Immunology and Allergy
The Starship Paediatric Immunology and Allergy Service is a tertiary referral service that provides inpatient and outpatient services for children with allergies and disorders of the immune system.
The team includes doctors and a clinical nurse specialist, and works closely with other paediatric doctors both at Starship and throughout New Zealand. The service also provides outreach clinics at some regional centres as well as telehealth clinics.
Immunology and Immune Deficiency
- The immune system provides defence against many types of infections. Children with primary immune deficiency have disorders where the immune system does not function properly, placing them at risk of recurrent infections and other immune problems. Many of these children will have multiple hospital admissions and will also be seen as outpatients. The service is involved in the care of immune deficient children from around New Zealand, in liaison with the child's local paediatrician.
- Some children will require ongoing immunoglobulin replacement therapy either at home or in the Day Stay Unit.
- All babies born in New Zealand will have Newborn Screening (NBS) performed, which includes testing for Severe Combined Immune Deficiency, the most severe form of primary immune deficiency. The immunology team works directly with the NBS team to identify and care for patients with abnormal screening tests - https://www.starship.org.nz/guidelines/severe-combined-immunodeficiency-scid/
- Other immune disorders can present with problems in the regulation of the immune system and can affect multiple body systems. The immunology service works alongside other paediatric specialists and teams in the diagnosis and care of such patients.
Allergy is extremely common and most children with allergy will be looked after by their general practitioner, sometimes with the assistance of a general paediatrician. Only a minority of children with allergy will need to be seen by the Starship Immunology and Allergy service.
- Examples of allergy problems that may need to be seen by the Starship Immunology and Allergy service include very severe allergic reactions / anaphylaxis, complicated food allergy, severe insect sting reactions and drug allergy. Most allergy patients will be seen only in outpatients.
- The service also sees patients with the following conditions:
- Allergic rhinitis (hayfever) for consideration of environmental immunotherapy https://www.allergy.org.au/patients/allergic-rhinitis-hay-fever-and-sinusitis/allergic-rhinitis-or-hay-fever
- Chronic urticaria (hives) when symptoms are frequent or recurrent, or related to particular triggers such as cold or exercise https://www.starship.org.nz/guidelines/urticaria/
- Angioedema including hereditary angioedema https://www.allergy.org.au/patients/skin-allergy/angioedema
- FPIES – food protein induced enterocolitis syndrome https://www.allergy.org.au/patients/food-other-adverse-reactions/food-protein-induced-enterocolitis-syndrome-fpies
- Dr Shannon Brothers Paediatrician
- Dr Jan Sinclair Paediatrician
- Dr Kuang-Chih Hsiao Paediatrician
- Dr Annaliesse Blincoe Paediatrician
The Starship Paediatric Immunology and Allergy service receives more referrals than it is possible to see. Many of these referrals will be forwarded to general paediatric services. Referrals from paediatricians or other specialists will always be accepted. Some referrals will be returned to the GP with advice if, from the details in the referral, an appointment is not needed.
The waiting time for an appointment depends on the nature of the referral. Referrals for possible immune deficiency will be seen urgently. Referrals for severe allergic reaction will generally be seen within 6 weeks, while referrals for less urgent allergy problems may wait longer to be seen.
At the clinic your child will be seen by a Consultant Immunologist or an Immunology Registrar (who will discuss each case with the consultant), and this may also be via a telehealth clinic over the phone or by video conferencing. The doctor will take a detailed history of symptoms and ask about previous illnesses and medications. The history is the crucial part of the consultation. There will be other questions about general health designed to add helpful information to diagnose what is causing your child's symptoms. The doctor will then examine your child. They will explain to you as they go the reasons for the examination and then what tests or treatments are coming. It is helpful to bring your child’s well child book to the appointment, particularly if there are concerns about growth or food allergy.
If relevant, the doctor may ask for skin tests to be performed, either on the first clinic appointment or at a subsequent appointment. Certain skin tests may take some time to perform (e.g. up to 2 hours for some antibiotic allergy tests).
