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Insect bites and stings - Management
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Definition
- Large local reactions present with severe pain, and oedema that extends beyond the site of the sting or bite. Most can be managed symptomatically.
- Late-onset reactions can occur (after several hours), which present as urticarial reactions or serum sickness-like reactions with urticaria, joint swelling, and arthralgia.
How do I manage large local reactions to an insect bite or sting?
- Treat pain with an oral analgesic (e.g. paracetamol or ibuprofen).
- Treat large local allergic reactions with a short course of an oral antihistamine.
- Offer a non-sedating antihistamine to control daytime symptoms.
- Consider giving an additional sedating antihistamine at night if the itch is interfering with sleep.
- Consider using a short course of an oral steroid (e.g. prednisolone for 3–5 days) if local swelling is severe.
- If the airway is affected, treat urgently as anaphylaxis — see the CKS topic on Angio-oedema and anaphylaxis for more information.
In depth
When is referral indicated?
- Admission may be required for observation when mild symptoms progress to a severe reaction (uncommon).
- The decision to admit will depend upon the type of reaction, social circumstances, and access to local medical facilities. Exercise clinical judgement in these circumstances.
- The Anaphylaxis Campaign recommends referral to an allergy clinic if there is a large local skin reaction, with redness and swelling over 10 cm in diameter. However clinicians should check the referral policy of their local allergy clinic as this may vary.
- Seek specialist advice from an allergy clinic or immunologist regarding local recommendations for interim management of anyone waiting to be seen by the allergy clinic.
What follow up is recommended?
- If a person has a local reaction to an insect bite or sting:
- Follow-up is not usually required unless symptoms are worsening.
- If the person presents with a severe local reaction, consider reviewing within 2–3 days.
- Advise urgent medical review if symptoms of systemic toxicity develop.
- Remember to consider indications for referral to an allergy clinic.
Prescriptions
Analgesia: use when required
Age from 1 month to 2 months
Paracetamol s/f susp: 30mg to 60mg up to three times a day
Paracetamol 120mg/5ml oral suspension paediatric sugar free
Take 1.25ml to 2.5ml every 8 hours when required for pain relief. Maximum of 3 doses in 24 hours.
Supply 100 ml.
Ibuprofen s/f susp: 5mg/kg three to four times a day (> 5kg)
Ibuprofen 100mg/5ml oral suspension sugar free
*WEIGHT REQUIRED* Take 5mg per kg bodyweight three to four times a day when required for relief of pain. Do not exceed the stated dose.
Supply 50 ml.
Age from 3 to 5 months
Ibuprofen s/f susp: 50mg three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take 2.5ml three times a day when required for pain relief. Do not exceed the stated dose.
Supply 50 ml.
Age from 3 to 11 months
Paracetamol s/f susp: 60mg to 120mg up to four times a day
Paracetamol 120mg/5ml oral suspension paediatric sugar free
Take 2.5ml to 5ml every 4 to 6 hours when required for pain relief. Maximum of 4 doses in 24 hours.
Supply 150 ml.
Age from 6 to 11 months
Ibuprofen s/f susp: 50mg three to four times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take 2.5ml three to four times a day when required for pain relief. Do not exceed the stated dose.
Supply 100 ml.
Age from 1 year to 3 years 11 months
Ibuprofen s/f susp: 100mg three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take one 5ml spoonful three times a day when required for pain relief. Do not exceed the stated dose.
Supply 100 ml.
Age from 1 year to 5 years 11 months
Paracetamol s/f susp: 120mg to 240mg up to four times a day
Paracetamol 120mg/5ml oral suspension paediatric sugar free
Take one to two 5ml spoonfuls every 4 to 6 hours when required for pain relief. Maximum of 4 doses in 24 hours.
Supply 300 ml.
Age from 4 years to 6 years 11 months
Ibuprofen s/f susp: 150mg three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take 7.5ml three times a day when required for pain relief. Do not exceed the stated dose.
Supply 150 ml.
Age from 6 years to 11 years 11 months
Paracetamol s/f susp: 250mg to 500mg up to four times a day
Paracetamol 250mg/5ml oral suspension sugar free
Take one to two 5ml spoonfuls every 4 to 6 hours when required for pain relief. Maximum of 4 doses in 24 hours.
Supply 300 ml.
Age from 7 years to 9 years 11 months
Ibuprofen s/f susp: 200mg up to three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take two 5ml spoonfuls three times a day when required for pain relief. Do not exceed the stated dose.
Supply 200 ml.
Age from 10 years to 11 years 11 months
Ibuprofen s/f susp: 300mg up to three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take three 5ml spoonfuls three times a day when required for pain relief. Do not exceed the stated dose.
Supply 300 ml.
Age from 12 years to 17 years 11 months
Paracetamol tablets: 500mg to 1g up to four times a day
Paracetamol 500mg tablets
Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.
Supply 50 tablets.
