Anaphylaxis in children and adolescents: The Portuguese Anaphylaxis Registry

Prevention of Food Allergy: Harmonizing Perspectives from the East and West

BACKGROUND

The global epidemiology of food allergies and anaphylaxis exhibits complex, heterogeneous patterns. While food allergy prevalence has stabilized in Western countries, anaphylaxis incidence continues to rise. In developing regions, data are limited, but urban centers show increasing food allergy prevalence, contrasting with lower rates in rural areas. These disparities likely stem from differences in environmental factors and urbanization levels across the globe. Furthermore, the dominant food allergens vary significantly by regions. Peanuts and tree nuts are the primary triggers in the USA and Europe, whereas eggs, milk, and shellfish are more common in Asia and Latin America.

SUMMARY

In this upcoming review, we will delve into the recommendations for preventing food allergies across Eastern and Western regions. These regional differences in allergen profiles and dietary patterns underscore the need for tailored food allergy prevention strategies. Current prevention guidelines focus on the timing and route of allergen exposure in early life. In high-prevalence regions, early oral exposure is recommended to promote oral tolerance and reduce allergy risk. Conversely, in lower-prevalence areas, non-delayed introduction of allergenic solids is preferred. Moreover, early skin exposure may increase allergy risk, and the role of early, whole-body use of specialized emollients requires further study. Proactive treatment of atopic dermatitis may reduce the incidence of food allergies in infants. Adapting prevention approaches to local contexts and continuously updating guidelines based on emerging evidence is crucial to comprehensively addressing the global burden of food allergies.

Anaphylaxis in infancy: An area that needs to be highlighted

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.

Incidence and trends of anaphylaxis among inpatients from 2003 to 2023 in Wuhan, China: A multicenter retrospective study

Background

The incidence of a disease can help health professionals to identify risk factors and health-care policymakers to develop corresponding policies. The realization of both purposes depends on comprehensive studies, especially studies done on a large scale. However, comprehensive studies on the incidence of anaphylaxis among inpatients in China are still notably scarce. Hence we aim to explore the incidence and clinical characteristics of anaphylaxis among inpatients over a span of 21 years in Wuhan, China.

Methods

We retrieved data on anaphylaxis cases from the Data Platform Application Portal (DPAP) across 3 medical centers of Tongji Hospital, Wuhan, China from January 1, 2003, to December 31, 2023.

Results

The data encompassed a total of 362 anaphylaxis patients from 2,139,272 inpatients. Among them 204 (56.4%) were male, and the median age was 45 years old. Over the past 2 decades, the incidence rate of anaphylaxis at Tongji Hospital was 16.92 per 100,000 individuals. After adjusting for gender and age, the annual standardized incidence rate was 234.53 per 100,000 individuals. The incidence rate of anaphylaxis among the inpatients revealed a relatively stable but slowly rising trend over the 21-year observation period. As for the triggers of anaphylaxis, drugs were responsible for 73.6% of triggers, with antibiotics representing the highest proportion of these cases (38.4%). Drug triggers also showed age-specific features: chemotherapy (17.9%) had the highest proportions among children aged 0-3 years; blood products were more prevalent in school-age children. 13.5% of the cases had an unknown cause. In anaphylaxis cases, despite that only 36.0% received epinephrine treatment, the application of epinephrine still showed an ascending trend. Moreover, the mortality rate for anaphylaxis was relatively low (1.6%), displaying a consistent downward trend.

Conclusion

Our study provides insights into the incidence of anaphylaxis among inpatients in Wuhan over a 21-year period. Drugs are the most common triggers for anaphylaxis, and the use of epinephrine in anaphylaxis management is far from optimal.

Retrospective evaluation of pediatric anaphylaxis cases according to WAO and NIAID/FAAN/EAACI criteria: A single center experience

Background

Anaphylaxis is an emergency that must be correctly recognized and treated by every health care professional. With the update of the World Allergy Organization (WAO) criteria in 2020, differences between the European Academy of Allergy and Immunology (EAACI)/The National Institute of Allergy and Infectious Diseases (NIAID) and the Food Allergy and Anaphylaxis Network (FAAN) and WAO criteria have come to the fore.

Objective

The aim of our study is to compare the effectiveness of these 2 criteria in diagnosing anaphylaxis in pediatric patients.

