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Transition of care needed across life span for allergy, immunology
When pediatric patients with allergy and immunologic diseases grow into adolescence and young adulthood, special considerations need to be addressed, including psychosocial concerns, specific conditions and self-efficacy to manage their symptoms, according to a review published in Pediatric Annals.
“Allergy and immunology [are specialties that place] importance on the transition of care due to the recognition that atopic conditions and immunologic diseases are often lifelong processes,” Flavia C. L. Hoyte, MD, assistant professor and the allergy/immunology fellowship director at National Jewish Health - University of Colorado, wrote. “In fact, the specialty of allergy and immunology is not a subspecialty of pediatrics or internal medicine, but rather has a single board [that] oversees both pediatric and adult allergists and immunologists.”
To address the needs that a pediatric patient may have when transitioning to adolescence and young adulthood, Hoyte examined the various conditions that an allergist or immunologist, or both, may encounter, including asthma; rhinitis, conjunctivitis and sinus disease; eosinophilic esophagitis; food allergy; anaphylaxis; mast cell disorders; and atopic dermatitis.
Presentations of allergic rhinitis and conjunctivitis are similar in pediatric and adult patients; however, each group is more likely to experience specific conditions associated with the diseases. Pediatric patients may experience more vernal keratoconjunctivitis, whereas common adult conditions include giant papillary conjunctivitis and atopic keratoconjunctivitis. When assessing these types of conditions, nasal polyps should cause concern for cystic fibrosis in children.
Asthma, a condition that often persists into adulthood, can be difficult to treat in adolescence because symptoms may ease as they transition out of childhood. Hoyte suggests that education on the condition’s natural history should be an integral part of treatment because symptoms may worsen once the patient reaches their twenties.
As a child transitions into adolescence and young adulthood, scarring and fibrostenotic changes may change the pattern of the symptoms associated with eosinophilic esophagitis. These symptoms can transform from abdominal pain, dysphagia, food refusal, nausea and failure to thrive in pediatric patients to food sticking, retrosternal pain and dysphagia in adulthood. Hoyte notes that a developed framework for transition of care already exists for this condition, which includes the need for multidisciplinary teams, intermittent or frequent endoscopies and home care companies.
Food allergies may appear in a patient at any time, making care across the continuum especially important. Children who experience peanut allergy have a prevalence of the sensitivity in adulthood of 0.6%, whereas tree nut allergies from childhood have a prevalence of 0.5% in adults. Adults are more likely to experience onset of fish allergy (prevalence = 0.5%) or shellfish allergy (prevalence = 2.5%).
The understanding of how to avoid allergen exposures and associated reactions can cause psychosocial implications for adolescents. Parents were less sure that their child could notice reactions, follow necessary restrictions and explain the requirements of the allergy. Many adolescents also experience high levels of anxiety due to this condition.
Anaphylaxis may be caused by many exposures, but only 61% of adolescents regularly carry an epinephrine autoinjector. Patients will need to be trained on the medication’s use and how to educate schools, camps and restaurants on their condition.
Mast cell disorders, a condition that differs in adult and pediatric populations, are usually limited to the skin in children. Hoyte notes that as patients with these disorders age, they should receive education on symptoms associated with systemic mastocytosis. Symptoms of this disorder may include flushing, presyncope and syncope, hives and anaphylaxis.
More than 10% of adults experience eczema, despite atopic dermatitis being more prevalent in childhood. Removing food allergens can relieve eczema in children, but additional precautions for children and adults include moisturizing, using anti-inflammatory therapies and breaking the itch-scratch cycle.
“Successful transition for patients with chronic allergic and immunologic conditions involves an understanding of the natural history of these conditions, education of adolescents and emerging adults about the expected trajectory of their disease, an emphasis on independence and self-management in these age groups, and careful communication between pediatric and adult specialists as care is transitioned,” Hoyte wrote. — by Katherine Bortz
Disclosure: The researcher provides no relevant financial disclosures.
