Recognize & Refer: Focus on anaphylaxis

This month’s spotlight is Pediatric Allergies as Contemporary Pediatrics sits down exclusively with Todd A. Mahr, MD, FAAP, FAAAI, FACAAI, president of the American College of Allergy, Asthma, and Immunology (ACAAI), director, Pediatric Allergy, Asthma, and Immunology at Gundersen Health System in La Crosse, Wisconsin, and adjunct clinical professor of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, to discuss the one key condition for which he believes community pediatricians should be especially aware-anaphylaxis.

Q. Dr. Mahr, why do you think anaphylaxis is of particular concern for pediatricians?

A. As a pediatric allergist, I see this in the community quite a bit. Anaphylaxis is a serious allergic or hypersensitivity reaction that’s rapid in onset and can lead to death. So, I can’t imagine a key condition that isn’t more practical for a pediatrician to know about. The issue with anaphylaxis is that the diagnosis is really based on clinical symptoms and signs for which pediatricians need to be aware. Also, there’s obviously the history-what activities lead up to it, and so on.

Q. What do you think are the underlying reasons for the increased severity or frequency of anaphylaxis in children?

A. Well, we know that for children anaphylaxis is becoming more prominent because we’re seeing more food allergies. Food allergies have increased by 18% from 2007 to 2012,¹ and another study found a 50% increase in episodes of food-induced anaphylaxis that presented to the emergency department (ED).² What we’re seeing is also more common in 0- to 5-year-olds, and that’s something that maybe a lot of pediatricians aren’t as familiar with. They’re thinking bee sting anaphylaxis or food allergy in an older child and not really thinking about anaphylaxis in that 0- to 5-year-old child and what we need to know about what to do for that child.

Q. What advice can you offer as far as those diagnostic clues that the pediatrician should be on the lookout for to properly diagnose anaphylaxis?

A. That’s a great question because basically it’s a little bit different. I mean, we all know what we think about. We think about anaphylaxis, we think about trouble breathing, hives, tightness in the throat, hoarse voice, feeling impending doom. In infants, that might be a bit different because the symptoms of anaphylaxis-vomiting, throat itching, and throat tightness-in an infant or toddler may be regurgitation or irritability and fussiness, drooling, inconsolable crying. and obviously they might have a rash, but they also might be lethargic and sleepy. So pediatricians need to be aware of that.

Anaphylaxis may not present in a used to seeing it in an older child. So, hives and vomiting are the most commonly described thing that people will see with anaphylaxis in infants and toddlers. We do know that, so that’s something they need to be aware of. Anaphylaxis is not always going to present with hives, but when there are hives and there’s vomiting or any kind of gastrointestinal (GI) complaint, that fits the criteria for anaphylaxis because it’s usually 2 symptoms within basically a system-2 different symptoms from that standpoint.

Q. What are the best treatment options for anaphylaxis in children?

A. What has also changed a little bit is that treatment is still epinephrine. We need it to be epinephrine-epinephrine is the first choice and the one that we should always be using. Epinephrine is now available in an infant dose for children, one that’s available at 0.1 mg and that actually is available. Pediatricians should have epinephrine stocked in their office, too, to make sure that they have it available.

Q. If pediatricians identify a patient that has anaphylaxis or with these diagnostic clues that you’ve given, at what point should they refer to a specialist?

A. That’s another great question. So, you’ve treated that anaphylaxis in your office. You then send the child to the ED, which would be the proper thing to do. The ED may give Benadryl or some other things after you’ve given the epinephrine. Then it’s really finding out what caused this anaphylaxis, what’s the trigger of the anaphylaxis. That basically means sending the patient to an allergist to help figure that all out; do the proper training for the self-injectable epinephrine at home; go over with parents what they need to be looking for and how they can avoid that trigger in the future. If it’s a food, what to look for, for cross-contamination and so on. So almost any child who has had anaphylaxis really should be sent to a pediatric allergist or an allergist.

Q. Is there anything else that you would like to add as a final thought for our community of pediatricians?

A. Well, I think it’s not to be afraid of using epinephrine. If that child is presenting to you, there are some people who feel you can’t use epinephrine until that child is shocky. You can’t give it until they’ve dropped their blood pressure or they’re really having trouble breathing, and you’re going to give them nebulizer first or you’re going to give Benadryl first. Epinephrine is the one drug that will actually treat the anaphylaxis and most of the symptoms to the greatest degree, so don’t be afraid of it and to feel really comfortable with its use in your office.

Disclosures:

Dr. Mahr reports receiving honoraria from Kaléo, ALK-Abelló, GlaxoSmithKline, AstraZeneca, Sanofi/Regeneron, and Optinose, and consulting fees from Kaléo and ALK-Abelló.

References:

1. Branum AM, Lukacs SL. Food allergy among children in the United States. Pediatrics. 2009;124(6):1549-1555.

 2. Parlaman JP, Oron AP, Uspal NG, DeJong KN, Tieder JS. Emergency and hospital care for food-related anaphylaxis in children. Hosp Pediatr. 2016;6(5):269-274.