Stings

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS clinical disclaimer

Aim

To guide PCH ED staff with the assessment and management of bee, wasp and ant stings.

Background

• Bees, wasps and ants belong to the insect order Hymenoptera
• Stings are common in children, particularly during spring and summer
• Native Australian bees rarely sting; the introduced honeybee and to a lesser extent, the European wasp is responsible for the majority of problematic insect stings
• Allergic reactions to bull ants, especially Jack Jumper ants (Myrmecia genus), are an increasing concern in eastern Australia. March flies and ticks may cause similar reactions.¹

There is little immunologic cross-reactivity between the venom of bees and wasps, and a history of allergy or anaphylaxis to one doesn't imply a risk of reaction to the other.

Bees sting only once, leaving the sting and poison sac in the victim, after which the bee dies.

Wasps can sting multiple times, don't leave their sting in the victim, and don't die after stinging.  

Assessment

Reactions to stings1,2
Local reaction - due to irritating / toxic effects of the venom Pain, erythema, swelling and itching around the sting site are common In severe cases of local reaction the swelling and erythema may extend to the entire limb and persist for several days
Allergic reactions - these are generally IgE-mediated, and reflect previous sensitisation Usually mild and non-life threatening. Generalised urticaria, pruritus and angio-oedema are typical Anaphylaxis: Airway oedema, bronchospasm and vasogenic shock require emergency treatment. Abdominal pains and vomiting are signs of insect venom anaphylaxis.
Toxic reaction - direct toxicity from the large amount of venom injected following multiple stings from bees, wasps or ants (usually > 25). This is rare in Australia.2 Airway and circulatory symptoms are unlikely. Gastrointestinal symptoms (vomiting, diarrhoea) predominate. Renal failure due to release of tissue breakdown products may complicate multiple stings (bee or wasp) several days after the event Treatment is supportive
Delayed serum sickness6 - this may occur 7-14 days after the sting, with morbiliform rash, uticaria, myalgia, arthralgia and low grade fever.

Management

• The majority of children who are stung will not require any medical treatment.

Who should seek medical attention following a sting

• Any person with a known allergy or history of anaphylaxis to the particular sting
• Stings inside the mouth, even if the person isn't allergic to the sting
• Multiple stings: > 5 in a child, or > 10 in an adult.

First aid for stings Remove sting (if present) as quickly as possible, by scraping with the edge of a flat object (long fingernail, knife blade) Analgesia - Simple analgesics and a cold compress applied to the sting site may relieve pain

Anaphylaxis - this is a medical emergency. Refer to Anaphylaxis

Local symptoms Symptoms often resolve in a few hours and an oral analgesic and cold compress may be helpful Oral antihistamines may alleviate itch and may prevent progression to systemic reactions in children with a previous history of systemic reactions to insect stings. 'Less sedating' antihistamines: Loratadine3 1-2 years, oral 2.5 mg once daily > 2 years and <30 kg, oral 5 mg once daily >30 kg, oral 10 mg once daily Cetirizine4 1-2 years, oral 2.5mg twice daily 2-6 years, oral 5mg once daily or 2.5mg twice daily 6-12 years, oral 10mg once daily or 5mg twice daily 12-18 years, oral 10mg once daily Neck and facial stings may cause swelling which may compromise the airway - consider observation in hospital Although data for the efficacy of corticosteroids is lacking, oral prednisolone (1 mg/kg/day up to maximum 40mg/day)5 for a few days may be considered if severe swelling occurs of the face or impacts on the function of a limb. Large local reactions commonly peak at 24-48 hours and may persist for several days. Elevate the affected limb and apply a cold compress. The appearance may resemble cellulitis but antibiotics should be avoided unless swelling increases more than 48 hours after the sting or systemic signs suggest secondary infection.

Prevention of future episodes

• Avoid obvious risk spots such as beehives in hollow stumps and take care around flowers
• High risk activities to be avoided include walking barefoot in warm weather and wearing strong perfumes
• Picnic foods should be covered

Referral

• Venom immunotherapy desensitisation is very effective in preventing future systemic reactions. All patients who have experienced a severe allergic reaction following bee, wasp and/or ant sting should be referred to a clinical immunologist / allergist
• Children who have had only urticaria and angio-edema do not require desensitisation.

Bibliography

1. Jack Jumper Ant Allergy - Australasian Society of Clinical Immunology and Allergy (ASCIA). Updated 2019. Cited December 2021
2. Bee, yellow jacket, wasp, and other Hymenoptera stings: Reaction types and acute management Theodore Freeman, MD  UpToDate, accessed 3/2021
3. AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd 2021, [Internet] Loratidine; [Modified July 2021, Cited 18 Oct 2021,] Available from: Loratadine - AMH Children's Dosing Companion (health.wa.gov.au)
4. AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd 2021, [Internet] Certirizine; [Modified July 2021, Cited 18 Oct 2021,] Available from: Cetirizine - AMH Children's Dosing Companion (health.wa.gov.au)
5. AMH Children’s Dosing Companion (2021) Australian Medicines Handbook Pty Ltd 2021, [Internet] Prednisolone/Prednisone; [Modified July 2021, Cited 18 Oct 2021,] Available from: Prednisolone/prednisone - AMH Children's Dosing Companion (health.wa.gov.au)
6. Del Pozzo-Magaña, Blanca R., and Alejandro Lazo-Langner. "Serum sickness-like reaction in children: review of the literature." Dermatology 7 (2019): 106-111
7. Fleisher, Gary R. Ludwig, Stephen. Textbook of Pediatric Emergency Medicine, 8th Edition. 2021 Wolters Kluwer Medknow Publications

 

Endorsed by:	CAHS Drug & Therapeutics Committee	Date:	Dec 2022
		Review date:	Dec 2022

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