That about sums it up. Along with other wording in the school forms that is not good it also states that all drugs must be premeasured. What if that isn't the proper dosage for the child? What happens then?
I did speak with my allergist's office. They said I *could* go with the premeasured but noted that it would be short almost 1/2 a dose. She said to be sure they know by doing this they run a greater possibility of needing the epi pen. She thought maybe being sure to point that out that maybe they will review that policy. She also said that there is a shortage of the premeasured benedryls anyway so that is another issue.
Well, in their defense, such a policy does reduce dosing errors, which are far more common than you might imagine.
12.5 mg diphenhydramine is available in MANY formulations-- not just Benadryl brand.
Look for thinstrips (Triaminic Allergy) or for generic liquid doses at Target, WalMart or Walgreens, maybe.
I'd probably tend toward having the doc okay a doubled dose rather than one 50% low. KWIM?
Quote from: MomTo3 on April 30, 2012, 06:28:29 PM
That about sums it up. Along with other wording in the school forms that is not good it also states that all drugs must be premeasured. What if that isn't the proper dosage for the child? What happens then?
I did speak with my allergist's office. They said I *could* go with the premeasured but noted that it would be short almost 1/2 a dose. She said to be sure they know by doing this they run a greater possibility of needing the epi pen. She thought maybe being sure to point that out that maybe they will review that policy. She also said that there is a shortage of the premeasured benedryls anyway so that is another issue.
So this: She said to be sure they know by doing this they run a greater possibility of needing the epi pen.
I thought Benadryl doesn't stop anaphylaxis? So if an epi is needed...it's needed, right?
Adrienne
how would being short on a dose of Benadryl make it more likely the epi pen would be needed?
As I understand it giving Benadryl does nothing to halt anaphylaxis and cannot stop it. Just curious about this.
sorry adrienne, we were apparently on the same plane, posting same time.
editing to add that many doctors have stopped putting benadryl first, epi second in their healthplans, especially school allergy plans.
From what I recall there is something DS is allergic to in the thinstrips. I know there are other 12.5 mg strengths but the order is for 15 mg/5ml strength.
As for Benadryl not stopping an ana reaction, I don't think I have ever heard that before. I will look into that. They said that going double could really mess with DS (knock him out pretty much) so doing the 12.5mg would be better than ODing him. Our FAAP still is Benadryl for XYZ, Benedryl and EPI for ABC and XYX. I think it is the same one FAAN puts out so it does call for both.
Ummm, if 15 mg is the 'precise' dose by weight, then 12.5 should be-- truly-- just fine.
Dosing is by total mass of drug, btw, NOT by volume of a particular formulation, or a particular concentration. (Just so that you know that in the future, in case you didn't.)
Sorry, but I think that you're probably overthinking this one just a bit. (I say that with all compassion as someone who has BTDT. Truly.)
Overdosing on Benadryl can cause respiratory depression and death, so I would not give a double dose of Benadryl.
I was almost a nurse and worked in a pharmacy for year. I understand dosing, strengthen and so on. DS is suppose to get 7.5 ml of Benedryl 15 mg/5ml. The dose available in the premeasured is 12.5 mg/5ml. So he need to take something like 17 or 22.5 mg (dont have the math here with me now) of medication. A premeasured is only going to give him 12.5 mg or 2 would be 25 mg.So no matter what he isn't going to get the prescribed dose from a premeasured thing.
I hope you don't interpret this as me being rude, because I truly don't intend it that way. I really do know my pharmacology this well (yes, really, and I do have the credentials to prove it), but I'm not asking you to take my word for it because I am someone you only know through the internet. I could be anyone, right? Please ask your doc/pharmacist about it; but explain what the school wants and ask how big a deal it is, really, in the grand scheme of things. My guess is that the answer is "well, not very, really..." For the reasons I outlined below. 1. Premeasured dosing makes it much SAFER for untrained aids and instructional staff to give medication, 2. Benadryl really shouldn't be a 'regular' thing at school or there are other problems which need addressing, and 3. Benadryl can't save your child's life.
??? Seriously-- not really grasping the problem here, with all due respect. This is really not a big deal.
7.5 mL of a 3mg/mL syrup* (this is what 15 mg/5 mL means in terms of concentration) = 22.5 mg of the drug.
22.5 mg is within about 10% of 25 mg, which is two of the premeasured doses. Seriously, if you don't believe me, ask your pharmacist.
