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Venom Allergy in Children

Q.I recently evaluated a previously well 2-year-old toddler, who abruptly developed diffuse urticaria and questionable lower lip swelling while eating a peanut butter sandwich during a visit to a “pumpkin patch” in Northern California, in October. He was seen in the ED at the time of symptoms.

In the ED, his vital signs were normal, and his physical exam was unremarkable with the exception of the cutaneous findings. He had no ocular, nasal, respiratory, cardiovascular, or neurologic symptoms. He was treated with oral diphenhydramine, with resolution of urticaria.

The toddler was seen by his pediatrician in follow-up, and she had initially questioned peanut as the trigger for his symptoms. Peanut testing in our allergy/immunology clinic was subsequently negative. He has since consumed peanuts and peanut butter without incident, and has been eating these on a regular basis for the past couple months.

His parents are now questioning other possible triggers for the urticaria, specifically “bee sting allergy”. They recall seeing “a few” bees in the pumpkin patch, and wonder if he might have been stung. They do not recall a specific sting or site of injury. The boy was wearing shoes throughout his visit to the pumpkin patch, and they do not recall seeing any nests or hives.

I have two questions related to the possibility of stinging insect hypersensitivity in this young patient:
1. Can a child of this age be treated with hymenoptera venom immunotherapy?
2. Is hymenoptera venom skin testing indicated in this patient?

A. Young children who have experienced systemic adverse reactions to hymenoptera stings should be treated with hymenoptera venom immunotherapy (VIT). Anaphylactic reactions to stings can occur decades apart, with or without interval stings. Children with a history a systemic reaction who do not receive VIT are at risk of subsequent similar reactions even decades later.

Patients 16 years of age and younger who have experienced cutaneous systemic reactions without other allergic manifestations have a 10% chance of a systemic reaction if re-stung. If a systemic reaction does occur with a subsequent sting the patient has less than a 5% chance of more severe reaction and less than 1% risk of life-threatening anaphylaxis. VIT is generally not necessary for patients 16 years or younger who have experienced only cutaneous systemic reactions. VIT is an acceptable option if requested by the patient’s parents, or if the patient is likely to experience frequent or multiple stings.

Given the patient’s history, VIT would not necessarily be recommended for this patient. If the patient’s parents are reassured by the natural history data above, and do not believe patient will have multiple or frequent stings in the future, venom immunotherapy would not be recommended. If VIT is not being considered, there is no need to perform hymenoptera venom testing.


1. Golden DB. Insect Sting Anaphylaxis. Immunology and Allergy Clinics of North America 2007; 27(2):261-72.

2. Golden DB, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D, Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI); American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology. Stinging Insect Hypersensitivity: a Practice Parameter Update 2011. J Allergy Clin Immunol. 2011 Apr;127(4):852-4.

3. Golden DB, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D, Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI); American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology. Stinging Insect Hypersensitivity: a Practice Parameter Update 2011. J Allergy Clin Immunol. 2011 Apr;127(4):852-4.

4. Golden DB, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D, Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI); American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology. Stinging Insect Hypersensitivity: a Practice Parameter Update 2011. J Allergy Clin Immunol. 2011 Apr;127(4):852-4.

5. Golden DB, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D, Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI); American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology. Stinging Insect Hypersensitivity: a Practice Parameter Update 2011. J Allergy Clin Immunol. 2011 Apr;127(4):852-4.

 
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