine should remain in the vicinity of the place of vaccination for at least 15 minutes.

Anaphylaxis is characterised by a sudden onset of respiratory distress circulatory collapse usually within 5 minutes (can occur within hours) of administration of the vaccine. Initial symptoms may include:

• pallor
• anxiety
• development of an urticarial rash (itchy wheals covering part or all of the body)
• onset of stridor due to angioedema of the upper airway
• onset of wheeze due to bronchospasm
• hypotension with weak central pulse
• loss of consciousness.

In comparison signs and symptoms of a vaso-vagal episode usually occur within minutes of the vaccine being administered and include:

• cool, clammy skin
• normal respirations
• light headedness
• strong central pulse
• loss of consciousness which corrects once child is supine.

Answer 4

Assess airway, breathing and cardiovascular status (ABC). Position child on left side to:

• clear airway
• apply high flow oxygen via face mask
• administer intramuscular adrenaline if any signs suggestive of anaphylaxis are present (see dose below). If only mild flushing of the skin is present observe child initially
• monitor oxygen saturation by oxymetry if available
• ECG monitoring if available
• reassess airway (ABC)
• IV assess may be required
• Steroids and antihistamines may be required.

Dose of adrenaline: adrenaline 1:1000 is universally available. It is more practical to use a 1 mL syringe for accuracy of measurement.

Adrenaline 1:1000 contains 1 mg of adrenaline per 1 mL of solution.

Dose: (1:1000) is 0.01 mL/kg body weight up to a maximum of 0.5 mL or 0.5 mg by deep intramuscular injection (Table 1).

Adrenaline 1:10 000 contains 1 mg of adrenaline per 10 ml solution. It may be useful to have available for young infants who require very small doses of adrenaline (Table 2).

Answer 5

No. All vaccines can be administered to infants and children who have a minor illness (without an acute systemic illness and with a current temperature below 38.5) may be vaccinated safely.

Feedback

Major illness or high fever may be confused with vaccine side effects and increase discomfort to the child. When a more severe illness is present immunisation should be postponed for 2-3 days until the child is well. A return appointment for immunisation should be made at the time of deferral.