While overdosing on benadryl is a problem (and is a good reason to use premeasured doses, especially with laypersons, btw), the dosage window is incredibly wide for typical kids 5y+. This is NOT something that I expect most nurses to know, nor is it necessarily one that pharmacy techs know. Pharmacologists, pharmacists and allergists certainly do, however. Some drugs have VERY narrow therapeutic ranges, but first gen antihistamines are not among them, and even less so with the second gen variety which are, as a class, more selective and do not cause blockade of both H1 and H2 receptors the way diphenhydramine does. (CNS depression is the cause of dangerous symptoms in overdose with first gen antihistamines, btw.) The other thing that such a wide therapuetic range gives you is some therapeutic efficacy even at significant underdosing. Personally, given my knowledge there, my household ROUTINELY 'titrates' this type of drug from 20% of recommended dosing up to about 75% of the upper limit of safety (notice that I build a healthy buffer in there for safety). But definitely NO advice there, as I definitely have experience and information that most laypersons do not, and I can hazard good guesses about individual drug clearance rates for my family members, too.
Overdosing by 10-15% (at worst, since by the end of the school year that number is likely to shrink to more like 5%) is not something to be overly concerned about in most kids, other than the obvious cognitive impairment, but that is going to be an issue with dosing at recommended levels anyway, so it probably ought to be addressed in a 504 plan either way. Another option to discuss with your allergist might be a non-sedating antihistamine like cetirizine instead, if that puts your mind at ease about CNS side-effects (and if your child can tolerate swallowing pills or can have the orally-dissolving type).
(*Benadryl is actually 12.5 mg/5mL, btw, NOT 15 mg/mL, which, okay-- this is really 2.5 mg/mL, so 7.5 mL of that is 18.75 mg... which is midway between 12.5 mg and 25 mg, but well within safety of dosing for 25 mg, and probably within minimal efficacy for 12.5. Take your pick, really. )
Again, with all due respect, this is probably not something you want to spend a lot of time arguing about with the school. You'd be burning good will which-- trust me-- you're going to wish you'd retained later when something else comes up (and it always seems to).
Choose whether you prefer underdosing or overdosing (with your physician's input, of course), and realize that in any case, you are HOPING that dosing with benadryl won't ever be a ROUTINE thing at school anyway. It's NOT LIFE-SAVING. This is why many allergists are preferring to leave antihistamines entirely OUT of school action plans; to avoid delays in administration of epinephrine.
Understand that-- and realize that making a big deal about this with school personnel may well give them the wrong idea about that point.
Again, I'm really just trying to help you. Remember, some of us have been doing this for well over a decade (or more); we're just sharing our experience.
My DH once gave my then-not-quite-2yo 2 tsp (that's ~10 mL) of benadryl during an allergic reaction in a hotel room.
Her correct dose at the time was 1/2 tsp (2.5 ml) (well, this was probably something of an underdose, knowing me). The lettering, written in Sharpie, had partially worn away off of the dosing spoon. She had it down the hatch before I could intervene-- I noticed that it seemed like an awfully large volume. :misspeak: Yes, that was a 400% dose. It was a complete accident, but it happened, and my DH and I are both pretty on-top-of-it people.
Yes, she was as loopy as a monkey on a three-day bender for a few hours... but, um... she was FINE in terms of CNS depression. So truly, when I say that the dosing window for safety is "wide," um, yeah. VERY wide. I would never have done that on purpose, of course-- but it was nice to have reassurance that dosage didn't need to be very exact. ;)
I tell this story to point out how I know that this isn't a very big deal... but also to illustrate how easy it is to MAKE that kind of dosing error in the heat of the moment when you need to measure a dose yourself. Premeasured doses didn't exist at the time, or we'd have been carrying them after THAT, I'll tell you what. When we found thinstrips many years later, we were completely sold on them, and safety in dosing is part of the reason.
My DH is not a "medical" guy, as terrific as he is in many other ways. I would never have made that kind of error, but I can easily see how the average teacher/grandparent/babysitter/school secretary might.
CMdeux- Thanks. No, I didn't think you were being rude at all. I just wasn't sure if I was explaining myself so I just wanted to restate the numbers and all.
