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Food-induced Anaphylaxis in Infants and Children
Abstract
Background:
Recent recommendations to introduce peanut products to infants for peanut allergy prevention requires a focused assessment of infant anaphylaxis.
Objective:
This study describes the symptomatology of food-induced anaphylaxis (FIA) in infants (<12 months) compared to older pediatric cohorts.
Methods:
Retrospective review between June 2015 and June 2017 of children presenting with FIA at a large urban children's hospital emergency department (ED).
Results:
A total of 357 cases of FIA were evaluated: 47 in infants (<12 months), 43 in toddlers (12 to 24 months), 96 in young children (2 to 6 years), and 171 in school-aged children (>6 years). Infants presented with gastrointestinal (GI) involvement more frequently than any other age group (89% vs 63% [P = .003], 60% [P <.001], and 58% [P <.001]). Additionally, infants and young children presented with skin involvement more frequently than school-aged children (94% and 91% vs 62% [P <.001]). Respiratory symptoms were more common in older cohorts (17% in infants vs 44% in young children [P <.001] and 54% in school-aged children [P <.001]). Egg and cow's milk were more common causes of FIA in infants compared to school-aged children (egg, 38% vs 1% [P <.001]; milk, 17% vs 7% [P =.03]). Only 21% of infants with FIA had eczema and 36% had a history of food allergy.
Conclusion:
Infants with FIA primarily presented with GI and skin manifestations. Egg was the most common food trigger in infants. Most infants with FIA did not have eczema or a history of food allergy.
... Several studies have reported that there are age-related differences in the clinical presentation of anaphylaxis in children. 7,13 During infancy, most common symptoms involve the skin (generalized urticaria, flushing, and angioedema), the GI system (vomiting), and the respiratory system (cough, wheezing, and stridor). Less frequently observed symptoms of infant anaphylaxis are cardiovascular symptoms (tachycardia and hypotension) and neurologic symptoms (change in behavior and irritability) (Figure 1). ...
... Comparison of manifestations of infant anaphylaxis by organ systems in reported studies.3,13,5,7,15,16,18 ...
Anaphylaxis, the most severe end of the spectrum of allergic reactions, has shown increasing incidence globally over recent years. This hypersensitivity reaction can occur at any age, including infancy. Recent data, although scarce, show that anaphylaxis is increasingly reported in infancy, with food identified as the leading cause of anaphylaxis cases in this age group. Infants constitute a unique subgroup with specific challenges regarding diagnosis of anaphylaxis due to a variety of factors, such as lack of age-specific diagnostic criteria, inability of infants to describe their symptoms, and the broad spectrum of clinical manifestations that may be mistaken as normal findings. Additionally, there are special issues in reference to the treatment of anaphylaxis during infancy, such as the limited availability of weight-appropriate epinephrine autoinjectors for infants weighing <15 kg. In this study, we review the current literature regarding specific characteristics of anaphylaxis in infants as well as unique challenges in terms of diagnosis, acute treatment, and long-term management of this medical emergency in this vulnerable age group
... Moreover, symptoms of food-induced anaphylaxis tend to be less severe in infants than in older children, usually manifesting as urticaria and vomiting, with remarkably less cardiorespiratory involvement. 8 In addition, the maximum plasma concentration of propranolol is achieved 1-2 hours after administration, and the plasma half-life is 3-6 hours. 9 Therefore, plasma levels will vary significantly over the course of the day, and may be below the threshold for having any effect on epinephrine at the time of anaphylaxis. ...
... Propranolol is also usually stopped at around one year of age due to the natural involution seen after this point, conveniently as children become more independent and inquisitive, and at higher risk of inadvertent exposure to allergens. 8 Propranolol is an exceptionally effective treatment for IH, and even more so when considering alternative treatments. Topical timolol has no effect on deep IH, and is ineffective in treating proliferative IH. ...
... Its prevalence ranges between 1%-2% (1). Egg was reported to be the most seen allergen at children with anaphylaxis under one year old and 35% of children with atopic dermatitis especially boys with severe form of eczema (2,3). ...
... In a recent study egg was found to be the most common allergen causing anaphylaxis <12 months of children (2). Nine of our patients had history of anaphylaxis and 16 had anaphylaxis during OFC. ...
... 29,32 As observed for children in general, food is also the most common trigger for anaphylaxis in infancy, with the predominance of cow milk and eggs as culprits. 12,15,20,31,[34][35][36] Among the infants in our study, food was the main suspected trigger (72.7%), but the main associated foods were milk and nuts (peanuts/chestnuts/hazelnuts), as observed by others. 33,37,38 The spectrum of food allergies varies according to geography, lifestyle, and dietary habits. ...
... This observation is in line with other studies that also reported higher presence of gastrointestinal symptoms among infants when compared to older children, especially vomiting. 34,38 However, this could be explained by foods being the most frequent trigger in this age group. ...
Objective
Assess the incidence of anaphylaxis in the emergency room (ER) of a private pediatric hospital in the city of São Paulo, Brazil, and describe associated factors.
Method
This was a cross-sectional, retrospective, and observational study based on the medical records of patients from 0 to 18 years old seen at the emergency unit during the years of 2016–2019, who had a diagnosis potentially related to anaphylaxis according to ICD-10. All medical records were individually reviewed for the presence of compatible signs and symptoms that identified “possible” cases of anaphylaxis. Cases were considered probable anaphylaxis when medical history was compatible and indicative of anaphylaxis in the opinion of at least 2 allergists.
Results
The incidence of anaphylaxis was 0.013%. Among the 56 patients identified (mean age 4.2 years), food was the most predominant suspected factor (53%), followed by unknown factors (32%), and drugs (12.5%). All patients presented with cutaneous symptoms, 74% with respiratory, and 53% with gastrointestinal. Allergic disease as a comorbidity was found in 39% of the children and 11% had a history of previous anaphylaxis. There were neither cases of syncope or shock, nor deaths. Intramuscular (IM) adrenaline was prescribed in 37.5% of cases.
Conclusions
The incidence of anaphylaxis was low when compared to the worldwide incidence. The severity of most cases was mild, cutaneous symptoms were predominant, and food was the suspected trigger most frequently associated with reactions.
... These two food allergens are involved in 55-83% of food-related reactions during infancy. [26][27][28] Although peanut is reported to be a major allergen in previous reports, anaphylaxis with tree nuts was more common in our patients. This difference is probably caused by dietary differences in our country. ...
Background:
Diagnosing anaphylaxis in children within the first 2 years of life can be difficult due to the often confusing and nonspecific signs and symptoms.
Objective:
This study focuses on the phenotype of anaphylaxis in children within the first 2 years of life and aims to increase awareness of anaphylaxis in this age group.
Methods:
The study included children between 0 and 2 years who were diagnosed as having anaphylaxis by pediatric allergists in 11 tertiary hospitals.
Results:
A total of 402 anaphylaxis episodes experienced by 360 patients (68.7% males) were included in the study. Food was the most common causative agent (n = 374, 93%), with the most common foods being cow's milk (n = 179, 44.6%). Drugs were the second most common trigger (n = 15, 3.7%). The most common clinical findings were cutaneous (95%) and respiratory (72%); nonspecific symptoms such as weakness (n = 63, 15.6%) and hoarseness (n = 14, 3.4%) were also reported. There was a biphasic course in 3 infants (0.8%). Only 3 of the 41 parents who had an adrenaline autoinjector used it during anaphylaxis.
Conclusion:
Infants experience anaphylaxis most often when they are at home with their mothers, and the most common triggers are foods, particularly cow's milk and egg. Greater awareness of anaphylaxis symptoms and autoinjector use among mothers can facilitate management.
Impact:
Infant anaphylaxis cases may present with different symptoms compared to classic presentations, potentially leading to diagnostic oversight. The study elucidates the clinical course of anaphylaxis in children under 2 years of age. It details the treatment strategies employed in managing these cases. Anaphylaxis triggers were identified over several years. Cases from 11 regions of Turkey were included, representing a population reflective of national data. The study highlights the distinctiveness of anaphylaxis cases in children within the first 2 years of life.
... However, milk proteins are among the foods that are susceptible to induce allergy. Allergic reactions to milk proteins can lead to a variety of adverse reactions including gastrogut disturbances, rhinitis, wheezing, pulmonary infiltrates, and diarrhea in infants (Golkar et al., 2019;Samady et al., 2018). The global prevalence of cow's milk protein allergy in infants less than 1 year is about 1. 8% to 7. 5%, and it is even higher in developing countries (Mousan & Kamat, 2016). ...
Milk protein sensitivity is a major challenge in infant feeding, especially for infants who cannot receive adequate breastfeeding. Hydrolyzed milk protein is a mainstream way to address this difficulty. The aim of this study was to assess the effect of differences in whey protein concentrate (WPC) source and the degree of hydrolysis on blocking allergy and to analyze the possible mechanisms by which hydrolyzed infant formula (IF) blocks allergy through colony‐metabolism–immunity response. First, we prepared six groups of goat's milk IF with unhydrolyzed, partially, and extensively hydrolyzed WPC, which come from cow's milk WPC and goat's milk WPC. Subsequently, we evaluated their effects on allergy. The results showed that the hydrolyzed IF improved the allergic characteristics of mice, including low levels of total immunoglobulin E (IgE), specific IgE, histamine, and mucosal mast cell protease‐1 (mMCP‐1). Furthermore, the hydrolyzed IF promoted the immune response of T helper 1 (Th1) and regulatory T (Treg) cells by enhancing the messenger RNA (mRNA) expression of T‐box transcription factor 21 (T‐bet) and forkhead box protein P3 (Foxp3), which in turn suppressed the T helper 2 (Th2) overexpressed immune response in allergy (GATA‐binding protein 3 (GATA‐3) and retinoic‐acid‐receptor‐related orphan receptor gamma t (RORγt) mRNA expression, as well as interleukin 4 (IL‐4) and interleukin 5 (IL‐5) levels). Hydrolyzed IF promoted an increase in beneficial gut microbe Lactobacillus and Alistipes, which in turn promoted an increase in intestinal butyrate levels. The beneficial bacteria and their metabolized butyrate may have suppressed the abundance of the allergy‐characterizing bacterium Rikenellaceae‐RC9‐gut‐group. The final result we obtained was that for both cow's milk WPC and goat's milk WPC, at similar levels of hydrolysis, they did not bring about a significant effect on allergy symptoms. The hydrolyzed IF improved the allergic characteristics of mice, the deeper the degree of hydrolysis of WPC, the more obvious the effect of reducing allergic symptoms in model mice.
