Paeds · allergy-and-immunology
Insect-sting hypersensitivity
Also known as Hymenoptera venom allergy · Venom hypersensitivity · Bee and wasp sting allergy · Stinging-insect anaphylaxis · Venom immunotherapy indication
Fellowship topic on insect-sting (Hymenoptera venom) hypersensitivity in children: the reaction spectrum from normal local and large local reactions through cutaneous and systemic anaphylaxis; the culprits (honeybee, wasp and yellowjacket, ants including jack-jumper and fire ant); the IgE-mediated mast-cell and basophil mediator cascade; why baseline serum tryptase and clonal mast-cell disease mark out the severe reactor; the acute algorithm of early intramuscular adrenaline, positioning and fluids; the trigger-confirmation workup of venom-specific IgE, skin testing and component-resolved diagnostics; the decisive role of venom immunotherapy giving 90 to 98 per cent protection; and the discharge package of an adrenaline autoinjector, written action plan, medical identification and school education, citing the 2011 and 2023 practice parameters, the EAACI Hymenoptera venom allergy guideline, the Cochrane venom immunotherapy review, the predictors-of-severity tryptase study, and the paediatric venom allergy literature.
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Target exams
Red flags
- Stridor, drooling, tongue or throat swelling, or a sensation of throat closure after a sting — impending upper-airway obstruction; give IM adrenaline now and call for airway help
- Wheeze, marked respiratory distress, SpO2 below 92 per cent or silent chest after a sting — severe bronchospasm; magnified by asthma and a leading threat to life in venom anaphylaxis
- Hypotension, pallor, collapse or altered consciousness after a sting — distributive shock; lie the child flat, legs raised, and give IM adrenaline and IV fluid boluses
- A reaction that needed two or more adrenaline doses, or a child on a beta-blocker — refractory or protracted anaphylaxis; escalate to an adrenaline infusion and senior or PICU support
- An elevated or rising baseline serum tryptase, or known systemic mastocytosis — a severe-reactor phenotype at high risk of recurrence; refer for lifelong venom immunotherapy and KIT testing
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and Allergy: insect-sting hypersensitivity — reaction spectrum, recognition and when to refer for venom immunotherapy
- Emergency and resuscitation: intramuscular adrenaline first-line for sting anaphylaxis, weight-banded dose and repeat at five minutes
- Renewed curriculum — Allergy & immunology (LG): venom IgE pathophysiology, baseline tryptase and clonal mast-cell disease, venom immunotherapy
- Acute and critical care: refractory sting anaphylaxis, biphasic observation and the adrenaline infusion
- General Paediatrics / ED: recognise systemic reaction to a sting (including no skin signs) and give IM adrenaline without delay
- Resuscitation: ABCDE, remove the embedded sac, oxygen, IV fluid bolus, escalating to an adrenaline infusion in refractory disease
- Long Case / Structured discussion: the child who reacted badly to a bee or wasp sting — workup, venom immunotherapy decision and prevention package
- Communication station: explaining the adrenaline autoinjector, the action plan and venom immunotherapy to a family and school
- Level 2 / 3 — Allergy: stinging-insect hypersensitivity as a preventable cause of anaphylaxis; reaction grading and the referral for venom immunotherapy
- Patient safety and quality: avoidable factors — delayed adrenaline, unrecognised mastocytosis, failure to provide an action plan
- Foundation of Practice (FOP): culprits, reaction spectrum and clinical features of insect-sting hypersensitivity
- Applied Knowledge in Practice (AKP): acute algorithm, venom-specific IgE and tryptase interpretation, venom immunotherapy indications
- History-taking and management: the child stung by a bee or wasp
- Communication: teaching adrenaline autoinjector use, avoidance and the action plan to a family and school
- General Pediatrics Content Outline — insect-sting hypersensitivity: recognition and management
- Allergy & Immunology: venom IgE mechanism, large local versus systemic reactions, mastocytosis association
- Emergency Medicine: resuscitation, adrenaline dosing and the observation decision
- Patient Care: recognise and manage sting anaphylaxis with early IM adrenaline, fluids and the refractory pathway
- Systems-Based Practice: the action plan, autoinjector access, venom immunotherapy referral and school readiness
- Medical Knowledge: venom pathophysiology, reaction grading, tryptase and venom immunotherapy