I think one of the things that may be an issue is that the nurse when I was speaking with her yesterday said 7.25 ml which when calculated would be closer to the 12.5 (I think, again it's early and I have an infant who was up and down all night). I think that's why she said to go with the lower does. I agree that he (hopefully) won't need it often/at all but it needs to be there. The pharmokinetics I get. I didn't think of it that in depth (see above ;) )
I do understand that dosing errors are possible and in an emergency situation the easier things are the better!
I guess the question remains what happens if I can't get the premeasured dose spoons?
Also, why is the standard protocol Benadryl and epi if that isn't going to stop a reaction? I was poking around and was reading how benadryl protects some body tissues from the histamine reaction vs. the vasoconstriction of the epi but if it won't stop an ana reaction, why is that the standard?
Again, thanks for all the input. I'll call the Dr. again and see what they say again after I remind her what my paperwork says (7.5mg vs 7.25 mg).
For premeasured dose I use Luer Lock syringe and label the outside.
As for wiggle room on Benadryl, that's something I've found as a concensus amongst ped, allergist, EMT, and ER docs (attending, not residents) of late: that we could go as high as double dosing with proper supervision after. That's the notes from my last few ambulance rides.
I think that standard treatment a few years back was hives/itchiness give benadryl, if symptoms persist (vomiting, difficulty breathing, any other system reacting) give the epi pen.
I believe that this caused confusion, some doctors believe benadryl can "mask" a reaction that is progressing and delays people using the epi pen.
Benadryl only makes the person more comfortable in terms of relieving itchiness etc. Will not stop anaphylaxis from setting in.
I have seen Dr. Sicherer from Mt. Sinai in his office as well at Q/A sessions. The last few times, his FIRST item was use that epi pen sooner than later.
Benadryl will do nothing if your reaction is progressing throughout your systems....drop in blood pressure, loss of consciousness, thready pulse etc.
Sicherer doesn't tell all patients epi first. We saw him less than a year ago and the EAP is Benadryl first even for a known ingestion for an allergen that has a proven history of anaphylaxis including respiratory. We're due back to see him in a couple of months, for sure I'm going to question that again considering how many times I hear he typically says opposite. That's too glaring an inconsistency in our case.
Quote from: twinturbo on May 01, 2012, 06:44:11 AM
For premeasured dose I use Luer Lock syringe and label the outside.
Do I need to get those from the Dr. or can I get them anywhere? Found them on Amazon. Do you put them in something so they aren't accidentally pushed? A hard pencil case perhaps? Maybe I am over thinking again!
You are all fantastic! I am learning so much (and I though I was pretty knowledgeable already ;) ) I did also call my local fire dept. yesterday to find out if they have epi and the authority to use it. I was happy that all squads in the city as well as the fire trucks all carry epi and are authorized to give it to pediatric patients!
http://www.medscape.org/viewarticle/733658 (http://www.medscape.org/viewarticle/733658)
http://www.dailyrx.com/news-article/pediatric-food-allergies-are-increasing-16777.html (http://www.dailyrx.com/news-article/pediatric-food-allergies-are-increasing-16777.html)
Both abstracts he talks about concerns in the delay of administering Epi pen.
When you see him again, please ask. I may go to his Q/A this month, if I do, I'll ask him again to clarify.
Quote from: Carefulmom on April 30, 2012, 10:20:58 PM
Overdosing on Benadryl can cause respiratory depression and death, so I would not give a double dose of Benadryl.
Double dose is on my child's Allergy Action Plan.
And I do think Benadryl can HELP even in Anaphylaxis - it just may not be enough. But Epi+ Benadryl likely to be more effective than Epi alone. Hospital ER's use Benadryl for this reason!
That's a good question for school storage. There's with cap or without cap, obviously you want with cap. In our family we need syringes by the case. If you only need a couple a local medical supply store would probably have individuals for sale. The pencil box sounds good to me since it's a hard case that you can label.
What we did was buy a bag recommended by some kind soul here, a waterproof bag from Magellan's travel supply. On the outside we put a pic of child on label with name, medicines inside with dosage amount, parent contact info and allergens. Taped it all over with tough clear tape to repel liquids. On the inside we have epis, bottle of antihistamine, syringes, insurance card, EAP. The bag has a waist strap so the teachers can carry it around easily. In our case one medicine bag stays in the classroom, the other a teacher wears when they go outside the classroom.