Methods

Patients aged 0-18 years who applied to Ankara Bilkent City Hospital Pediatric Immunology and Allergy Clinic between September 1, 2020 and September 1, 2023 due to systemic allergic reaction and were diagnosed with anaphylaxis were evaluated retrospectively. The clinical findings of the patients were re-evaluated accordingto WAO 2020 and NIAID/FAAN/EAACI criteria.

Results

Included in the study were 492 patients who met the inclusion criteria. Median age was 3.8 years (IQR: 0.9-11.4). The majority of patients were male (59.6%). There were 466 patients (94.1%) diagnosed with anaphylaxis according to both NIAID/FAAN/EAACI and WAO criteria. Three patients (0.6%) with isolated laryngeal involvement and 23 (4.7%) patients with isolated respiratory findings (bronchospasm) were diagnosed only according to WAO Criterion 2, for a total of 26 patients (5.3%).

Conclusion

Although the majority of patients were diagnosed with both criteria, 5.3% were diagnosed only according to the WAO criteria. After contact with a suspected or known allergen, the presence of isolated respiratory or laryngeal findings without skin findings should be a warning before anaphylaxis progresses to more serious stages.

Improving Clinical Practice Through Patient Registries in Allergy and Immunology

Patient registries are a mechanism for collecting data on allergic and immunologic diseases that provide important information on epidemiology and outcomes that can ultimately improve patient care. Key criteria for establishing effective registries include the use of a clearly defined purpose, identifying the target population and ensuring consistent data collection. Registries in allergic diseases include those for diseases such as inborn errors of immunity (IEI), food allergy, asthma and anaphylaxis, pharmacological interventions in vulnerable populations, and adverse effects of pharmacologic interventions including hypersensitivity reactions to drugs and vaccines. Important insights gained from patient registries in our field include contributions in phenotype and outcomes in IEI, the risk for adverse reactions in food-allergic patients in multiple settings, the benefits and risk of biologic medications for asthma during pregnancy, vaccine safety, and the categorization and genetic determination of risk for severe cutaneous adverse reactions to medications. Impediments to the development of clinically meaningful patient registries include the lack of funding resources for registry establishment and the quality, quantity, and consistency of available data. Despite these drawbacks, high-quality and successful registries are invaluable in informing clinical practice and improving outcomes in patients with allergic and immunological diseases.

Characteristics of childhood anaphylaxis in different age groups

BACKGROUND

Anaphylaxis is a severe systemic hypersensitivity reaction that usually has a rapid onset and can be fatal. Presentations of childhood anaphylaxis vary widely in accordance with the triggers and the patient's age, geographical region and dietary and lifestyle habits.

METHODS

The medical records of 177 paediatric patients diagnosed with anaphylaxis between January 2021 and January 2024, whose disease progression was monitored at a single tertiary care centre, were reviewed retrospectively.

RESULTS

The study included 177 patients diagnosed with anaphylaxis (107 males and 70 females with a median age of 48 months). The most common allergen responsible was food (53.7%). Egg allergy was the most common source of anaphylaxis, afflicting 35 patients (19.3%), while beta-lactam provoked the most common drug allergy, affecting 24 patients (13.6%). The most common organ involved was the skin (92.7%). When the patients were analysed by age group, there were more males in the infancy, preschool and school age groups, while there were more females in the adolescent group (p = 0.44). Food-induced anaphylaxis became less common with increasing age, whereas the rate of drug-induced anaphylaxis increased (p = 0.01 and p = 0.01, respectively). Cardiovascular system findings were observed more frequently in adolescents compared to other age groups (p = 0.003). Most cases stemming from a food allergy were mild, whereas most drug-induced cases were moderate or severe (p < 0.05). When severity was analysed by age group, mild cases in infants were more common than moderate to severe cases.

CONCLUSION

The aetiological and clinical manifestations of childhood anaphylaxis vary among different age groups.

Pediatric idiopathic anaphylaxis: practical management from infants to adolescents

Idiopathic anaphylaxis (IA) remains a frustrating challenge for both patients and physicians. The aim of this paper is to focus on IA in pediatric ages and suggest possible diagnostic algorithms according to specific age ranges (infants, children, and adolescents). In fact, in a variable percentage of patients, despite extensive diagnostic tests, the cause of anaphylactic episodes cannot be identified. Moreover, the lack of a unanimous IA definition requires a careful and detailed diagnostic workup. Prompt recognition of signs and symptoms, especially in younger children, and an accurate clinical history often allow a choice of the most appropriate diagnostic tests and a correct differential diagnosis.