Ibuprofen tablets: 200mg to 400mg three to four times a day
Ibuprofen 200mg tablets
Take one or two tablets 3 to 4 times a day when required for pain relief. Do not exceed the stated dose.
Supply 56 tablets.
Age from 18 years onwards
Paracetamol tablets: 1g up to four times a day
Paracetamol 500mg tablets
Take two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.
Supply 50 tablets.
Ibuprofen tablets: 400mg three times a day
Ibuprofen 400mg tablets
Take one tablet three times a day when required for pain relief. Do not exceed the stated dose.
Supply 21 tablets.
Sedating oral antihistamines (for itch at night)
Age from 1 year to 5 years 11 months
Hydroxyzine syrup: 5 to 15 mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 2.5ml to 7.5ml at night when required for relief of itching.
Supply 100 ml.
Age from 1 year 1 month to 1 year 11 months
Chlorphenamine oral solution: 1 mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml at night when required for relief of itching.
Supply 50 ml.
Age from 2 years to 5 years 11 months
Chlorphenamine oral solution: 1-2mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml to 5ml at night when required for relief of itching.
Supply 100 ml.
Age from 6 years to 11 years 11 months
Chlorphenamine oral solution: 2-4 mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take one to two 5ml spoonfuls at night when required for relief of itching.
Supply 100 ml.
Hydroxyzine syrup: 15mg to 25mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 7.5ml to 12.5ml at night when required for relief of itching.
Supply 200 ml.
Age from 12 years onwards
Chlorphenamine tablets: 4 mg at night when required
Chlorphenamine 4mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Hydroxyzine tablets: 25mg at night when required
Hydroxyzine 25mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Non-sedating oral antihistamines
Age from 2 years to 5 years 11 months
Cetirizine s/f solution: 5mg once a day
Cetirizine 1mg/ml oral solution sugar free
Take one 5ml spoonful once a day.
Supply 100 ml.
Loratadine syrup: 5mg once a day
Loratadine 5mg/5ml oral solution
Take one 5ml spoonful once a day.
Supply 100 ml.
Age from 6 years to 11 years 11 months
Cetirizine s/f solution: 10mg once a day
Cetirizine 1mg/ml oral solution sugar free
Take two 5ml spoonfuls once a day.
Supply 100 ml.
Loratadine syrup: 10mg once a day
Loratadine 5mg/5ml oral solution
Take two 5ml spoonfuls once a day.
Supply 100 ml.
Age from 12 years onwards
Cetirizine tablets: 10mg once a day
Cetirizine 10mg tablets
Take one tablet once a day.
Supply 14 tablets.
Fexofenadine tablets: 180mg once a day
Fexofenadine 180mg tablets
Take one tablet once a day.
Supply 14 tablets.
Loratadine tablets: 10mg once a day
Loratadine 10mg tablets
Take one tablet once a day.
Supply 14 tablets.
Short course of oral prednisolone (adults)
Age from 12 years onwards
Prednisolone tablets: 40mg each morning for 3 days
Prednisolone 5mg tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
Prednisolone tablets: 50mg each morning for 3 days
Prednisolone 5mg tablets
Take ten tablets each morning (as a single dose) for 3 days.
Supply 30 tablets.
Prednisolone tablets: 40mg each morning for 5 days
Prednisolone 5mg tablets
Take eight tablets each morning (as a single dose) for 5 days.
Supply 40 tablets.
Prednisolone tablets: 50mg each morning for 5 days
Prednisolone 5mg tablets
Take ten tablets each morning (as a single dose) for 5 days.
Supply 50 tablets.
Prednisolone e/c tablets: 40mg each morning for 3 days
Prednisolone 5mg gastro-resistant tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
Prednisolone e/c tablets: 50mg each morning for 3 days
Prednisolone 5mg gastro-resistant tablets
Take ten tablets each morning (as a single dose) for 3 days.
Supply 30 tablets.
Prednisolone e/c tablets: 40mg each morning for 5 days
Prednisolone 5mg gastro-resistant tablets
Take eight tablets each morning (as a single dose) for 5 days.
Supply 40 tablets.
Prednisolone e/c tablets: 50mg each morning for 5 days
Prednisolone 5mg gastro-resistant tablets
Take ten tablets each morning (as a single dose) for 5 days.
Supply 50 tablets.
Short course of oral prednisolone (children)
Age from 1 month to 1 year 11 months
Prednisolone soluble tablets: 10mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take two tablets each morning (as a single dose) for 3 days.
Supply 6 tablets.
Age from 2 years to 5 years 11 months
Prednisolone soluble tablets: 20mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take four tablets each morning (as a single dose) for 3 days.
Supply 12 tablets.
Age from 6 years to 11 years 11 months
Prednisolone soluble tablets: 30mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take six tablets each morning (as a single dose) for 3 days.
Supply 18 tablets.
Prednisolone soluble tablets: 40mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
© NHS Institute for Innovation and Improvement