In any case I'd load the pencil box with about 3 pre-loads of Benadryl in luer lock w/cap, scotch tape the cap in place. I'd label each tube with name and dose and medication contained within stating in bold "ONE DOSE" or similar, expiration date might be good idea, too. Then I'd label the outside well with whatever info you deem necessary, adding to the box whatever else goes in for child (epis, action plan, etc.).
Periodically I go in to the medicine bags at school to check on them, make sure everything looks good, fully stocked, expirations are still good. Our teachers are terrific on always carrying the bag but not the best at temp control.
Quote from: Mfamom on May 01, 2012, 08:32:25 AM
http://www.medscape.org/viewarticle/733658 (http://www.medscape.org/viewarticle/733658)
http://www.dailyrx.com/news-article/pediatric-food-allergies-are-increasing-16777.html (http://www.dailyrx.com/news-article/pediatric-food-allergies-are-increasing-16777.html)
Both abstracts he talks about concerns in the delay of administering Epi pen.
When you see him again, please ask. I may go to his Q/A this month, if I do, I'll ask him again to clarify.
Oh, he never mentioned
delaying the epi in the face of clear anaphylaxis but the EAP was clear on Benadryl as a first line every time a reaction happened when it wasn't anaphylaxis yet according to the grading system.
QuoteI think that standard treatment a few years back was hives/itchiness give benadryl, if symptoms persist (vomiting, difficulty breathing, any other system reacting) give the epi pen.
^This is what our EAP from Sinai says. I questioned the directive to give Benadryl first on a known ingestion of allergen with previous anaphylaxis and it was yes.
So are we talking about the same thing? I'm confused.
Gotta run but wanted to say thank you for the links... and any insight you have on what/if the EAP protocol has changed. Because my understanding based on the docs I've read is there's good reason to epi first on known ingestions of allergens that have history of causing anaphylaxis. That's most likely what I'd do anyhow regardless of what the EAP said.
Hope that made some sense. I'm at the point where I feel like I have to start carrying the papers endorsing use of epinephrine first in appropriate instances where it's warranted (i.e., not delaying) because of all the difficulty in the ambulance and ER. I was caught off guard by our EAP from Sinai. Actually, I think we were somewhat taken to task by Sicherer's assistant for our statement the ER should have given epi the first reaction, like we had to prove he had anaphylaxed from peanut 5 years ago. Gee, his eyes were swollen shut, he was grabbing at his throat, mucous and tears were streaming from his nose, mouth and eyes, then he started to pant for air. For our other child his first epi was given by the allergist in office, all he had to do was read the report.
It was somewhat frustrating but I think I should bring in the links and use that as the medium to talk about it rather than parent of patient to doctor or doctor's assistant. At least give it one more try for clarification.
Glad you understood what I was saying there.
You might try finding out whether or not the school will accept medications which are not in their original packaging before you invest in luer-lock syringes and try going that route.
(If they are concerned about drug safety and protocols to prevent accidental administrations, etc... they may be thinking about liability and NOT be willing to take any medication which is not in original packaging. As inconvenient as it is, I can understand that with OTC medications. Any chance that your physician will give you a SCRIPT for diphenhydramine that you can fill at a compounding pharmacy? Then they might have to take it and deal with dosing themselves.)
As for diphenhydramine versus epinephrine, honestly, there is pharmacology to support the use of diphenhydramine for anaphylaxis. BUT-- there are significant caveats.
a) LARGE dose (like 200%)
b) FAST administraion (within a few seconds, usually, of the onset of initial symptoms)
c) meticulous observation for progressing symptoms and rapid epinephrine for ANY vascular, airway, or neurological symptoms.
This is how our allergist has handled DD's systemic reactions in-office, and it's also how we've been instructed to manage things. The reason that more allergists recommend "epi first" has to do with the relative complexity of that series of things.
The reason it works is that knocking out a high percentage of histamine receptors at the very onset of the cascade can prevent additional second-messenger relase (cytokines, etc.) and may actually help prevent progression, which in catastrophic anaphylaxis can be thought of as being like a snoball rolling down a hill. IF you do it soon enough and with a high enough dose, you can stop that snowball while it is little. BUT-- if you wait just a little too long, you can't and nothing but epinephrine will help, and benadryl is just a waste of precious time...
The reason that many top allergists have told people to stop using benadryl to treat reactions is that far too many people think that it has life-saving properties, and it doesn't. It does tend to delay the administration of epinephrine in laypersons, particularly in school personnel.
