Clinical characteristics and management of pediatric egg-induced anaphylaxis: A cross-sectional study.

BACKGROUND: Egg is the third most common food allergy in children; however, data on pediatric egg-induced anaphylaxis are sparse. OBJECTIVE: To describe the clinical characteristics, management, and outcomes of pediatric egg-induced anaphylaxis. METHODS: Children presenting with anaphylaxis were recruited from 13 emergency departments as part of the Cross-Canada Anaphylaxis Registry, from which data on anaphylaxis triggered by egg were extracted. Multivariate logistic regression was used to determine factors associated with prehospital epinephrine autoinjector (EAI) use and to compare anaphylaxis triggered by egg with other triggers of food-induced anaphylaxis (FIA). RESULTS: We recruited 302 children with egg-induced anaphylaxis. The mean age was 2.6 years (SD = 3.6), and 55.3% were male. Only 39.4% had previously been diagnosed with an egg allergy. Prehospital EAI use was 32.1%, but this was not significantly lower than in other triggers of FIA (P = .26). Only 1.4% of patients required hospital admission. Relative to other triggers of FIA, patients with egg-induced anaphylaxis were significantly younger (P < .001) and exhibited more vomiting (P = .0053) and less throat tightness (P = .0015) and angioedema (P < .001). CONCLUSION: To the best of our knowledge, this is the largest published cohort of pediatric egg-induced anaphylaxis. In this cohort, prehospital EAI use was very low. In addition, we identified certain symptoms that distinguish egg-induced from other triggers of FIA. Taken together, high suspicion is crucial in identifying egg-induced anaphylaxis, given the younger patient demographic and frequent lack of FIA history.

Milk-induced anaphylaxis among children presenting to Canadian emergency departments.

BACKGROUND: Cow's milk is one of the most common and burdensome allergens in pediatrics, and it can induce severe anaphylactic reactions in children. However, data on cow's milk-induced anaphylaxis are sparse. OBJECTIVE: To describe the epidemiology of pediatric cow's milk-induced anaphylaxis and to determine risk factors for repeat emergency department (ED) epinephrine administration. METHODS: Between April 2011 and May 2023, data were collected on children with anaphylaxis presenting to 10 Canadian EDs. A standardized form documenting symptoms, triggers, treatment, and outcome was used. Multivariate logistic regression was used. RESULTS: Of 3118 anaphylactic reactions, 319 milk-induced anaphylaxis cases were identified (10%). In the prehospital setting, 54% of patients with milk-induced anaphylaxis received intramuscular epinephrine. In those with milk-induced anaphylaxis, receiving epinephrine before presenting to the ED was associated with a reduced risk of requiring 2 or more epinephrine doses in the ED (adjusted odds ratio, 0.95 [95% CI, 0.90-0.99]). Children younger than 5 years of age were more likely to experience a mild reaction compared with that in older children, who experienced a moderate reaction more often (P < .0001). Compared with other forms of food-induced anaphylaxis, children presenting with milk-induced anaphylaxis were younger; a greater proportion experienced wheezing and vomiting, and less experienced angioedema. CONCLUSION: Prehospital epinephrine in pediatric milk-induced anaphylaxis is underused; however, it may decrease risk of requiring 2 ED epinephrine doses. Milk-induced anaphylaxis in children younger than 5 years of age may be less severe than in older children. Wheezing and vomiting are more prevalent in milk-induced anaphylaxis compared with that of other foods.

Management of anaphylaxis after pre-hospital epinephrine use in children with food-induced anaphylaxis.