... Improving the tolerability of OIT is an essential goal [66]. The most common approach is represented by the reduction of the allergenic power through thermal treatments [67]. ...
Hen’s egg allergy is one of the most common food allergies in the Western world, with an increase in recent years. It affects about 9.5% of the pediatric population, and the onset most often occurs before the first year of life. The occurrence of spontaneous oral tolerance acquisition varies among studies, but it is generally high by school age. Nowadays, allergen immunotherapy may represent the only therapeutic strategy able to modify the natural history of hen’s egg allergy. Specifically, many children with hen’s egg allergy may tolerate baked eggs. Food processing, specifically high temperatures, alters the allergenicity of hen’s egg proteins by causing conformational changes in allergen epitopes, which makes them less allergenic. This review aims to discuss the scientific evidence in the field of baked egg oral immunotherapy in hen’s egg-allergic children, with a meticulous examination of the pertinent literature surrounding the subject matter.
... Além disso, nessa faixa etária, os sintomas gastrointestinais são mais frequentes quando comparados com crianças com mais de 12 meses de idade. (89%, p = 0,006)(Samady et al., 2018). Outro estudo retrospectivo e multicêntrico de crianças coreanas com idade entre 0 e 2 anos encontrou, de forma similar, as manifestações cutâneas (98,6%) como mais comuns.Mas, em contraste com o estudo anterior descrito, essas foram seguidas por manifestações respiratórias (83,2%) e gastrointestinais (29,8%), enquanto que o acometimento do sistema cardiovascular esteve presente em apenas 7,7% dos casos (Jeon et al., 2019). ...
... In a study of 88 children with CMA who were advised to avoid certain foods, 35 (40%) experienced allergic reactions owing to food mishandling over a one-year period [4]. In addition, research on children with food-induced anaphylaxis in pediatric emergency departments has shown that older children have more severe allergic reactions compared with toddlers [5]. ...
A 12-year-old girl with severe cow's milk allergy (CMA) was able to safely consume 300 mL of unhydrolyzed cow's milk after three and a half years of oral immunotherapy (OIT) with extensively hydrolyzed milk. The treatment consisted of gradually increasing the intake of hydrolyzed and partially hydrolyzed milk and reintroducing cow's milk. Despite some allergic reactions during treatment, the patient was able to consume more than 200 ml of milk consistently for more than six months without recurrence of symptoms. This case suggests the possibility of an alternative treatment for persistent CMA: not only OIT with cow's milk alone but also a safer introduction to treatment with extensively hydrolyzed formulas.
... Ongoing patient education is essential to help navigate a FA diagnosis to reduce the risk of accidental reactions and to appropriately recognize and treat a reaction. Although FA can be diagnosed at any age [63], there is some evidence supporting that infants under age 1 year are the most likely to develop allergies, more likely to have milder symptoms such as dermatological and gastrointestinal symptoms, and less likely to have respiratory and cardiovascular symptoms than older children [64]. Parents have described feeling the most overwhelmed at the time of diagnosis for reasons that range from the volume of learning needed to manage FA to the risk of reaction and the lack of emotional support [61]. ...
Purpose of Review
IgE- and non-IgE-mediated food allergies are increasing in prevalence in children and adults worldwide. A food allergy diagnosis can be associated with a sense of overwhelm and stress and commonly has a negative impact on quality of life.
Recent Findings
While there is an increased recognition of the psychosocial effects of food allergy, the current research reflects the experience of mostly White, well-educated wealthier populations. Some studies have now explored the psychosocial impact among other populations; however, further study is needed.
Summary
It is important that physicians and allied health professionals screen for the potentially negative psychosocial effects of food allergy and provide education to promote safety and self-efficacy at each visit; however, time may be a limiting factor. Numerous validated questionnaires are now available to help assess the psychosocial impact of food allergies. Allergy-friendly foods are typically more expensive, and thus, it is imperative that physicians screen for food insecurity as well. Educational resources should be offered regarding living well with food allergies at each visit. For patients and families experiencing anxiety or food allergy burden that is difficult to manage, referral to a mental health provider should be considered. Resources regarding programs to help accessing safe foods should also be available. Further research is needed among diverse populations focusing on interventions to best support patients and families with food allergy.
... 63 Two retrospective studies from the United States demonstrated lower rates of respiratory symptoms in infants presenting with food allergy reactions compared with older children. 64,65 In addition, both observational and randomized controlled trials have demonstrated that early introduction of allergens is safe, with very low rates of anaphylaxis. 63 In the Enquiring About Tolerance (EAT) study, a randomized controlled trial of early versus standard (3 vs 6 months) ingestion of 6 common allergens among 1303 general population infants, there were no cases of anaphylaxis with either early or standard introduction of peanut. ...
Coronavirus disease 2019 (COVID-19) is a highly contagious viral disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has various effects on asthma, allergic rhinitis, atopic dermatitis and urticaria and may change the course of the disease depending on the severity of the infection and control status of the disease. Conversely these diseases may also impact the course of COVID-19. Chronic urticaria and atopic dermatitis patients may have COVID-19-induced disease exacerbations and biological treatments reduce the risk of exacerbations. Poor asthma control is linked to severe COVID-19 while allergic asthma is associated with lower risk of death and a lower rate of hospitalization due to COVID-19 compared to non-allergic asthma. The use of intranasal corticosteroids is associated with lower rates of hospitalization due to COVID-19 in allergic rhinitis patients, whereas the effect of inhaled corticosteroids is confounded by asthma severity. These observations reinforce the importance of keeping allergic diseases under control during pandemics. The use of biologicals during COVID-19 is generally regarded as safe, but more evidence is needed. The pandemic substantially changed the management of allergic disorders such as home implementation of various biologicals, allergen immunotherapy, food introduction and increased use of telemedicine and even home management of anaphylaxis to reduce emergency department burden and reduce risk of infection. Physicians need to be aware of the potential impact of COVID-19 on allergic diseases and educate their patients on the importance of continuing prescribed medications and adhering to their treatment plans to maintain optimal control of their disease.
... Samady et al.4 performed a retrospective study of 357 children with food-induced anaphylaxis who were seen at a large, urban US children's hospital emergency department. The authors noted that cardiac manifestations with hypotension were uncommon and occurred in only 2% of children <12 months old, 2% of children 12-23 months old, 1% of children 2-6 years old, and 2% of children >6 years old (trend not statistically significant) compared with other clinical manifestations across all age cohorts in the dataset. ...
... Anaphylaxis is defined by the involvement of the respiratory or cardiovascular systems as part of a multisystemic hypersensitivity reaction, with significant broncho spasm as a key characteristic (Erlewyn-Lajeunesse et al., 2010). Egg and cow's milk were the most common foods causing anaphylaxis in infants (Samady et al., 2018). ...
Abstract Food allergy is the reaction of the immune system of the body that occurs after consuming specific foods. During specific physiological ages of pregnancy, women are more prone to different allergic reactions and mostly these reactions may prolong and have long‐term effects. The hypersensitivity of different types of allergens is mainly linked with the adversity of reactions. The chances of suffering food allergies in women are greater than in men; women are usually more prone to get allergic to some foods during their specific physiological age of pregnancy. Food allergies are more common in pregnant women as every fifth pregnant woman is affected by some kind of allergy. The specific reasons and evidence of the causes of these food allergies during pregnancies have yet to be explored. A pregnant woman should take a balanced diet and avoid consuming known allergic foods to minimize the risk and complications. This review aimed to broaden the knowledge on food allergies during pregnancies, their onset in the babies, and to make it easy for pregnant women to cope with the complications caused by these food allergies. It also aimed to figure out the certain food that might be responsible for the onset of allergies in women during pregnancy and the effect of these allergies on their babies.
... May 11, 2023 T h e ne w e ngl a nd jou r na l o f m e dicine P eanut allergy affects approximately 2% of children in the United States, Canada, and other westernized countries, and the prevalence has risen rapidly over the past 20 years. [1][2][3][4] Peanut allergy is a common cause of pediatric anaphylaxis, [5][6][7][8] has substantial economic costs, 9,10 and persists into adulthood for the majority of those affected. 11,12 Peanut is a common culinary ingredient, which complicates strict avoidance; severe reactions can occur from unintended exposure to small quantities. ...
Background:
No approved treatment for peanut allergy exists for children younger than 4 years of age, and the efficacy and safety of epicutaneous immunotherapy with a peanut patch in toddlers with peanut allergy are unknown.