A case-control study for comorbidity and laboratory factors associated with food-induced anaphylaxis

Background: Food-induced anaphylaxis (FIA) is a serious and potentially life-threatening allergic reaction triggered by food allergens. Objective: This case-control study aimed to investigate comorbidities and laboratory factors associated with FIA in the pediatric population of Israel. Methods: Retrospective data from the electronic health records of Leumit Health Care Services were used to identify 711 pediatric patients with FIA and 2560 subjects with food allergy and without anaphylaxis matched for age, gender, and ethnicity. Comorbidities were identified based on medical billing diagnosis codes, and laboratory characteristics were compared between the two groups. Results: The mean ± standard deviation age of patients with FIA was 4.1 ± 4.1 years, and 37.3% were girls. Laboratory analysis revealed increased eosinophil counts (p < 0.001), elevated immunoglobulin E (IgE) (p < 0.001), and IgA levels (p = 0.001) in the FIA group compared with the controls. With regard to comorbidities, the FIA group had higher prevalence rates of allergic diseases, including allergic rhinitis (odds ratio [OR] 1.72; p < 0.001), allergic conjunctivitis (OR 1.84; p = 0.001), asthma (OR 1.36; p < 0.001), angioedema (OR 6.37; p < 0.001), atopic dermatitis (OR 1.77; p < 0.001), and contact dermatitis (OR 1.42; p = 0.001). There was a trend toward significance for chronic spontaneous urticaria (p = 0.051). There was a significant negative association between helminthiases, particularly enterobiasis, and FIA (OR 0.76 [95% confidence interval, 0.59-0.98]; p = 0.029). Conclusion: This study provides valuable epidemiologic evidence on the associations among FIA, comorbidities, and laboratory factors in the pediatric population.

Trends and Hospital Outcomes in HOSPITAL Admissions for Anaphylaxis in Children with and without Asthma in Spain (2016-2021)

(1) Background: To assess and compare the temporal trends in the incidence, characteristics and hospital outcomes among children with and without asthma who were hospitalized with anaphylaxis in Spain from 2016 to 2021, and identify the variables associated with severe anaphylaxis among children with asthma. (2) Methods: An observational, retrospective study was conducted using a population-based database. The study population included pediatric patients with anaphylaxis. This population was stratified based on whether they had asthma. (3) Results: The number of hospital admissions was stable from 2016 to 2019, dropping in 2020 and raising to the highest number in 2021. A total of 60.63% of hospitalizations occurred in boys and the most common anaphylactic reactions were due to food consumption (67.28%), increasing over time. The in-hospital mortality (IHM) remained stable and under 1% in all the years studied. The incidence of anaphylaxis was 2.14 times higher in children with asthma than in those without asthma (IRR 2.14; 95% CI 1.87-2.44). Furthermore, it was 1.79 times higher in boys with asthma than in those without asthma (IRR 1.79; 95% CI 1.06-2.45) and 2.68 times higher in girls with asthma than in those without asthma (IRR 2.68; 95% CI 2.23-3.12). Asthma was not associated with severe anaphylaxis (OR 1.31; 95% CI 0.88-1.96). (4) Conclusions: The number of hospitalizations for anaphylaxis in children remained stable from 2016 to 2019, dropping in 2020 and recovering in 2021. IHM was low and remained stable during the study period. The incidence of hospitalizations for anaphylaxis was higher in asthmatic children than in non-asthmatics, but there were no differences in the occurrence of severe anaphylaxis among them.

Prehospital epinephrine administration for treating anaphylaxis among those with comorbid asthma: A scoping review

BACKGROUND

Prompt and correct use of epinephrine for treating anaphylaxis is considered essential in reducing the risk of fatal outcomes from anaphylaxis. Nevertheless, prehospital use of epinephrine remains low. Although asthma is a common comorbidity in individuals experiencing severe allergic reactions, little attention has been given to whether asthma functions as a predictor of prehospital epinephrine administration.

OBJECTIVE

To perform a scoping review of the extant literature on using epinephrine to manage anaphylaxis in patients with comorbid asthma before presenting to the emergency department.

