Introduction
This guideline relates to suspected insect allergies
in paediatric patients including pre-referral assessment, treatment and
investigations.
The most common insects that cause allergic reactions are bees, wasps
and less often jack jumper ants. In severe reactions consistent with
anaphylaxis, a course of desensitisation with injections (immunotherapy) is
usually indicated, which is a treatment lasting up to 5 years. This treatment
is only available in tertiary allergy centres.
An allergic reaction to an insect sting or bite may involve one or more
of the following signs and symptoms:
Mild-moderate allergic reaction
- Swelling of lips, face or eyes
- Hives or welts
Severe systemic allergic reaction
(anaphylaxis)
Abdominal symptoms are more likely to indicate a
severe systemic allergic reaction in insect sting reactions than in food
allergy reactions, hence why these symptoms are considered to be a severe
reaction if there is an insect trigger, compared to food triggers where GI
symptoms are considered a mild-moderate reaction
- Difficulty breathing
- Swelling of the tongue and/or throat
- Difficulty talking
- Hoarse voice, wheezing or persistent cough
- Loss of consciousness and/or collapse
- Infants and young children appearing pale and
floppy
Severe allergic reaction (anaphylaxis) will typically include
multiple organ systems (i.e. hives and respiratory symptoms). If there is only
respiratory or cardiovascular system involvement, this is still considered
anaphylaxis.
When to refer
- ALWAYS
refer confirmed or suspected anaphylaxis to the RCH Department of Allergy and
Immunology. This is an URGENT REFERRAL
- Anaphylaxis to stinging insects is an indication
for desensitisation
- ssIgE testing to the insect (bee, wasp or jack
jumper ant), total IgE and baseline serum tryptase is recommended prior to
referral only if there is a history of anaphylaxis secondary to insect stings
Do not refer
- For allergy screening if there is no clear history
of an allergic reaction
- When the family history is positive, in a
healthy patient who does not have an allergic condition
- Large localised reaction only or mild-moderate
reactions as these are NOT indications for desensitisation
- Concerns with mosquito reactions, as these only
result in localised reactions and are not at risk of systemic/severe reaction
Services available
closer to home
Alternative paediatric allergy services available in
Victoria include:
- Public paediatric allergy services:
- The Northern Hospital
- Sunshine Hospital
- Monash Children’s Hospital
- Consider referral to a private allergist as an
alternative to RCH. Options available on ASCIA website: Locate a
specialist
Referral
criteria/required information
The GP at first consultation is in the best position to get
the most comprehensive information from parents on the details of an allergic
reaction. Please collect and include in your referral as much detail as
possible. Referrals may be rejected if information is insufficient to triage
appropriately
Please include:
- CLEARLY INDICATE if the child has confirmed or
suspected ANAPHYLAXIS. The referral will be triaged as urgent
- Date reaction(s) occurred and timing of
commencement of symptoms
- Allergic reaction signs/symptoms
- Which insect
- ssIgE results if available
- Treatment given and patient response
- Please include discharge summary if child seen
in emergency department
- Previous or subsequent exposure to allergen
How to refer
Please complete the above and submit via:
Suggested pre-referral work-up/management
History:
- Stinging insect- circumstances, insect
prevalence in the area
- Nature/location of the bite or sting reaction
- Presence of a stinger or recognisable insect-
can the insect be identified? Note:
if the insect is killed, keep or photograph and bring o consultation for
identification
- Details of signs/symptoms, including timing of
these in relation to the trigger
- Treatment/management provided and response
- Previous and subsequent sting history and nature
of reaction
- History of atopy (e.g., particularly asthma)
- Relation of reaction to exercise
Diagnostics:
- Detection of allergen-specific sIgE (previously called RAST) test to the
insect venom of interest is only required if there is a history of a severe
reaction, consistent with anaphylaxis e.g., vomiting, abdominal pain,
respiratory/airway or cardiovascular signs
- ssIgE testing is not required for local reactions or mild-moderate
reactions
- ssIgE testing is available for bee venom, wasps and Jack Jumper ant
- Skin testing to insect venom must only be performed by a specialist allergist
and is rarely required
- Interpretation of allergen ssIgE:
- Demonstration of allergen specific IgE does
NOT necessarily indicate presence of clinical allergy. Many in the population
may be sensitised to certain insects, but not present a clinical allergy to
these insects
- Test results should be interpreted together
with history and only performed if
required
Management for severe reactions
consistent with anaphylaxis:
- Prescribe Epi-Pen/Epi-Pen Junior
- Can be discussed with an allergist,
paediatrician or ED on-call (via number below) to access authority funding
- Provide education on correct use of Epi-Pen
- ASCIA Anaphylaxis Action Plan with education
(even if trigger not yet confirmed)
- Ensure asthma is well controlled
- Educate on avoidance of allergen to which child
reacted e.g., wearing shoes outside, especially in spring and summer, avoiding
settings where bees are highly prevalent
- Support parent with school/child care
communication
- Do not attempt to perform a challenge to the
allergen. This should only be done in a specialist allergy unit
Management for mild-moderate
reactions:
- Antihistamine will alleviate symptoms of hives
and itches but will not address anaphylaxis
- Loratidine (Claratyne) and Certirizine (Zyrtec)
are suitable for infants and children and are available in syrup form
- For large localised reactions, may apply localised cold compresses and
if swelling persists and affecting function (e.g., large foot, hand or
peri-ocular swelling), may use oral steroids daily for 1-2 days (eg
prednisolone 1mg/kg, max 50mg)
- Minimise risk of exposure e.g., for bee allergy, wear shoes when
outdoors, avoid perfumes, use ventilation systems in vehicles rather than open
windows and avoid drinking from containers where you cannot see the contents
(e.g., cans)
Information for
families
Resources and links
Acknowledgements
The
development of this guideline
was coordinated by the Department of Allergy and
Immunology (Dr Jo Smart and Dr Paulina Alhucema). Guideline reviewed in January 2025.