Methods:
We conducted this phase 3, multicenter, double-blind, randomized, placebo-controlled trial involving children 1 to 3 years of age with peanut allergy confirmed by a double-blind, placebo-controlled food challenge. Patients who had an eliciting dose (the dose necessary to elicit an allergic reaction) of 300 mg or less of peanut protein were assigned in a 2:1 ratio to receive epicutaneous immunotherapy delivered by means of a peanut patch (intervention group) or to receive placebo administered daily for 12 months. The primary end point was a treatment response as measured by the eliciting dose of peanut protein at 12 months. Safety was assessed according to the occurrence of adverse events during the use of the peanut patch or placebo.
Results:
Of the 362 patients who underwent randomization, 84.8% completed the trial. The primary efficacy end point result was observed in 67.0% of children in the intervention group as compared with 33.5% of those in the placebo group (risk difference, 33.4 percentage points; 95% confidence interval, 22.4 to 44.5; P<0.001). Adverse events that occurred during the use of the intervention or placebo, irrespective of relatedness, were observed in 100% of the patients in the intervention group and 99.2% in the placebo group. Serious adverse events occurred in 8.6% of the patients in the intervention group and 2.5% of those in the placebo group; anaphylaxis occurred in 7.8% and 3.4%, respectively. Serious treatment-related adverse events occurred in 0.4% of patients in the intervention group and none in the placebo group. Treatment-related anaphylaxis occurred in 1.6% in the intervention group and none in the placebo group.
Conclusions:
In this trial involving children 1 to 3 years of age with peanut allergy, epicutaneous immunotherapy for 12 months was superior to placebo in desensitizing children to peanuts and increasing the peanut dose that triggered allergic symptoms. (Funded by DBV Technologies; EPITOPE ClinicalTrials.gov number, NCT03211247.).
... Food allergy was the leading cause of anaphylaxis in our study group as observed in other pediatric studies [2,3,7,10,11], being CM and tree nuts as the most common elicitor. In the first two years of life, food (most commonly CM) was almost the only anaphylaxis elicitor (32 of 34 infants), except for two infants, one of the triggering factors was a drug and the other was a vaccine. ...
Background:
Childhood anaphylaxis presents with a heterogeneous clinic. Elicitors and epidemiologic factors associated with anaphylaxis differ with age, geographic location and lifestyle. This study aimed to determine the clinical features and age-specific patterns of childhood anaphylaxis in a single referral center in Turkey.
Methods:
We conducted a retrospective study of anaphylaxis in children aged between 0 and 18 years of age, attending an allergy department in a children's hospital.
Results:
A total of 95 children diagnosed with anaphylaxis were analyzed. Among all, 35.8% of the first anaphylaxis episodes occurred ininfancy and 57.9% in preschool age. Foods were the most common culprits (57.9%) and followed by drugs (15.8%). Patients with foodinduced anaphylaxis were younger in age (p < 0.001). Food-related anaphylaxis was most common with cow's milk (36.4%) and followed by tree nuts (20%). Cow's milk played a significant role as a trigger in infancy, and tree nuts as a trigger in preschoolers and school-age children. Mucocutaneous manifestations were almost universally present (94.7%), followed by respiratory compromise (56.8%), with gastrointestinal (55.8%), cardiovascular (9.5%), and neurologic (4.2%) symptoms being less common. Respiratory and cardiovascular system-related symptoms were found more frequently in school-age children (p = 0.02 and p = 0.014, respectively). The severity of anaphylaxis was higher in school-age children (p = 0.015).
Discussion:
Findings reveal that children diagnosed with anaphylaxis differ in terms of etiological and clinical findings according to age groups. This difference shows the dynamically changing clinic of anaphylaxis over time and the importance of evaluating childhood anaphylaxis according to age groups.
... Hen eggs are one of the commonest causes of food allergies in infancy and childhood among the European population [1] and, specifically, affects 0.9% of all children and 1.3% of children < 5 years old in the United States [2], having been found to be the most common food trigger of anaphylaxis in infants < 12 months of age [3]. There is currently no cure for an egg allergy, and the only way to prevent egg allergy symptoms is to avoid the consumption of eggs. ...
The heat treatment of food proteins induces structural modifications that influence their interaction with human fluids and cells. We aimed to evaluate the Caco-2 cell response induced by peptides produced after digestion of heat-treated egg white proteins. In vitro digestion of ovalbumin (OVA), ovomucoid (OM), and lysozyme (LYS), untreated or previously heated, was performed. The digestibility of proteins and the response of Caco-2 cells exposed to peptides (<10 kDa) generated during digestion were evaluated. Intact OVA and LYS persisted after the digestion of native proteins, whereas OM was completely hydrolysed. A heat treatment at 65 °C for 30 min did not alter the digestibility of OVA, whereas at 90 °C for 3 min, protein degradation was favoured. The digestibility of OM and LYS was not affected by heat treatment. Peptides derived from OVA and OM digestion induced IL-6 and IL-8 production. OVA and LYS digestion promoted the expression of Tslp, and Il6 and Il33, respectively. A heat treatment prior to OVA digestion reduced IL-6 production and Tslp expression. It was concluded that heat treatments can reduce the release of OVA-derived peptides, but not OM and LYS, with proinflammatory activity during digestion.
... Emerging real-world evidence has demonstrated that performing oral immunotherapy for food allergy early, especially during infancy and preschool age (< 6 years old), is significantly safer, more effective, and more likely to result in sustained unresponsiveness, compared to starting later in older children [13][14][15][16][17][18][19]. It is also known that infants and toddlers have fewer allergic reactions involving the respiratory, cardiovascular, and neurological systems compared to older children [20][21][22]. Evidence on the safety of using food ladders to desensitize older children and adolescents with persistent allergy to baked egg and milk is also lacking. ...
A food ladder is a form of home-based dietary advancement therapy that gradually increases exposure to an allergenic food through the gradual introduction of egg or milk containing food with increasing quantity and allergenicity from extensively heated forms, such as baked goods, to less processed products. While widely considered safe, the food ladder is not risk-free and most of the egg and milk ladder studies only included preschoolers with mild egg and milk allergies, and with no or well-controlled asthma. We propose a Food Ladder Safety Checklist to assist with patient selection using "4 A's" based on available evidence for food ladders, including Age, active or poorly controlled Asthma, history of Anaphylaxis, and Adherence.
... Also, none of the LEAP infants in the early introduction arm experienced anaphylaxis at first ingestion, and no known fatalities following early introduction occurred [3]. Even if anaphylaxis were to occur at the first ingestion, one American study from 2018 showed that only 4% of infants experiencing anaphylaxis had truly severe symptoms, which was lower than in older children, and no fatalities were reported [61]. Another recent American study of food allergy-related emergency room visits found that infants presenting with anaphylaxis tended to do so after the first known ingestion of the offending food, and that children under 2 years of age were less likely to meet anaphylaxis criteria than older children [62]. ...
Infants at high risk for developing a food allergy have either an atopic condition (such as eczema) themselves or an immediate family member with such a condition. Breastfeeding should be promoted and supported regardless of issues pertaining to food allergy prevention, but for infants whose mothers cannot or choose not to breastfeed, using a specific formula (i.e., hydrolyzed formula) is not recommended to prevent food allergies. When cow's milk protein formula has been introduced in an infant's diet, make sure that regular ingestion (as little as 10 mL daily) is maintained to prevent loss of tolerance. For high-risk infants, there is compelling evidence that introducing allergenic foods early-at around 6 months, but not before 4 months of age-can prevent common food allergies, and allergies to peanut and egg in particular. Once an allergenic food has been introduced, regular ingestion (e.g., a few times a week) is important to maintain tolerance. Common allergenic foods can be introduced without pausing for days between new foods, and the risk for a severe reaction at first exposure in infancy is extremely low. Pre-emptive in-office screening before introducing allergenic foods is not recommended. No recommendations can be made at this time about the role of maternal dietary modification during pregnancy or lactation, or about supplementing with vitamin D, omega 3, or pre- or probiotics as means to prevent food allergy.
... No reports on anaphylactic reactions resulting from the exposure to hydrolysed formulae have been described in several surveys analysing the causes for anaphylactic reactions and in particular those due to food (De Silva et al., 2008;Worm et al., 2014;Samady et al., 2018). The total number of subjects included in the three surveys was more than 1,400. ...
Abstract The food enzyme trypsin (EC 3.4.21.4) is extracted from porcine pancreas by Ningbo Linzyme Biosciences Co., Ltd. It is intended to be used for the hydrolysis of whey proteins for use in infant formulae and follow‐on formulae. Based on maximum use levels and the maximum permitted protein content in infant formula, dietary exposure to the food enzyme–total organic solids (TOS) was estimated to be 16.8 mg TOS/kg body weight (bw) per day for infants. In the toxicological evaluation, clinical studies with pancreatic enzymes were considered. Hypersensitivity to the pharmaceuticals was identified as the major side effect. However, allergic reactions to porcine pancreatic enzymes in hydrolysed foods have not been reported. The Panel considered that a risk of allergic sensitisation to this food enzyme after consumption of products prepared by hydrolysis of milk proteins could not be excluded in infants, but it considered the likelihood to be low. Based on the origin of the food enzyme from an edible tissue of pigs, the data provided by the applicant, the information from the evaluation of clinical studies based on pancreatic enzymes and the estimated dietary exposure, the Panel concluded that the trypsin from porcine pancreas does not give rise to safety concerns under the intended conditions of use.
... Furthermore, this may be due to the vaginal colonization with uropathogens or entry of colonizing uropathogens into the bladder via urethra (5,16). This is well-evidenced that many drugs, as well as foods like milk, egg nuts, and seafood, can trigger anaphylactic reactions in children (17,18). Concurrent to this, we also observed an allergy to fish and milk in our study. ...