BACKGROUND: Previous guidelines recommend prompt epinephrine administration, followed by observation in the emergency department (ED). The need for transfer in all cases of anaphylaxis has recently been challenged. OBJECTIVE: To evaluate the need for additional ED treatment among children with anaphylaxis who received prehospital epinephrine. METHODS: Between 2011 and 2023, data were collected on symptoms, triggers, comorbidities, and prehospital and in-hospital management from children (<18 years) with food-induced anaphylaxis who received at least 1 dose of prehospital epinephrine presenting at 7 pediatric EDs. Multivariable logistic regression assessed factors associated with the use of 2 or more prehospital epinephrine autoinjectors (EAIs), epinephrine use in the ED, and hospital admission. RESULTS: Of the 1127 children (mean 8.1 ± 5.3 years; 60.6% male sex) with food-induced anaphylaxis who used at least 1 EAI prehospital, the most common trigger was peanuts (25.3%). There were 209 (18.5%) children who received additional epinephrine in the ED, most of whom (88.0%) received 1 dose. A total of 30 (2.7%) patients were admitted to hospital. Among all patients, severe reactions (cardiovascular instability/cyanosis/loss of consciousness) (adjusted odds ratio [aOR] 1.22; 95% CI 1.12-1.33) and reactions to tree nuts (aOR 1.09; 95% CI 1.03-1.16) were associated with increased odds of in-hospital epinephrine use. Prehospital inhaled ß-agonists (aOR 1.08; 95% CI 1.01-1.16) use and severe reactions (aOR 1.13; 95% CI 1.05-1.22) were associated with the use of 2 or more EAI prehospital. CONCLUSION: A minority of anaphylaxis cases that used prehospital EAIs required additional treatment, supporting that shared decision making about transfer to ED works for most patients.

Managing anaphylaxis: Epinephrine, antihistamines, and corticosteroids: More than 10 years of Cross-Canada Anaphylaxis REgistry data.

BACKGROUND: Epinephrine is the first-line treatment for anaphylaxis but is often replaced with antihistamines or corticosteroids. Delayed epinephrine administration is a risk factor for fatal anaphylaxis. Convincing data on the role of antihistamines and corticosteroids in anaphylaxis management are sparse. OBJECTIVE: To establish the impact of prehospital treatment with epinephrine, antihistamines, and/or corticosteroids on anaphylaxis management. METHODS: Patients presenting with anaphylaxis were recruited prospectively and retrospectively in 10 Canadian and 1 Israeli emergency departments (EDs) between April 2011 and August 2022, as part of the Cross-Canada Anaphylaxis REgistry. Data on anaphylaxis cases were collected using a standardized form. Primary outcomes were uncontrolled reactions (>2 doses of epinephrine in ED), no prehospital epinephrine use, use of intravenous fluids in ED, and hospital admission. Multivariate regression was used to identify factors associated with primary outcomes. RESULTS: Among 5364 reactions recorded, median age was 8.8 years (IQR, 3.78-16.9); 54.9% of the patients were males, and 52.5% had a known food allergy. In the prehospital setting, 37.9% received epinephrine; 44.3% received antihistamines, and 3.15% received corticosteroids. Uncontrolled reactions happened in 250 reactions. Patients treated with prehospital epinephrine were less likely to have uncontrolled reactions (adjusted odds ratio [aOR], 0.955 [95% CI, 0.943-0.967]), receive intravenous fluids in ED (aOR, 0.976 [95% CI, 0.959-0.992]), and to be admitted after the reaction (aOR, 0.964 [95% CI, 0.949-0.980]). Patients treated with prehospital antihistamines were less likely to have uncontrolled reactions (aOR, 0.978 [95% CI, 0.967-0.989]) and to be admitted after the reaction (aOR, 0.963 [95% CI, 0.949-0.977]). Patients who received prehospital corticosteroids were more likely to require intravenous fluids in ED (aOR, 1.059 [95% CI, 1.013-1.107]) and be admitted (aOR, 1.232 [95% CI, 1.181-1.286]). CONCLUSION: Our findings in this predominantly pediatric population support the early use of epinephrine and suggest a beneficial effect of antihistamines. Corticosteroid use in anaphylaxis should be revisited.

Sesame-induced anaphylaxis in pediatric patients from the cross-Canada anaphylaxis registry.