- Medical Expert: insect-sting hypersensitivity diagnosis, adrenaline-first management and venom immunotherapy
- Health Advocate: equitable autoinjector access, regional insect risks and community education
- Communicator: explaining the action plan, autoinjector and venom immunotherapy to families
The same wasp, two outcomes
The large local reaction
The systemic anaphylaxis
Normal local is everyone, large local needs reassurance not adrenaline, cutaneous systemic needs referral, and anaphylaxis needs adrenaline now plus venom immunotherapy later. The two numbers the examiner wants are 90 to 98 per cent protection from venom immunotherapy and a baseline tryptase that, when high, points to clonal mast-cell disease and a severe-reactor phenotype. [1] [9]
Overview & Definition
Picture an eight-year-old playing barefoot in the garden who stands on a wasp, and within three minutes is rubbing an itchy swelling on her foot. Her mother watches and waits — most of the time, that is the whole story. Now picture the same child who, five minutes after the same sting, becomes flushed and wheezy, her lips swelling, before she goes grey and collapses in her mother's arms. The gap between those two pictures is the entire clinical problem of insect-sting hypersensitivity, and the fellowship task is to know which child is which, to treat the dangerous one immediately, and to make sure the dangerous one never has another dangerous sting. [8] [11]
Insect-sting hypersensitivity is the allergic, IgE-mediated response to the venom of stinging insects of the order Hymenoptera. The clinically important families are the bees (the honeybee Apis mellifera), the vespids (yellowjackets and wasps — Vespula and Polistes), and the ants (the jack-jumper Myrmecia in Australasia and the imported fire ant Solenopsis). Venom carries potent allergens — phospholipase, hyaluronidase, melittin, antigen 5 — and in a sensitised child these cross-link venom-specific IgE on mast cells and basophils to release the mediators of anaphylaxis. The reaction is graded by how far beyond the sting site it travels, because that grading is what predicts the next sting and what drives every management decision. [1] [3]
The clinical work splits into the two halves the examination always separates. The first is the acute event: recognise a systemic reaction, remove the embedded venom sac if a bee left one, give intramuscular adrenaline early and escalate if it does not resolve. The second is the long view: confirm which insect caused it, work out how severe the next sting might be, and — for any systemic reaction — offer venom immunotherapy, the one treatment that actually changes the natural history rather than just rescuing the next emergency. A candidate who stops at the adrenaline and forgets the immunotherapy has answered only half the question. [1] [4]
References12ShowHide
- [1]Golden DB; Moffitt J; Nicklas RA; et al Stinging insect hypersensitivity: a practice parameter update 2011. J Allergy Clin Immunol, 2011.PMID 21458655
- [2]Golden DBK; Wang J; Waserman S; et al Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol, 2024.PMID 38108678
- [3]Sturm GJ; Varga EM; Roberts G; et al EAACI guidelines on allergen immunotherapy: Hymenoptera venom allergy. Allergy, 2018.PMID 28748641
- [4]Boyle RJ; Elremeli M; Hockenhull J; et al Venom immunotherapy for preventing allergic reactions to insect stings. Cochrane Database Syst Rev, 2012.PMID 23076950
- [5]Ruëff F; Przybilla B; Biló MB; et al Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: importance of baseline serum tryptase-a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity. J Allergy Clin Immunol, 2009.PMID 19895993
- [6]Bilò MB; Tontini C; Martini M; et al Clinical aspects of hymenoptera venom allergy and venom immunotherapy. Eur Ann Allergy Clin Immunol, 2019.PMID 31594296
- [7]Vetander M; Helander D; Flodström C; et al Anaphylaxis and reactions to foods in children--a population-based case study of emergency department visits. Clin Exp Allergy, 2012.PMID 22417215
- [8]Golden DB Anaphylaxis to insect stings. Immunol Allergy Clin North Am, 2015.PMID 25841552
- [9]Bonadonna P; Scaffidi L Hymenoptera Anaphylaxis as a Clonal Mast Cell Disorder. Immunol Allergy Clin North Am, 2018.PMID 30007463
- [10]Severino M; Simioni L; Bonadonna P; et al Efficacy and safety of honeybee and wasp tyrosine-adsorbed venom immunotherapy. World Allergy Organ J, 2019.PMID 31768218
- [11]Giovannini M; Mori F; Barni S; et al Hymenoptera venom allergy in children. Ital J Pediatr, 2024.PMID 39707411
- [12]Golden DBK Update in stinging insect hypersensitivity. Allergy Asthma Proc, 2025.PMID 40958191