Complications of urinary tract infections (UTIs) like kidney failure and septicaemia develop once infections spread from the upper urinary tract to other parts of the body by haematogenous dissemination and they pose great health and economic burden to the countries. This retrospective study was conducted among 132 patients with bacterial UTIs in the inpatient department of tertiary care hospital in Abha, Saudi Arabia. During the study period, Escherichia coli ( E. coli ) and Klebsiella pneumonia ( K. pneumonia ) along with other 15 different bacteria were isolated. A significant difference ( P < 0.05) was observed between the male and female children population in different age groups. We observed fever (84.09%) as a major symptom ( P < 0.05), and seizure (9%) was reported as a major concomitant condition among UTI cases. Around 31.82% of E. coli was found to be the most common uropathogens in pediatric cases followed by 25% in K. pneumoniae . E. coli was observed to be more susceptible (92.86%) to amikacin, ceftriaxone, levofloxacin, ertapenem, gentamycin, meropenem, piperacillin-tazobactam, tigecycline, and ceftazidime. However, meropenem, tigecycline, and amikacin were observed to be effective in 100% of cases of K. pneumoniae . Meanwhile, cephalosporins were the most commonly prescribed drug category among different classes of drugs. Almost 99% of pediatric cases, based on their age, were admitted to the ward, and drugs were administered intravenously. We concluded that microbiology laboratory evidence on the causative organisms and choice of treatment together allows tailoring appropriate treatment regimens in conjunction with clinical experiences.
... We found that 1.4% of infants had cardiovascular involvement, which was similar to the frequency of 2% for cardiovascular involvement in a cohort of 47 infants aged ＜1 year with anaphylaxis. 36 However, the rate was much lower than those reported in other studies. For example, the rate was 8% in another cohort of 363 children aged 0-2 years who were diagnosed with anaphylaxis. ...
Background:
Little is known about anaphylaxis in Chinese children. This study aimed to determine the age-specific patterns of anaphylaxis in Chinese children.
Methods:
We conducted a retrospective study of anaphylaxis cases attending an allergy department in a tertiary children's hospital.
Results:
A total of 279 anaphylactic reactions in 177 patients were analyzed. Overall, 57.6% (102/177) of first anaphylaxis events occurred in infants (0-2 ys). Foods were the most common culprits (88.5%), followed by food + exercise/exercise (4.7%), and drugs (4.3%). The main food allergens were cow's milk (32.9%), egg (21.4%), and wheat (20.7%) in infants, compared with fruits/vegetables at 35.9% in preschool-age children (3-6 ys) and 31.6% in school-age children (7-12 ys). The most commonly implicated drug triggers were vaccines (n = 5, comprising DTaP n = 2, group A + C meningococcal polysaccharide vaccine n = 1, Sabin vaccine n = 1, and not specified n = 1). Among the 5 vaccine-induced anaphylaxis patients, 4 had severe cow's milk allergy. The clinical manifestations were mainly mucocutaneous (86.0%), followed by respiratory (68.8%), gastrointestinal (23.7%), neurological (10.4%), and cardiovascular (0.7%). Compared with patients of other ages, infants had higher rates of hives (0-2ys 77.4%, 3-6ys 50%,7-12ys 57.9%, 13-17ys 38.9%, p = 0.016) and vomiting (0-2ys 20.7%, 3-6ys 1.6%,7-12ys 8.8%, p < 0.001), while wheezing was more frequent in school-age children (0-2ys 21.4%, 3-6ys 25%, 7-12ys 38.6%, 13-17ys 5.6%, p = 0.017) and abdominal pain was more common in adolescents (0-2ys 2.1%,3-6ys 15.6%, 7-12ys 14.0%, 13-17ys 72.3%, p < 0.001). Regarding treatment, 9.3% of anaphylaxis events and 24.1% of life-threatening reactions were treated with epinephrine.
Conclusions:
We observed age-related clinical patterns of anaphylaxis in this study, with hives and vomiting most commonly reported in infants and cardiovascular symptoms rarely reported in children. Wheat was the third most culprit food allergen after egg and milk in infancy. Education regarding more aggressive use of epinephrine in the emergency setting is clearly needed. Recognition of age-related symptoms in anaphylaxis can aid physicians in prompt diagnosis and acute management.
Food allergies pose significant challenges including the risk for severe allergic reactions. This review article highlights the advantages and disadvantages of the historic standard management approach—avoidance and carrying epinephrine in case of accidental ingestion—and argues, based on accumulating evidence, that oral immunotherapy (OIT) should play a key role in preschool food allergy management. Firstly, our review will highlight pitfalls with the ‘wait‐and‐see’ approach to natural resolution of food allergies, with recent data pointing to lower resolution than previously thought. For those who do not outgrow their allergies, waiting until school age to offer OIT means missing the window of opportunity where OIT is safest, and prolongs unnecessary dietary restrictions. For those who do outgrow their allergies, research indicates they may not reintroduce the food due to fear and aversion and can become re‐sensitised, putting them at risk of severe reactions. Secondly, the risks associated with allergen avoidance are higher than previously believed. Allergen avoidance is imperfect and carries an increased risk of severe reactions when compared with the risk of severe reactions while on OIT, particularly in preschoolers. Although an allergic reaction can be stressful, it is preferable to have this occur during OIT where caregivers are vigilant following a scheduled dose, rather than having this occur at a potentially unexpected time following an accidental exposure. Lastly, there is a growing body of evidence supporting favourable safety and effectiveness of OIT in preschoolers, and preliminary data suggesting higher likelihood of remission in infants. OIT has the potential to significantly improve quality of life, and future research is needed to answer this important question in preschoolers. In summary, while ongoing research will further clarify cost‐effectiveness, long‐term adherence and psychosocial impacts of OIT, this review suggests that OIT should play a key role in preschool food allergy management.
Purpose of review
To share important highlights on the management of anaphylaxis from the latest 2023 practice parameter.
Recent findings
The 2023 Allergy Immunology Joint Task Force on Practice Parameters (JTFPP) anaphylaxis practice parameter provides updated anaphylaxis guidance. Criteria for the diagnosis of anaphylaxis are reviewed. The parameter highlights that while anaphylaxis is not more severe in younger children, age-specific symptoms can vary. Activation of emergency medical services may not be required in patients who experience prompt resolution of symptoms following epinephrine use and caregivers are comfortable with observation. For children weighing <15 kg, the anaphylaxis parameter suggests the clinician may prescribe either the 0.1 mg or the 0.15 mg epinephrine autoinjector, with the 0.3 mg autoinjector prescribed for those weighing 25 kg or greater. In patients with heart disease, discontinuing or changing beta blockers and/or angiotensin converting enzyme inhibitors may pose a larger risk for worsened cardiovascular disease compared with risk for severe anaphylaxis with medication continuation. Furthermore, in patients with a history of perioperative anaphylaxis, shared decision-making based on diagnostic testing and clinical history is recommended prior to repeat anesthesia use. Beyond the recent parameter update, novel contemporary therapies can decrease risk of community anaphylaxis.
Summary
The 2023 JTFPP Anaphylaxis Guidelines offer up-to-date guidance for the diagnosis and management of anaphylaxis in infants, children, and adults.
Background and objectives:
The 2017 Prevention of Peanut Allergy Guidelines recommend incorporating peanut protein into infants' diets to prevent peanut allergy. The goal of this study was to explore US caregivers' awareness, beliefs, practices, and outcomes around peanut introduction.
Methods:
A parent-report survey was administered between January and February 2021 to a population-based sample of 3062 US parents/caregivers of a child between age 7 months and 3.5 years. The survey evaluated awareness, beliefs, feeding practices, primary care provider (PCP) interactions, and food reactions.
Results:
Overall, 13.3% of parents/caregivers reported Prevention of Peanut Allergy Guidelines awareness. Caregivers who reported being white, 30 to 44 years of age, educated, high income, or cared for a child with food allergy or eczema were more likely to be guideline-aware (P < .001). Among US parents/caregivers, 47.7% believed that feeding peanuts early prevented peanut allergy; 17.2% first offered peanut-containing foods before age 7 months and 41.8% did so between ages 7 and 12 months. Peanut introduction occurred earlier among guideline-aware parents/caregivers: 31% offered it before 7 months (P < .001). Overall, 57.8% of parents/caregivers reported discussing peanut introduction with their PCP. PCP counseling was the most common facilitator for peanut introduction before 7 months (odds ratio 16.26 [9.49-27.85]), whereas fear of reactions was the most common reason for delaying peanut introduction beyond 7 months (32.5%). Actual reactions during peanut introduction were reported by 1.4%.
Conclusions:
Early peanut feeding practices are gaining traction among US parents/caregivers; however, disparities exist. Future efforts to increase guideline adherence need to address disparities, provide support for medical providers, and educate about the true incidence of reactions.