METHODS

Per Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review guidelines, peer-reviewed articles published in English or French were searched for within the Medline, Cumulative Index to Nursing and Allied Health Literature, and Embase databases between June 11 and June 18, 2021. We excluded studies that did not contain primary data.

RESULTS

The literature search yielded 1022 articles that were screened at the title and abstract level by 2 independent reviewers. Of these, 90 (8.8%) advanced to full-text review, and ultimately, 8 studies (0.8% of all articles; 8.9% of full-text articles) were included in the analysis. Overall, the association between comorbid asthma and epinephrine use in the prehospital setting for managing anaphylaxis was inconsistently reported in the literature. Three studies reported a positive association, whereas 2 others suggested a link, but their results were no longer significant when controlling for other study variables. Three studies described no significant association.

CONCLUSION

Although asthma is frequently comorbid in individuals experiencing anaphylaxis, the association between comorbid asthma and prehospital epinephrine treatment rates remains an understudied area of patient care.

"Frequency of fatal and recurrent anaphylaxis due to COW'S milk: A systematic review and meta-analysis of observational studies"

Cow's milk allergy can result in anaphylactic reactions. The estimated prevalence of cow's milk allergy in developed countries ranges from 0.5% to 3% at age 1 year. Our objective was to perform a systematic review and, if possible, a meta-analysis to assess the frequency of fatal and recurrent anaphylaxis induced by cow's milk. We searched PubMed/MEDLINE, EMBASE, and the Web of Science for studies that had assessed fatal and recurrent anaphylaxis induced by cow's milk for the population of a country or at least an administrative region. Our review included cohort, cross-sectional, and registry studies that had assessed the incidence or prevalence of recurrent anaphylaxis or the incidence of fatal anaphylaxis due to cow's milk. The pooled prevalence of recurrence (PR) for at least an episode of anaphylaxis was 26.98% (3.85-189.1). Teymourpour et al (Iran) reported the highest PR (53.10%); the two studies with the lowest PR were from France (5.2 and 0.42, respectively) (p < .01). Nine studies on fatal anaphylaxis were selected (41 deaths) and found to be highly heterogeneous (I2  = 75.9%). Levy et al and Bassagio et al reported the highest incidence rate (IR 0.15 and 0.6 deaths per million persons-year). The PR of anaphylaxis was approximately one quarter of patients with anaphylaxis due to cow's milk, while deaths from anaphylaxis caused by cow's milk were very rare, although some studies report rates as high as 15 times the lowest IR.

Different age groups present different clinics in anaphylaxis with children: one size does not fit all children

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.

Impact of Reaction Setting on the Management, Severity, and Outcome of Pediatric Food-Induced Anaphylaxis: A Cross-Sectional Study

BACKGROUND

Prompt epinephrine autoinjector (EAI) use is the primary treatment for anaphylaxis. However, limited Canadian data exist on the impact of reaction location on EAI use for food-induced anaphylaxis (FIA).

OBJECTIVE

We sought to investigate the setting, management, and severity of pediatric FIA.

METHODS

We recruited children presenting with FIA from 11 Canadian emergency departments. Patient demographics and the setting, management, and symptoms of FIA were collected by standardized questionnaire. Factors associated with prehospital EAI use and reaction severity were determined by logistic regression.

RESULTS

We recruited 3,604 children; 60.2% were male and the median age was 5.0 years (interquartile range 1.8-11.0). Among cases with a known location of FIA (85.0%), home was the most common setting (68.1%), followed by school/daycare (12.8%), other locations (11.4%; eg, park, car), and restaurants (7.4%). In the prehospital setting, EAI was administered in 36.7% of reactions at home, 66.7% in school/daycare, 40.2% in other locations, and 44.5% in restaurants. Relative to reactions occurring at school/daycare, prehospital EAI use was less likely at home (adjusted odds ratio [aOR] 0.80; 95% CI 0.76-0.84), in restaurants (aOR 0.81; 95% CI 0.75-0.87), and in other settings (aOR 0.77; 95% CI 0.73-0.83), when data were adjusted for reaction severity, sex, age, comorbidities, and province. The FIA setting was not associated with reaction severity or hospitalization.

CONCLUSIONS

Prehospital EAI use was higher at school/daycare than in other settings, potentially owing to the presence of policies and training on FIA. Setting-specific interventions including educational programs and policies/laws mandating training and stocking an EAI may improve anaphylaxis recognition and treatment.

