The following pre-referral guideline gives suggested management and investigations before referral to RCH Department of Allergy and Immunology.

Initial work-up

History

• History of allergic disease (e.g. atopic eczema/allergic rhinitis).
• Family history of allergic disease.
• History of asthma symptoms:
  • Severity and pattern - infrequent episodic, frequent episodic, persistent.
  • Worsening symptoms in pollen season (e.g. October to February).
  • Symptoms at night or early morning (e.g. house dust mite).
• Physical examination.
• Concurrent allergic rhinitis?

Diagnostics

• RAST test to assess for specific allergy, if the history indicates (e.g. cat dander, dust mite, grass pollen).

Notes - asthma and food allergy

• Food allergens are uncommon triggers for asthma.
• As few as 2-5% of people with asthma react to foods.
• Acute food allergen-induced respiratory symptoms may be due to anaphylaxis, not asthma - particularly if associated with urticaria or angioedema.
• Any child with suspected anaphylaxis should be referred to the RCH Department of Allergy and Immunology immediately.

Recommended pre-referral treatment

Asthma treatment and management:

• Use standard treatment (preventer and reliever).
• Emphasize correct MDI or dry power inhaler technique.
• Asthma Action Plan.
• First Aid education

Allergen avoidance

• Only do dust mite avoidance if RAST and history strongly indicate perennial rhinitis and dust mite.
• No evidence exists that dust mite avoidance works and it is expensive. Sprays do not work. Err on the side of under-recommending.

Treat allergic rhinitis

• Allergic rhinitis can exacerbate asthma symptoms.

Medications to avoid

• Aspirin.
• Non-steroidal anti-inflammatory medicines.
• Beta blockers.
• 'Natural' remedies (e.g. echinacea or royal jelly) that may cause allergic reaction.

When to refer

Refer to the RCH Department of Allergy and Immunology when

• History indicates allergy is a causative factor for asthma.

AND

• Positive RAST test result.

AND one of the following

• Persistent, unstable asthma despite regular preventer therapy.
• Food allergy also present.

Note: Unstable asthma is a risk factor for fatal food-induced anaphylaxis and patients with both conditions should be assessed by a specialist at the RCH.

Information needed

• Symptoms (including onset, duration and pattern).
• Treatment given and patient response.
• RAST test result.
• Presence or absence of allergic rhinitis.
• Presence or absence of food allergy.
• Presence or absence of any other allergic disease.

Contact information

Resources

• Factsheet for parents on Asthma
• Clinical Practice Guideline on acute Asthma
• Asthma Australia, including Asthma Action Plans
  
  

References

Paediatric Handbook Ninth Edition (2015) , Blackwell Publishing. By the staff of the Royal Children's Hospital, Melbourne, Australia.

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