Knowledge gaps in the diagnosis and treatment of anaphylaxis impede the clinician's ability to effectively manage patients with anaphylaxis. This review will emphasize the lack of a global consensus on defining and determining the severity of anaphylaxis; the need for validating biomarkers used for diagnosing anaphylaxis; and data collection deficiencies. Perioperative anaphylaxis has a wide differential diagnosis, often requires treatment beyond epinephrine, and poses a challenge for the clinician in identifying the responsible trigger(s), and in preventing future reactions. Consensus-derived definitions and determination of risk factors for biphasic, refractory, and persistent anaphylaxis are needed, recognizing that these often impact the emergency department observation time following recovery from initial anaphylaxis. Knowledge gaps exist in the use of epinephrine, including route of administration, dosage, needle length, and ideal timing for administration. Consensus is needed on when and how many epinephrine auto-injectors to prescribe and how to prevent patient underuse and accidental injury. The role of antihistamines and corticosteroids in the prevention and treatment of anaphylaxis requires consensus and additional research. A consensus-derived algorithm for management of idiopathic anaphylaxis is needed. The role of beta blockers and angiotensin-converting enzyme inhibitors in the incidence, severity, and treatment of anaphylaxis remain unanswered. Rapid recognition and treatment of anaphylaxis in the community needs improvement. The article will conclude with exploring the recommended components of both a patient-specific and generic anaphylaxis emergency plan, including when to activate emergency medical services, all of which are paramount to improving patient outcomes.
Recent research has shown that feeding allergenic foods in infancy has a greater inhibitory effect on the development of food allergies (FA) than eliminating the allergenic foods in infancy. In future, FA research is expected to shift toward prevention rather than treatment. However, dietary guidance for infants at high risk of FA must be conducted in a safety manner, and methodologies for such strategies must be established as early as possible. We conducted a multicenter randomized trial in infants with atopic dermatitis to compare the subsequent development of FA to mixed powder (MP) consisting of a mixture of dried egg white, powdered milk, wheat, soy, peanuts, buckwheat and gut flora preparations, versus placebo. The results showed that the MP group had significantly fewer FA episodes than the placebo group. Adverse reactions experienced were minor, such as facial redness after administration, but none were serious. Treating eczema from infancy and carefully early feeding of allergenic foods may prevent many FA.
Objective: We quantified the anxiety among mothers about food allergies with baby food and investigated the factors that enhanced the anxiety.
Methods: During a 2-month period from March to April 2020, mothers of infants seen for late-term infant health examinations at pediatric outpatient facilities were asked if they had experienced food allergy with baby food and were surveyed about this anxiety using a Likert scale. In addition, the anxiety about food allergy was compared to the anxiety about aspiration and food poisoning.
Results: A total of 533 questionnaires were collected from 36 institutions. Among the respondents, 16.4% had experienced food allergy symptoms. Most of the food allergy symptoms were mild, but even mild symptoms, such as partial urticaria, were significantly high on the anxiety scale and led to food avoidance (P < 0.01). The anxiety scale was highest for aspiration, followed by food poisoning, and lowest for food allergy.
Conclusion: Although most mothers' anxiety about food allergy was not high, the experience of even mild food allergy symptoms led to increased anxiety about weaning and food avoidance.
Food allergy can manifest in various ways through multiple organ systems, including the respiratory tract. Clinically, the presentation of food allergy-induced respiratory symptoms may vary with respect to upper versus lower airway involvement, age of the patient, mechanism of action, route of exposure, and underlying comorbidities, such as asthma. Most importantly, food allergy-induced respiratory reactions often occur as part of systemic reactions and can serve as an important indicator of severe anaphylaxis.
Anaphylaxis is an extremely dangerous systemic hypersensitivity reaction that develops rapidly and can be fatal. Infants make up the most difficult group of patients with anaphylaxis, given the first episode of reaction occurring at an early age, there are age-related difficulties in interpreting complaints, unpredictability of clinical symptoms, prolonged process of diagnosis, and prescribing the appropriate treatment. These factors determine the risk of fatal outcomes, even in case of nearly healthy infants. For this group of patients, such problems as lack of available diagnostic tests, limited standard doses of epinephrine autoinjectors, the absence of predic-tors of occurrence, and severity of systemic allergic reactions are still relevant. This chapter presents the available information on the prevalence of anaphylaxis, the most common triggers, diagnosis, clinical symptoms, severity, and treatment in infants.
To date, there is no consistent evidence for any specific modification of maternal diet during pregnancy or lactation and the prevention of allergic disease. It remains unclear whether vitamin D supplementation, polyunsaturated fatty acid ingestion, pre- and probiotic supplementation, nor diversity of maternal diet influences childhood allergy development. It is unclear whether breastfeeding influences allergy development, with the exception of early childhood wheeze. Hydrolyzed formulas in general are not recommended as a means of allergy prevention in mothers who cannot or choose not to breastfeed. The role of infant vitamin D supplementation, polyunsaturated fatty acid ingestion, and pre- and probiotic supplementation remains unclear. There is level one evidence that early ingestion of egg and peanut has a role in the prevention of food allergy. Observational data do support a benefit to infant dietary diversity in allergic disease prevention, in particular for food allergy, and no harm to this approach has been seen.
Recent guideline recommendations have shifted from recommending prolonged avoidance of allergenic foods in the first three years of life to a primary prevention approach involving the deliberate early introduction to infants at risk of developing food allergy. Despite this, some infants, especially those with severe eczema who are at highest risk for developing peanut allergy, fail to receive the preventative benefits of early peanut introduction due to hesitancy and other factors. Difficulty adhering to regular ingestion following introduction further reduces the effectiveness of primary prevention. As emerging real-world evidence has demonstrated that performing peanut oral immunotherapy (OIT) among infants is effective and safe, peanut OIT could be a treatment option for infants with peanut allergy. This review discusses the benefits, risks, and barriers to offering peanut OIT to infants who fail primary prevention strategies. We propose the novel concept that infants with peanut allergy be offered peanut OIT as soon as possible after failed peanut introduction through a shared decision-making process with the family, where there is a preference for active management rather than avoidance.
Résumé
L'anaphylaxie est de plus en plus fréquente au cours des 20 dernières années, notamment chez le jeune enfant et pour les causes alimentaires. Les décès par anaphylaxie chez l'enfant sont rares. Les aliments (arachide, laits de mammifères et fruits à coque principalement) sont la première cause d'anaphylaxie de l'enfant, avant les médicaments et les hyménoptères. Chez le nourrisson, la reconnaissance de l'anaphylaxie est souvent difficile et le clinicien doit être attentif à des signes non spécifiques souvent au premier plan (irritabilité, pleurs ou voix rauque.).
Il existe des profils d'enfants à risque d'anaphylaxies graves ou récurrentes : antécédent d'anaphylaxie, antécédents d'asthme et/ou maladies atopiques, allergie à certains aliments à haut risque (arachide, laits, fruits à coque, soja.), polyallergie alimentaire, adolescence, troubles du comportement et conduites à risque.
En France, les indications pour la prescription des trousses d'urgence avec auto-injecteur d'adrénaline et les critères de mise en place des projets d'accueil individualisé pour allergie sont désormais consensuels. La circulaire actualisant le projet d'accueil individualisé (PAI-RS du 14 avril 2021) permet d'uniformiser la prise en charge et de proposer des documents uniques sur le plan national. Depuis 2019, les établissements scolaires du second degré doivent être équipés en auto-injecteurs d'adrénaline, et des actions de formation sur le thème des allergies alimentaires et de l'anaphylaxie doivent être proposées.
Anaphylaxis is a systemic allergic reaction that can be caused by food, drugs, insect bites, or unknown triggers in infants and toddlers. Anaphylaxis rates are increasing. Infants and toddlers may have increased exposure to known and unknown allergens, decreased ability to describe their symptoms, and an expanded differential diagnosis for consideration on presentation. The most common symptoms in these age groups are cutaneous and gastrointestinal. Age-specific language may be helpful for caregivers to identify and describe the symptoms of anaphylaxis in infants and toddlers. Long-term management of anaphylaxis includes allergy evaluation to guide avoidance and assess prognosis and education on allergic reaction management; this incorporates the prescription of epinephrine autoinjector and provision of an allergy emergency plan.
Anaphylaxis-related emergency department (ED) visits and hospitalizations are increasing. Triggers for anaphylaxis include food, medications, and stinging insects. Idiopathic anaphylaxis accounts for 30% to 60% of cases of anaphylaxis in adults and up to 10% of cases in children with novel allergens such as galactose-α-1,3 galactose reclassifying these cases. Recent practice guidelines have recommended against the routine use of systemic corticosteroids and antihistamines for the prevention of biphasic reactions and recommend an extended observation, up to 6 hours, for those with risk factors for biphasic anaphylaxis and those with lack of access to epinephrine and to emergency medical services.
Food allergy is increasing in prevalence worldwide. This review summarizes progress made studying relationships between food allergy and quality of life (QOL), with an emphasis on recent work in the field. Early work examining QOL among food allergy patients established that stress and anxiety associated with continuous allergen avoidance and the looming threat of anaphylaxis were associated with significantly impaired food allergy quality of life (FAQOL) for children with food allergy and their caregivers. Recent clinical studies suggest that undergoing oral food challenge to confirm food allergy and oral immunotherapy to treat food allergy may each improve FAQOL among both patients and their caregivers. Other intervention modalities, such as nurse-facilitated counseling and educational workshops, also hold promise, but additional work is needed. Future work must strive to recruit more representative, population-based samples, including adult patients, in order to improve the generalizability and clinical relevance of findings.
Pediatric food allergy is a growing health problem in the United States that has been found to adversely impact the quality of life of both affected children and their caregivers. This article provides a review of how food allergy affects the quality of life of patients and their families within the domains of school, social activities, relationships, and daily life. Efforts to improve food allergy-related quality of life among caregivers are also discussed.
ICON: Anaphylaxis provides a unique perspective on the principal evidence-based anaphylaxis guidelines developed and published independently from 2010 through 2014 by four allergy/immunology organizations. These guidelines concur with regard to the clinical features that indicate a likely diagnosis of anaphylaxis -- a life-threatening generalized or systemic allergic or hypersensitivity reaction.
