Eight-Year-Old with a Known Nut Allergy at a Birthday Party
You are helping at a children's birthday party in a community hall. An 8-year-old boy with a known peanut allergy ate a slice of cake about five minutes ago. He started coughing, then said his throat feels 'tight'. You can see swelling of his lips and a rash spreading across his neck and face. He is wheezy, his voice has become hoarse, and he says he feels 'funny and dizzy'. He sits down on the floor and leans forward. His mother is not present. His named adrenaline auto-injector (0.3 mg) is in his backpack with the other adult in charge, who says: 'He just needs his inhaler, he has asthma too.' A blue reliever inhaler is also in the bag. There is no mobile signal inside the hall, but there is a landline at reception. The boy remains conscious and able to speak in short sentences.
1. Is this anaphylaxis or an asthma attack, and what in the presentation drives your decision?
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This is anaphylaxis. Three systems are involved after a known allergen: airway (lip swelling, hoarse voice, throat tightness), breathing (wheeze) and circulation (dizziness, feeling faint). The hoarse voice and throat tightness are the decisive features - they indicate laryngeal oedema, which can close the airway, and an inhaler does nothing for that.
Asthma alone would not produce lip swelling, a spreading rash or faintness, and a reliever inhaler would not reverse airway swelling. Adrenaline is the only first-line treatment and must not be delayed while an inhaler or antihistamine is tried. Reassure the boy, keep him with you, and keep him sitting leaning forward, because he is struggling to breathe - do not make him lie flat or stand up and walk.
2. Which drug do you give, by what route and dose, and what position do you keep him in while help is summoned?
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Give the prescribed 0.3 mg adrenaline auto-injector by intramuscular injection into the anterolateral thigh - the outer mid-thigh, through clothing if necessary. That dose is correct for his age: 0.3 mg is the 6–12 year dose, 0.15 mg is used under 6 years, and 0.5 mg for adults. Follow the device's own instructions for hold time (commonly 3–10 seconds depending on brand) and note the exact time given.
Keep him sitting up and leaning forward, because he is breathing with difficulty; lying him flat in this state can worsen respiratory distress, while making him stand can cause a catastrophic drop in blood pressure in anaphylaxis. If he becomes drowsy, vomits, or breathing becomes easier but he feels faint, lay him flat with the legs raised.
Send someone to the landline to call 112 and state clearly: 'child, anaphylaxis, adrenaline given'.
3. What are your criteria and timing for a second dose, and why must he go to hospital even if he improves quickly?
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Reassess continuously. If there is no improvement, or he deteriorates, five minutes after the first injection, give a second dose from a second device into the other thigh. Five minutes is the accepted interval; the common error is waiting 15–20 minutes while the airway swells. If only one device is available, keep giving oxygen-free supportive care, keep him sitting, and get the ambulance there.
Even if he improves dramatically after one dose, he must be taken to hospital by ambulance and observed. Anaphylaxis can follow a biphasic course, with a second reaction hours after the first without further exposure, and adrenaline itself needs monitoring. The inhaler and any antihistamine are adjuncts only after adrenaline, never instead of it.
Handover to the crew: the allergen, time of each adrenaline dose, dose given, response, and any other medication he takes.