The above is definitely not something that I want other people caring for my child to do because of the relative risk... but it's also true that in a child with contact sensitivity, benadryl is going to be a way of life. We've never had diphenhydramine expire in our house. Not in 13 years.
Another good read is down in Reactions here-- there are a pair of threads stickied down there regarding antihistamines and epinephrine and their relative role during anaphylaxis.
Compounding pharmacy sounds like *the* way to go where feasible. I would love to see what ours could come up with.
FWIW, Our school requires that all meds be in their original packaging.
I called the nurse and they want the original packaging BUT I must have it measured out into syringes.
Such a wise group! :clap:
Quote from: regular member on May 01, 2012, 08:45:11 AM
Quote from: Carefulmom on April 30, 2012, 10:20:58 PM
Overdosing on Benadryl can cause respiratory depression and death, so I would not give a double dose of Benadryl.
Double dose is on my child's Allergy Action Plan.
And I do think Benadryl can HELP even in Anaphylaxis - it just may not be enough. But Epi+ Benadryl likely to be more effective than Epi alone. Hospital ER's use Benadryl for this reason!
How much is the dose and how much does your child weigh?
Quote from: regular member on May 01, 2012, 08:45:11 AM
Quote from: Carefulmom on April 30, 2012, 10:20:58 PM
Overdosing on Benadryl can cause respiratory depression and death, so I would not give a double dose of Benadryl.
Double dose is on my child's Allergy Action Plan.
And I do think Benadryl can HELP even in Anaphylaxis - it just may not be enough. But Epi+ Benadryl likely to be more effective than Epi alone. Hospital ER's use Benadryl for this reason!
Unfortunately hospital ERs are infamous for treating anaphylaxis improperly far too often. There have been several studies on this and many ERs do not epi when they should nearly often enough (and do everything BUT epi for some weird reason) and fail to keep the people in the ER for observation for the recommended 4-6+ hours and fail to give a prescription for epi to even first timers. Looking to hospital ERs for proper treatment of ana is a mistake unfortunately. The National Institute of Health came out with guidelines for the treatment of anaphylaxis that makes it clear only epi has life saving capabilities and that antihistamines do not have any life saving capabilities.
A person may feel better on both epi and antihistamine but I haven't ever read anywhere from a medical source that a person is likely to have a better outcome with both. Would I give both? Yes. Would benadryl be a priority of any sort? not really. Getting that epi in and calling 911 would be priorities and if recommended, getting a dose of steroid in those who have docs who recommend it.
Quote from: MomTo3 on May 01, 2012, 02:04:41 PM
I called the nurse and they want the original packaging BUT I must have it measured out into syringes.
Such a wise group! :clap:
That's best case scenario, actually! Our school used to let us do this and now they say only in the original packaging. I do NOT want them fumbling around trying to measure Benadryl when DS needs 911 to be called. I want them to epi, call 911 and then worry about Benadryl. You are actually lucky with this outcome!~
Quote from: regular member on May 01, 2012, 08:45:11 AM
Quote from: Carefulmom on April 30, 2012, 10:20:58 PM
Overdosing on Benadryl can cause respiratory depression and death, so I would not give a double dose of Benadryl.
Double dose is on my child's Allergy Action Plan.
And I do think Benadryl can HELP even in Anaphylaxis - it just may not be enough. But Epi+ Benadryl likely to be more effective than Epi alone. Hospital ER's use Benadryl for this reason!
I just noticed the last line in this quote. I was focused on the "double dose", which I really don`t know what dose you consider to be a "double dose" and how much your child weighs. But I have worked in hospital ERs, and the reason of epi + benadryl being more likely to be effective than epi alone is not true. That is
not why we give epi + benadryl. We give Benadryl after epi because the epi can wear off quickly and that way the antihistamine is kicking in when the epi is wearing off. I don`t think anyone in an ER actually thinks epi + benadryl is more effective than epi alone.
so, you are supposed to fill the syringe with the benadryl and supply the packaging it came from? do they want you to label the syringe? it seems like if there is chance for error this way too because you can't verify what is in the syringe. any chance a syringe full of benadryl could get mixed up with someone else's syringe filled with a different med?
I will put a few labeled, pre filled syringes into a hard pencil case with the original box. I will put labels on all they syringes as well as on the case with his picture on it.