They also concur about prompt initial treatment with intramuscular injection of epinephrine (adrenaline) in the mid-outer thigh, positioning the patient supine (semi-reclining if dyspneic or vomiting), calling for help, and when indicated, providing supplemental oxygen, intravenous fluid resuscitation and cardiopulmonary resuscitation, along with concomitant monitoring of vital signs and oxygenation. Additionally, they concur that H1-antihistamines, H2-antihistamines, and glucocorticoids are not initial medications of choice.
For self-management of patients at risk of anaphylaxis in community settings, they recommend carrying epinephrine auto-injectors and personalized emergency action plans, as well as follow-up with a physician (ideally an allergy/immunology specialist) to help prevent anaphylaxis recurrences.
ICON: Anaphylaxis describes unmet needs in anaphylaxis, noting that although epinephrine in 1 mg/mL ampules is available worldwide, other essentials, including supplemental oxygen, intravenous fluid resuscitation, and epinephrine auto-injectors are not universally available.
ICON: Anaphylaxis proposes a comprehensive international research agenda that calls for additional prospective studies of anaphylaxis epidemiology, patient risk factors and co-factors, triggers, clinical criteria for diagnosis, randomized controlled trials of therapeutic interventions, and measures to prevent anaphylaxis recurrences. It also calls for facilitation of global collaborations in anaphylaxis research.
In addition to confirming the alignment of major anaphylaxis guidelines, ICON: Anaphylaxis adds value by including summary tables and citing 130 key references. It is published as an information resource about anaphylaxis for worldwide use by healthcare professionals, academics, policy-makers, patients, caregivers, and the public.
Although there has been increasing data on pediatric anaphylaxis, information about anaphylaxis in the 1st year of life is scarce. This study provides detailed information on clinical signs and symptoms of anaphylaxis in the 1st year of life. A retrospective review was performed of our pediatric allergy database between 2007 and 2011. Children who met the diagnostic criteria of anaphylaxis were included. They were categorized as "infant" if they were ≤12 months of age at the time of anaphylactic reaction and "children" if >12 months. There were 104 patients (60 male and 44 female subjects) who met the diagnosis criteria of anaphylaxis. From the 104 cases of anaphylaxis, 23 (22.1%) were infants. Boys (p = 0.043), atopic eczema (p = 0.049), and history of food allergy (p < 0.001) were significantly higher in infants than in children with anaphylaxis. Severe anaphylaxis was less frequent in infants than in children (p = 0.04). There was no significant difference between infants and children considering cutaneous and respiratory symptoms (p > 0.05 for both) but persistent vomiting was (p = 0.023). Irritability, persistent crying, and somnolence are the signs which are difficult to interpret in infants with anaphylaxis. Within these signs, irritability, persistent crying, and somnolence were present in 69.6, 43.5, and 26.1% of infants, respectively. Blood pressure was measured in 5 infants (21.7%) compared with 44 children (54.3%; p = 0.005). Four children (4.9%) required more than one epinephrine treatment, but no infant did. Median observation periods were 4 hours in both groups (p = 0.087) and no biphasic reactions occurred in either. Food (p < 0.001) was significantly more and drugs (p = 0.015) were a less frequent cause of anaphylaxis in infants than in children. Anaphylaxis in infants is not rare but many signs of anaphylaxis are overlooked and still undertreated.
To determine the most frequent food allergens causing immediate hypersensitivity reactions in Swiss children of different age groups and to investigate the clinical manifestation of IgE-mediated food allergies in young patients.
The study was a prospective analysis of children referred for assessment of immediate type I food hypersensitivity reactions. The diagnostic strategy included a careful history, skin prick tests with commercial extracts and native foods, in vitro determination of specific IgE to food proteins and food challenges when appropriate. A total of 278 food allergies were identified in 151 children with a median age of 1.9 years at diagnosis.
Overall, the most frequent food allergens were hen's egg (23.7%), cow's milk (20.1%), peanut (14.0%), hazelnut (10.4%), wheat (6.1%), fish (4.3%), kiwi and soy (2.2% each). In infancy, cow's milk, hen's egg and wheat were the most common allergens. In the second and third year of life however, the top three food allergens were hen's egg, cow's milk and peanut, whereas above the age of 3 years, peanut was number one, followed by hen's egg and fish. Overall, urticaria (59.0%) and angioedema (30.2%) were the most frequent clinical manifestations. Gastrointestinal symptoms were found in 25.9% and respiratory involvement in 25.2%. There were 13 cases (4.7%) of anaphylaxis to peanut, fish, cow's milk, hen's egg, wheat and shrimps.
A total of eight allergens account for 83% of IgE-mediated food allergies in Swiss infants and children, with differences in the distribution and order of the most frequently involved food allergens between paediatric age groups.
Background:
Food allergy is an important public health problem because it affects children and adults, can be severe and even life-threatening, and may be increasing in prevalence. Beginning in 2008, the National Institute of Allergy and Infectious Diseases, working with other organizations and advocacy groups, led the development of the first clinical guidelines for the diagnosis and management of food allergy. A recent landmark clinical trial and other emerging data suggest that peanut allergy can be prevented through introduction of peanut-containing foods beginning in infancy.
Objectives:
Prompted by these findings, along with 25 professional organizations, federal agencies, and patient advocacy groups, the National Institute of Allergy and Infectious Diseases facilitated development of addendum guidelines to specifically address the prevention of peanut allergy.
Results:
The addendum provides three separate guidelines for infants at various risk levels for the development of peanut allergy and is intended for use by a wide variety of health care providers. Topics addressed include the definition of risk categories, appropriate use of testing (specific IgE measurement, skin prick tests, and oral food challenges), and the timing and approaches for introduction of peanut-containing foods in the health care provider's office or at home. The addendum guidelines provide the background, rationale, and strength of evidence for each recommendation.
Conclusions:
Guidelines have been developed for early introduction of peanut-containing foods into the diets of infants at various risk levels for peanut allergy.
Background:
A recent randomized trial (the Learning Early About Peanut Allergy [LEAP] study) provided evidence that earlier dietary peanut introduction reduces peanut allergy prevalence in high-risk infants. However, questions remain as to how to identify and target the "at-risk" population to facilitate timely introduction of peanut.
Objective:
We sought to use population-based infant peanut allergy data to understand feasibility and implications of implementing the LEAP trial intervention.
Methods:
Using the HealthNuts study cohort (n = 5276) of 1-year-old infants, we explored the impact of using various criteria to identify infants at high risk of developing peanut allergy, and the implications of skin prick test (SPT) screening before peanut introduction.
Results:
Screening all infants with early onset eczema and/or egg allergy could require testing 16% of the population and would still miss 23% of peanut allergy cases; 29% of screened infants would require clinical follow-up because of being SPT-positive. Around 11% of high-risk infants were excluded from the LEAP study because of an SPT wheal size of more than 4 mm to peanut at baseline; data from the HealthNuts study suggest that 80% of these would be peanut allergic on food challenge. There were no life-threatening events among either low- or high-risk infants whose parents chose to introduce peanut at home in the first year of life, or in 150 peanut-allergic infants during hospital-based challenges.
Conclusions:
Based on this large epidemiological study, a population program aiming to identify and screen all infants at risk of peanut allergy would pose major cost and logistic challenges that need to be carefully considered. Further research might be required to provide data for low-risk infants.
Objectives:
Among patients with food-related anaphylaxis, to describe trends in emergency and hospital care and determine the revisit rate.
Methods:
This retrospective cohort study included children 6 months to 18 years of age with food-related anaphylaxis from 37 children's hospitals between 2007 and 2012. Summary statistics and trends for patient characteristics were evaluated. Multivariable regression was used to identify predictors for hospital admission. Revisit rates to either the emergency department (ED) and/or inpatient unit were calculated.
Results:
7303 patients were evaluated in the ED; 3652 (50%) were admitted to the hospital. Hospital admission rates varied widely (range, 20%-98%). Food-related anaphylaxis increased from 41 per 100 000 ED visits to 72 per 100 000 while hospital admission rates did not change. Males (odds ratio [OR], 1.2 [95% confidence interval (CI), 1.0-1.4]), patients <1 year old (OR, 1.8 [95% CI, 1.3-2.5]), those with anaphylaxis to either peanut (OR, 1.2 [95% CI, 1.0-1.5]) or tree nut (OR, 1.7 [95% CI, 1.3-2.1]), and patients with asthma (OR, 7.4 [95% CI, 5.8-9.3]) or a chronic complex condition (OR, 5.2 [95% CI, 3.0-9.0]) were more likely to be admitted to the hospital. The 3-day revisit rate was 3% for patients discharged from the ED and 0.6% for those admitted on the index visit.
Conclusions:
The incidence of food-related anaphylaxis in pediatric EDs is increasing, but rates of hospital admission are stable. Hospital admission is common but widely variable. Further research is needed to identify optimal management practices for this potentially life-threatening problem.
Rates of food-induced anaphylaxis among children remain uncertain. In addition, little is known about the demographics of children who have experienced food-induced anaphylaxis resulting in emergency department (ED) visits and/or subsequent hospitalizations.
To evaluate trends in ED visits and hospital admissions due to food-induced anaphylaxis among Illinois children and to identify socioeconomic variation in trend distribution.
Illinois hospital discharge data compiled by the Illinois Hospital Association were used to identify ED visits or hospitalizations for food-induced anaphylaxis in Illinois hospitals from 2008-2012. Data for children aged 0 to 19 years who were Illinois residents and received a diagnosis of food-induced anaphylaxis based on International Classification of Diseases, Ninth Revision, Clinical Modification codes (995.60 through 995.69) were included for analysis.
