Although diagnosis of a bee sting allergy is often straightforward, it’s important to go through the history. Ask when the child was stung, what type of reaction they had, and how soon after the sting they experienced symptoms.
A large local reaction can be impressive in size, but it may not be as serious as the child who presents with systemic symptoms such as hives or difficulty breathing.
Immediately direct a child experiencing acute anaphylaxis to emergency care. Acute effects will be seen right away, generally within 15-30 minutes. The parents of a child with a known sensitivity to bee stings, in particular, will know to head to the emergency department right away, especially after self-administration of epinephrine by an autoinjector.
It is more likely that a patient will come to you with a less severe reaction or for advice on how to manage their potential allergy. In general, local reactions are no larger than 10 cm, and you can treat the area with ice or cold compresses in your office. Typical local reactions are a little bump, a local hive, or an indurated area of swelling that is warm or hot.
Take photos of the allergic reaction. This can be very helpful if you later refer the child to a specialist. It helps to immediately see the size and location of the reaction.
Check to see if the stinger is still in place when a flustered child (or parent) comes in right after a bee sting. Although most people remove it immediately, some patients come in with the stinger still in their skin. You want to scrape or brush across the skin with a credit card or coin to remove the stinger. The removal technique is important because honey bees can leave both their stinger and venom sac behind as a last defense. If you just try to pull out the stinger, unintentional squeezing of the venom sac can mean more venom gets injected into the allergic child.
Consider referral to a pediatric allergy specialist if a child has a history of adverse or severe reactions to bee stings. The risk of future severe reactions, including anaphylaxis, will be elevated in a patient who has already spent any time in the emergency department, for example. When you refer, include a list of any local or systemic symptoms and any medications the child is taking.
Each subsequent exposure to bee venom increases the risk of a more severe reaction. One question I always get is: "I’ve been stung 15 times before. How come this time I developed an anaphylactic reaction?" I explain that a person needs to be stung only once before the body can develop an allergy, and any exposure after that may trigger a serious or life-threatening reaction.
You can perform allergy testing in your primary care office, but the question is what to do with the results. Such testing prior to referral does not tend to help us a lot. We often perform a more comprehensive evaluation. For example, as a general rule I order IgE protein-specific tests for the five common flying insect venoms, because most children cannot tell if a wasp, hornet, or bee stung them.
The good news is that if an individual meets criteria and is treated with immunotherapy or allergy shots, he or she has a success rate of about 98%. Even so, I recommend that a child with a history of bee sting adverse reactions carry an autoinjectable epinephrine device and practice bee avoidance measures.
You can educate children in the primary care setting how to stay away from bees. Tell them not to play in or around woods, for example. Make sure the child knows not to provoke or aggravate any bees they encounter, and that bees are attracted by bright-colored clothing, perfume, and cologne. I also tell patients to avoid drinking cans of soda outdoors. Bees attracted to the sweet soda will fly into these cans and, unfortunately, it is not uncommon for people to be very surprised and get stung in the mouth, on the tongue, or on the lips this way.
Dr. Doshi is director of pediatric allergy and immunology at Beaumont Hospital, Royal Oak, Mich.