Your child may be started on medications or asked to undergo further testing (e.g. blood tests) before being seen again in the clinic or may be discharged back to your GP for ongoing management. A letter will be sent to your GP (with a copy to the family) with treatment recommendations as well as the results of any tests that are undertaken.
Some patients will need other procedures arranged such as food or drug challenge, or venom immunotherapy. Wait times for these procedures vary considerably depending on clinical urgency.
Common Conditions / Procedures / Treatments
Allergy Skin Prick Tests
Many children referred for possible allergies will have skin prick tests done at the time of their appointment. It is important that no antihistamine (e.g. Phenergan, Lorapaed, Cetirizine, Fexofenadine, Dimetapp etc) has been taken for 5 days prior to skin tests, as these can interfere with the results. Skin testing involves placing small drops of the allergen (the allergen is the thing being tested, such as dust mite or peanut) on the skin and then pricking through the drop with a small lancet. The prick is very superficial, and most children are not upset by having skin tests done. The results will be read after 15 minutes and your child will be seen with the result.
Some allergy skin tests are more complicated. If the first stage skin prick tests show no reaction for antibiotics and venom then a second stage of intradermal (injections just under the skin) tests are done. This type of testing is often difficult in very young children, so may not always be pursued depending on the history of reaction.
Specific IgE Blood Tests (sometimes called RAST)
Specific IgE (sIgE) tests are a way of doing allergy tests by a blood test rather than a skin test. A variety of foods and environmental allergens can be tested for. These tests involve taking a teaspoon of blood and the results are generally available after about 7 days. For these reasons skin tests are the preferred option in the allergy clinic, as results are immediately available.
sIgE tests may be preferred in situations where skin tests cannot be done, such as with continuous antihistamine treatment or severe eczema. sIgE tests are sometimes used to predict the likely time course of growing out of a food allergy. Importantly neither sIgE tests nor skin tests can predict the severity of an allergic reaction.
Deciding whether a child is truly allergic to a food, or deciding whether a food allergy has resolved with time, can be difficult. At times having the child eat the food may be necessary to decide this. If there is a chance of a significant food allergic reaction then a supervised food challenge may be recommended.
Waiting times for food challenge vary. The Starship service generally runs a "summer catch up" food challenge programme, doing many food challenges over summer months when the hospital is generally quieter. If your child is waiting for a food challenge make sure we have your correct phone numbers / mobile - there are often last minute cancellations for children booked for food challenge, so you may be able to be offered a cancellation slot at short notice.
The most important part of determining whether a child is allergic to a certain medicine (drug), such as antibiotics is through a careful and detailed history. In some cases the child may require skin and intradermal testing to help with the diagnosis. In the case of penicillin allergy, the majority of children will not be truly penicillin allergic, and based on the history the team will frequently offer observed doses of the penicillin based drug when seen in clinic. In other patients a formal supervised graded challenge will be more appropriate.
If a child has a severe allergic reaction/anaphylaxis to a bee or wasp sting, immunotherapy or desensitisation will generally be recommended. This involves giving injections of venom, initially in tiny and then in increasing doses, to make the child tolerant of the venom, which will minimise the risk of a further severe sting reaction.
Environmental immunotherapy can reduce the severity of symptoms and the need for regular medication for many children with environmental allergies, for example those with house dust mite and grass allergies. Allergen immunotherapy involves giving either injections just under the skin (subcutaneous immunotherapy or SCIT) or oral preparations (sublingual immunotherapy) of allergen extracts over 3-5 years to make the child tolerant to what they are allergic to. Immunotherapy may be beneficial for children with allergic rhinitis and allergic driven asthma when symptoms are severe and not managed adequately with medications, the cause is difficult to avoid or when they prefer to avoid regular medications. In the case of subcutaneous injections these would be started at Starship and the patient would then be transferred to the care of their GP for monthly injections. https://www.allergy.org.au/patients/allergy-treatment/immunotherapy