There was a significant increase in the rate of ED visits and hospital admissions due to food-induced anaphylaxis among children in Illinois during the 5-year period, with an annual percent increase of 29.1% from 6.3 ED visits and hospital admissions per 100,000 children in 2008 to 17.2 in 2012 (P < .001). Increases in visit frequency were observed for all study variables, including age, sex, race/ethnicity, insurance type, metropolitan status, hospital type, and allergenic food. Visits were most frequent each year for Asian children and children with private insurance. However, the annual percent increase in visits was most pronounced among Hispanic children (44.3%, P < .001) and children with public insurance (30.2%, P < .001).
ED visits and hospital admissions for food-induced anaphylaxis have increased during a 5-year period among children in Illinois, regardless of race/ethnicity and socioeconomic status.
Copyright © 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
Background:
The prevalence of peanut allergy among children in Western countries has doubled in the past 10 years, and peanut allergy is becoming apparent in Africa and Asia. We evaluated strategies of peanut consumption and avoidance to determine which strategy is most effective in preventing the development of peanut allergy in infants at high risk for the allergy.
Methods:
We randomly assigned 640 infants with severe eczema, egg allergy, or both to consume or avoid peanuts until 60 months of age. Participants, who were at least 4 months but younger than 11 months of age at randomization, were assigned to separate study cohorts on the basis of preexisting sensitivity to peanut extract, which was determined with the use of a skin-prick test--one consisting of participants with no measurable wheal after testing and the other consisting of those with a wheal measuring 1 to 4 mm in diameter. The primary outcome, which was assessed independently in each cohort, was the proportion of participants with peanut allergy at 60 months of age.
Results:
Among the 530 infants in the intention-to-treat population who initially had negative results on the skin-prick test, the prevalence of peanut allergy at 60 months of age was 13.7% in the avoidance group and 1.9% in the consumption group (P<0.001). Among the 98 participants in the intention-to-treat population who initially had positive test results, the prevalence of peanut allergy was 35.3% in the avoidance group and 10.6% in the consumption group (P=0.004). There was no significant between-group difference in the incidence of serious adverse events. Increases in levels of peanut-specific IgG4 antibody occurred predominantly in the consumption group; a greater percentage of participants in the avoidance group had elevated titers of peanut-specific IgE antibody. A larger wheal on the skin-prick test and a lower ratio of peanut-specific IgG4:IgE were associated with peanut allergy.
Conclusions:
The early introduction of peanuts significantly decreased the frequency of the development of peanut allergy among children at high risk for this allergy and modulated immune responses to peanuts. (Funded by the National Institute of Allergy and Infectious Diseases and others; ClinicalTrials.gov number, NCT00329784.).
Although peanut allergy is among the most common food allergies, no study has comprehensively described the epidemiology of the condition among the general pediatric population. Our objective was to better characterize peanut allergy prevalence, diagnosis trends, and reaction history
among affected children identified from a representative sample of United States households with children. A randomized, cross sectional survey was administered to parents from June 2009 to February 2010. Data from 38,480 parents were collected and analyzed in regard to demographics, allergic
symptoms associated with food ingestion, and methods of food allergy diagnosis. Adjusted models were estimated to examine association of these characteristics with odds of peanut allergy. Of the 3218 children identified with food allergy, 754 (24.8%) were reported to have a peanut allergy.
Peanut allergy was reported most often among 6- to 10-year-old children (25.5%), white children (47.7%), and children from households with an annual income of 50,000‐99,999 (41.7%). Although peanut allergy was diagnosed by a physician in 76% of cases, significantly more
peanut allergy reactions were severe as compared with reactions to other foods (53.7% versus 41.0%, p < 0.001). Parents were significantly less likely to report tolerance to peanut as compared with the odds of tolerance reported for other foods (odds ratio 0.7, 95% confidence interval:
0.5‐0.9). Childhood peanut allergy, which represents nearly a quarter of all food allergy, presents more severe reactions and is least likely to be outgrown. Although it is diagnosed by a physician in nearly three-fourths of all cases, socioeconomic disparities in regard to diagnosis
persist.
In this rostrum we aim to increase awareness of anaphylaxis in infancy in order to improve clinical diagnosis, management, and prevention of recurrences. Anaphylaxis is increasingly reported in this age group. Foods are the most common triggers. Presentation typically involves the skin (generalized urticaria), the respiratory tract (cough, wheeze, stridor, and dyspnea), and/or the gastrointestinal tract (persistent vomiting). Tryptase levels are seldom increased because of infant anaphylaxis, although baseline tryptase levels can be increased in the first few months of life, reflecting mast cell burden in the developing immune system. The differential diagnosis of infant anaphylaxis includes consideration of age-unique entities, such as food protein-induced enterocolitis syndrome with acute presentation. Epinephrine (adrenaline) treatment is underused in health care and community settings. No epinephrine autoinjectors contain an optimal dose for infants weighing 10 kg or less. After treatment of an anaphylactic episode, follow-up with a physician, preferably an allergy/immunology specialist, is important for confirmation of anaphylaxis triggers and prevention of recurrences through avoidance of confirmed specific triggers. Natural desensitization to milk and egg can occur. Future research should include validation of the clinical criteria for anaphylaxis diagnosis in infants, prospective longitudinal monitoring of baseline serum tryptase levels in healthy and atopic infants during the first year of life, studies of infant comorbidities and cofactors that increase the risk of severe anaphylaxis, development of autoinjectors containing a 0.1-mg epinephrine dose suitable for infants, and inclusion of infants in prospective studies of immune modulation to prevent anaphylaxis recurrences.
Copyright © 2014 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
The present proteome study allows us to quantify wide-ranging proteins in SC, and AD is a representative target for this analysis. The clinical accuracy and applicability of this analysis were proven by the reduction in FLG in patients with EAD. Information obtained from this comprehensive study is useful not only for the evaluation of the patient's SC condition but also for the detection of critical proteins involved in the pathogenesis of AD.
Importance:
Describing the economic impact of childhood food allergy in the United States is important to guide public health policies.
Objective:
To determine the economic impact of childhood food allergy in the United States and caregivers' willingness to pay for food allergy treatment.
Design, setting, and participants:
A cross-sectional survey was conducted from November 28, 2011, through January 26, 2012. A representative sample of 1643 US caregivers of a child with a current food allergy were recruited for participation.
Main outcomes and measures:
Caregivers of children with food allergies were asked to quantify the direct medical, out-of-pocket, lost labor productivity, and related opportunity costs. As an alternative valuation approach, caregivers were asked their willingness to pay for an effective food allergy treatment.
Results:
The overall economic cost of food allergy was estimated at 20.6-4184 per year per child). Direct medical costs were 2.8-20.5 billion annually, including lost labor productivity, out-of-pocket, and opportunity costs. Lost labor productivity costs totaled 0.53-5.5 (95% CI, 6.4) billion annually, with 31% stemming from the cost of special foods. Opportunity costs totaled 10.5-20.8 billion annually ($3504 per year per child) for food allergy treatment.
Conclusions and relevance:
Childhood food allergy results in significant direct medical costs for the US health care system and even larger costs for families with a food-allergic child.
Initial food-allergic reactions are often poorly recognized and under-treated.
Parents of food-allergic children were invited to complete an online questionnaire, designed with Kids with Food Allergies Foundation, about their children's first food-allergic reactions resulting in urgent medical evaluation.
Among 1361 reactions, 76% (95% CI 74-79%) were highly likely to represent anaphylaxis based on NIAID/FAAN criteria. Only 34% (95% CI 31-37%) of these were administered epinephrine. In 56% of these, epinephrine was administered by emergency departments; 20% by parents; 9% by paramedics; 8% by primary care physicians; and 6% by urgent care centers. In 26% of these, epinephrine was given within 15 min of the onset of symptoms; 54% within 30 min; 82% within 1 h; and 93% within 2 h. Factors associated with a decreased likelihood of receiving epinephrine for anaphylaxis included age <12 months, milk and egg triggers, and symptoms of abdominal pain and/or diarrhea. Epinephrine was more likely to be given to asthmatic children and children with peanut or tree nut ingestion prior to event. Post-treatment, 42% of reactions likely to represent anaphylaxis were referred to allergists, 34% prescribed and/or given epinephrine auto-injectors, 17% trained to use epinephrine auto-injectors, and 19% given emergency action plans. Of patients treated with epinephrine, only half (47%) were prescribed epinephrine auto-injectors.
Only one-third of initial food-allergic reactions with symptoms of anaphylaxis were recognized and treated with epinephrine. Fewer than half of patients were referred to allergists. There is still a need to increase education and awareness about food-induced anaphylaxis.
Using clearly defined inclusion/exclusion criteria and predetermined cessation criteria, we describe outcomes from over 1000 oral food challenges in 12 month old population-recruited infants that will help to inform future standardization of food challenges.
Anaphylaxis incidence is increasing.
We sought to characterize anaphylaxis in children in an urban pediatric emergency department (PED).
We performed a review of PED records for anaphylactic reactions over 5 years.