Anaphylaxis in Children and Adolescents: Greek Data Analysis from the European Anaphylaxis Registry (NORA)

The European Anaphylaxis Registry (NORA) was designed in order to create a comprehensive Anaphylaxis Registry regarding anaphylactic reactions characteristics and management in several European countries, including Greece. This study aims to analyze Greek data obtained in the NORA framework and describe anaphylaxis’ characteristics in this pediatric cohort. An online questionnaire was filled out by the Allergy Unit of the 2nd Pediatric Department of NKUA, regarding reported anaphylaxis characteristics. A total of 284 pediatric patients were analyzed. Patients were predominantly male. A previous, mild reaction (59.5%) to the same allergen was documented in 44.4% of patients. The most common system involved was skin and/or mucosa, followed by the respiratory system. Food was the most common eliciting factor (82.4%). First line treatment was most administered solely by a healthcare professional, followed by a lay person (38.7%). Auto injected adrenaline use by lay persons was third in frequency (29.2%). Most patients received post-reaction counseling and appropriate drug prescription. This study provides insight in anaphylactic cases’ characteristics and management in a Greek pediatric cohort. A low rate of adrenaline autoinjector administration was noted in lay people; however, drug prescription and counseling following the reaction could help increase correct acute anaphylaxis management in the future.

Pediatric Anaphylaxis: A 20-Year Retrospective Analysis

BACKGROUND

Anaphylaxis is a steadily increasing global problem defined as an acute hypersensitivity multisystem reaction that is potentially fatal. In the pediatric age, the leading cause is food. In other allergic diseases, intrinsic heterogeneity has been reported in the clinical presentation, severity, and triggers of anaphylaxis. This study analyzes the features and management approach of the anaphylactic reactions in children evaluated at the pediatric clinic in Pavia.

MATERIALS AND METHODS

A retrospective study was conducted on patients with anaphylaxis between 2001 and 2021.

RESULTS

A total of 148 patients with a median age of 5 years were enrolled, and 80% of the patients had other atopic comorbidities that were correlated with the severity of anaphylaxis. The main trigger of anaphylaxis was food. Most reactions involved mucocutaneous, respiratory, and gastrointestinal systems, and occurred at home. Adrenaline was administered only in a minority of cases.

CONCLUSIONS

Considering that anaphylaxis is a potentially life-threatening condition requiring prompt management, the use of adrenaline should be implemented. Our data also suggest the importance of educating and spreading awareness of anaphylactic management within the medical community.

Anaphylaxis in Chinese Children: Different Clinical Profile Between Children with and without a History of Asthma/Recurrent Wheezing

Purpose

Asthma and recurrent wheezing (RW) have been identified as risk factors for anaphylaxis; however, little is known about the characteristics of anaphylaxis in children with a history of asthma or RW in Chinese children.

Patients and Methods

This was a retrospective, observational chart review of children who were diagnosed with anaphylaxis in a tertiary children's hospital between 2014 and 2021. Patients' demographics, symptoms, triggers and presence of physician-diagnosed asthma/RW history were collected from medical charts.

Results

A total of 399 anaphylactic reactions in 264 patients were analyzed; 119 patients (45.1%) had a history of asthma/RW. Food was the most common cause (85.5%, 341/399). Compared with patients without a history of asthma/RW, buckwheat-induced anaphylaxis was significantly more common in the asthma/RW group (9.4% vs 0.5%, p < 0.001), patients with a history of asthma/RW had higher rates of oropharyngeal symptoms (17.3% vs 8.6%, p = 0.011) and wheezing (34.5% vs 15.9%, p < 0.001). Ninety-one reactions (22.8%, 91/399) presented as severe anaphylaxis, but no difference existed between asthma/RW and non-asthma/RW groups. Children with a history of asthma/RW were more likely to receive inhaled β agonists than children without a history of asthma/RW (11.8% vs 2.5%, p = 0.003). A larger proportion of children without asthma/RW history were treated with epinephrine (11.7%) than children with asthma/RW history (6.9%).

Conclusion

Our finding revealed that different clinical profiles of anaphylaxis in children with and without a history of asthma/RW. Our study did not find that children with a history of asthma/RW have more severe anaphylactic reactions compared with children without asthma/RW. Buckwheat-induced anaphylaxis was more common in the asthma/RW group, wheezing and oropharyngeal symptoms affected a higher proportion of the asthma/RW group.