We identified 213 anaphylactic reactions in 192 children (97 male patients): 6 were infants, 20 had multiple reactions, and the median age was 8 years (age range, 4 months to 18 years). Sixty-two reactions were coded as anaphylaxis; 151 additional reactions met the second symposium anaphylaxis criteria. There was no increase in incidence over 5 years. The triggers included the following: foods, 71%; unknown, 15%; drugs, 9%; and "other," 5%. Food was more likely to be a trigger in multiple PED visits (P = .03). Epinephrine was administered in 169 (79%) reactions; in 58 (27%) reactions epinephrine was administered before arrival in the PED. Patients with Medicaid were less likely to receive epinephrine before arrival in the PED (P < .001). Twenty-eight (14.6%) patients were hospitalized, 9 in the intensive care unit. For 13 (6%) of the reactions, 2 doses of epinephrine were administered; 69% of the patients treated with 2 doses of epinephrine were hospitalized compared with 12% of the patients treated with a single dose (P < .001). Administration of both epinephrine doses before arrival to the PED was associated with a lower rate of hospitalization compared with epinephrine administration in the PED (P = .05).
Food is the main anaphylaxis trigger in the urban PED, although the International Classification of Diseases-ninth revision code for anaphylaxis is underused. Treatment with 2 doses of epinephrine is associated with a higher risk of hospitalization; epinephrine treatment before arrival to the PED is associated with a decreased risk. Children with Medicaid are less likely to receive epinephrine before arrival in the PED.
The goal of this study was to better estimate the prevalence and severity of childhood food allergy in the United States.
A randomized, cross-sectional survey was administered electronically to a representative sample of US households with children from June 2009 to February 2010. Eligible participants included adults (aged 18 years or older) able to complete the survey in Spanish or English who resided in a household with at least 1 child younger than 18 years. Data were adjusted using both base and poststratification weights to account for potential biases from sampling design and nonresponse. Data were analyzed as weighted proportions to estimate prevalence and severity of food allergy. Multiple logistic regression models were constructed to identify characteristics significantly associated with outcomes.
Data were collected for 40 104 children; incomplete responses for 1624 children were excluded, which yielded a final sample of 38 480. Food allergy prevalence was 8.0% (95% confidence interval [CI]: 7.6-8.3). Among children with food allergy, 38.7% had a history of severe reactions, and 30.4% had multiple food allergies. Prevalence according to allergen among food-allergic children was highest for peanut (25.2% [95% CI: 23.3-27.1]), followed by milk (21.1% [95% CI: 19.4-22.8]) and shellfish (17.2% [95% CI: 15.6-18.9]). Odds of food allergy were significantly associated with race, age, income, and geographic region. Disparities in food allergy diagnosis according to race and income were observed.
Findings suggest that the prevalence and severity of childhood food allergy is greater than previously reported. Data suggest that disparities exist in the clinical diagnosis of disease.
Food-induced anaphylaxis may be more difficult to recognize in younger children. We describe age-related patterns in the clinical presentation of children with anaphylaxis, which may facilitate the early recognition and treatment of this potentially life-threatening condition.
Pediatric food allergy is a serious health problem in the United States. As the number of affected children increases, more caregivers are charged with the responsibility of managing their child's food allergy.
To better understand the impact of pediatric food allergy on caregiver quality of life.
As part of a larger project examining the knowledge, attitudes, and beliefs of caregivers with food allergic children, the Food Allergy Quality of Life-Parental Burden questionnaire was administered to a large sample of caregivers across the United States from January 1, 2008, to January 31, 2009. Findings were analyzed to describe caregiver quality of life and to examine the impact of the manifestation of food allergy on participant response.
Data were collected from 1,126 caregivers. The impact of food allergy on caregiver quality of life varied widely with 1 exception: caregivers consistently reported being troubled by social limitations resulting from their child's food allergy. Poor quality of life was significantly more likely on a number of survey items among caregivers more knowledgeable about food allergy and among caregivers whose children had been to the emergency department for food allergy in the past year, had multiple food allergies, or were allergic to specific foods.
Previous research has emphasized the negative impact of food allergy on caregiver quality of life. This study illustrates the diverse experience of caring for a child with food allergy and the importance of considering the manifestation of disease when evaluating parental burden.
To describe the demographic characteristics, clinical features, causative agents, settings and administered therapy in children presenting with anaphylaxis.
This was a retrospective case note study of children presenting with anaphylaxis over a 5-year period to the Emergency Department (ED) at the Royal Children's Hospital, Melbourne.
One-hundred and twenty-three cases of anaphylaxis in 117 patients were included. There was one death. The median age of presentation was 2.4 years. Home was the most common setting (48%) and food (85%) the most common trigger. Peanut (18%) and cashew nut (13%) were the most common cause of anaphylaxis. The median time from exposure to anaphylaxis for all identifiable agents was 10 min. The median time from onset to therapy was 40 min. Respiratory features were the principal presenting symptoms (97%). Seventeen per cent of subjects had experienced anaphylaxis previously.
This is the largest study of childhood anaphylaxis reported. Major findings are that most children presenting to the ED with anaphylaxis are first-time anaphylactic reactions and the time to administration of therapy is often significantly delayed. Most reactions occurred in the home. Peanut and cashew nut were the most common causes of anaphylaxis in this study population, suggesting that triggers for anaphylaxis in children have not changed significantly over the last decade.
Food anaphylaxis is now the leading known cause of anaphylactic reactions treated in emergency departments in the United States. It is estimated that there are 30 000 anaphylactic reactions to foods treated in emergency departments and 150 to 200 deaths each year. Peanuts, tree nuts, fish, and shellfish account for most severe food anaphylactic reactions. Although clearly a form of immunoglobulin E-mediated hypersensitivity, the mechanistic details responsible for symptoms of food-induced anaphylaxis are not completely understood, and in some cases, symptoms are not seen unless the patient exercises within a few hours of the ingestion. At the present time, the mainstays of therapy include educating patients and their caregivers to strictly avoid food allergens, to recognize early symptoms of anaphylaxis, and to self-administer injectable epinephrine. However, clinical trials are now under way for the treatment of patients with peanut anaphylaxis using recombinant humanized anti-immunoglobulin E antibody therapy, and novel immunomodulatory therapies are being tested in animal models of peanut-induced anaphylaxis.
Severe anaphylactic reactions are medical emergencies requiring immediate recognition and treatment. Despite this, little is known on their clinical features, especially in infants and children.
To evaluate trigger factors, patterns of clinical reaction, site of occurrence and treatment modalities of reported reaction in infants and children below 12 years of age in Germany.
Paediatricians throughout Germany were asked by questionnaire to report accidental anaphylactic reactions over the previous 12 months. Severity of reported reactions was classified in grades I-IV according to reported symptoms.
Hundred and three cases of anaphylaxis were evaluated. Median age was 5 years, 58% were boys. Site of occurrence was the child's home in the majority of cases (58%). Foods were the most common causative allergen (57%), followed by insect stings (13%) and immunotherapy (SIT) (12%); in 8% anaphylactic agent was unknown. Among foods, peanuts and tree nuts were the most frequent allergens (20% of food allergens in each case). Severe reactions with cardiovascular involvement occurred in 24% of cases. No fatal reaction was observed. Recurrent episodes of anaphylaxis were reported in 27% of cases, half of these caused by the same allergen again. For treatment, 20% of children received adrenaline, in 8% of cases intravenously. Thirty-six per cent of patients with grade-IV reactions received adrenaline, 24% intravenously. In 17% of all children an adrenaline self-injector was prescribed after the episode.
Our data: (i) shows an uncertainty of physicians in diagnosing anaphylaxis, (ii) reveals remarkable under-treatment of the majority of children with anaphylaxis, (iii) reflects the need for guidelines and training for physicians in managing children with anaphylaxis and (iv) should encourage the development of self-management programmes for patients and families.
There is no universal agreement on the definition of anaphylaxis or the criteria for diagnosis. In July 2005, the National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network convened a second meeting on anaphylaxis, which included representatives from 16 different organizations or government bodies, including representatives from North America, Europe, and Australia, to continue working toward a universally accepted definition of anaphylaxis, establish clinical criteria that would accurately identify cases of anaphylaxis with high precision, further review the evidence on the most appropriate management of anaphylaxis, and outline the research needs in this area.
To improve understanding of the epidemiology of anaphylaxis.
We performed a qualitative review by hand of the major epidemiology studies of anaphylaxis. This review was restricted to articles in the English language.
Articles chosen were selected by the committee and dated back to 1968. There was no specific criterion used for selection except the determination of the members of the committee.
Data on anaphylaxis incidence and prevalence are sparse and often imprecise. Findings are based on diverse study designs and are not entirely comparable. These factors have contributed to widely varying estimates of the frequency of this important condition. The roundtable discussion led to an improved estimation of the frequency of anaphylaxis: approximately 50 to 2,000 episodes per 100,000 persons or a lifetime prevalence of 0.05% to 2.0%. The largest number of incident cases is among children and adolescents. In addition to underdiagnosis, we noted undertreatment, especially for those at highest risk (ie, those without immediate access to treatment with epinephrine).
Anaphylaxis is a relatively common problem, affecting up to 2% of the population. Further data on epinephrine dispensing could improve current estimates. Another way to improve current understanding would be through better population-based study designs in different geographic regions. A recurring theme was the importance of broader access to self-injectable epinephrine for high-risk populations. An improved epidemiologic understanding of this disorder would aid ongoing efforts to reduce morbidity and mortality from anaphylaxis and could provide important clues for primary prevention.
Anaphylaxis is likely underrecognized in infancy. Many episodes are "first" episodes. Infants cannot report symptoms. Diagnosis therefore depends on a high index of suspicion and on physical signs. The differential diagnosis of anaphylaxis in infancy includes age-unique entities such as congenital or metabolic disorders, child abuse, Munchausen syndrome by proxy, and sudden infant death syndrome. Management is based on empirical evidence. A prospective systematic study of anaphylaxis in infancy is needed.