BACKGROUND: Sesame can cause severe allergic reactions and is a priority allergen in Canada. OBJECTIVE: To assess clinical characteristics and management of pediatric sesame-induced anaphylaxis and identify factors associated with epinephrine treatment. METHODS: Between 2011 and 2021, children with sesame-induced anaphylaxis presenting to 7 emergency departments (ED) in 4 Canadian provinces and 1 regional emergency medical service were enrolled in the Cross-Canada Anaphylaxis Registry. Standardized recruitment forms provided data on symptoms, severity, triggers, and management. Multivariate logistic regression evaluated associations with epinephrine treatment pre-ED and multiple epinephrine dosages. RESULTS: Of all food-induced anaphylactic reactions (n = 3279 children), sesame accounted for 4.0% (n = 130 children), of which 61.5% were boys, and the average (SD) age was 5.0 (4.9) years. Hummus containing sesame paste triggered 58.8% of reactions. In the pre-ED setting, 32.3% received epinephrine, and it was more likely to be used in boys (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.08-1.50) and those with a known food allergy (aOR, 1.36; 95% CI, 1.11-1.68]). In the ED, 47.7% of cases received epinephrine, with older children more likely to receive multiple epinephrine doses (aOR, 1.00; 95% CI, 1.00-1.02). CONCLUSION: In Canada, hummus is the major trigger of sesame-induced anaphylaxis. Knowledge translation focused on prompt epinephrine use and product-labeling policies are required to limit sesame reactions in communities.

Tree nut-induced anaphylaxis in Canadian emergency departments: Rate, clinical characteristics, and management.

BACKGROUND: Data are sparse regarding tree nut-induced anaphylaxis (TNA). OBJECTIVE: To characterize rate, clinical characteristics, and management of TNA in children (0-17 years old) across Canada and evaluate factors associated with severe reactions and epinephrine use. METHODS: Between April 2011 and May 2020, data were collected on children presenting to 5 emergency departments in Canada. Multivariate logistic analysis was used to evaluate factors associated with severe reactions (stridor, cyanosis, circulatory collapse, or hypoxia) and epinephrine use. RESULTS: Among 3096 cases of anaphylaxis, 540 (17%) were induced by tree nut. The median age was 5.2 (interquartile range, 2.5-9.5) years and 65.4% were of male sex. Among all reactions, 7.0% were severe. The major tree nuts accounting for anaphylaxis were cashew (32.8%), hazelnut (20.0%), and walnut (11.5%). Cashew-induced anaphylaxis was more common in British Columbia (14.0% difference [95% confidence interval (CI), 1.6-27.6]) vs Ontario and Quebec, whereas pistachio-induced anaphylaxis was more common in Ontario and Quebec (6.3% difference [95% CI, 0.5-12.2]). Prehospital and emergency department intramuscular epinephrine administration was documented in only 35.2% and 52.4% of cases, respectively. Severe reactions were more likely among of male sex (adjusted odds ratio [aOR], 1.05 [95% CI, 1.01-1.10]), older children (aOR, 1.00 [95% CI, 1.00-1.01]), and in reactions triggered by macadamia (aOR, 1.27 [95% CI, 1.03-1.57]). CONCLUSION: Different TNA patterns in Canada may be because of differences in lifestyle (higher prevalence of Asian ethnicity in British Columbia vs Arabic ethnicity in Ontario and Quebec). Intramuscular epinephrine underutilization urges for epinephrine autoinjector stocking in schools and restaurants, patient education, and consistent policies across Canada.

Seafood-induced anaphylaxis in children presenting to Canadian emergency departments: Rates, clinical presentation, and management.

BACKGROUND: There is a lack of data on seafood-induced anaphylaxis in children in Canada. OBJECTIVE: To evaluate the rate, clinical features, and management of seafood-induced anaphylaxis in children presenting to emergency departments across Canada. METHODS: Children with anaphylaxis were recruited at 6 emergency departments between 2011 and 2020 as part of the Cross-Canada Anaphylaxis REgistry. A standardized form documenting symptoms, triggers, comorbidities, and management was used to collect data. RESULTS: There were 75 fish-induced and 71 shellfish-induced cases of suspected anaphylaxis, most of which were caused by salmon and shrimp, respectively. Mucocutaneous symptoms were most common, whereas respiratory symptoms were associated with patients with fish-induced reactions who have comorbid asthma (adjusted odds ratio [aOR], 1.18; 95% confidence interval [CI], 1.02-1.36). Prehospital epinephrine was underused (<35%), whereas in-hospital epinephrine was given to less than 60% of the patients. Among those with a known fish or shellfish allergy, prehospital epinephrine use was associated with known asthma (aOR 1.39 [95% CI, 1.05-1.84] and aOR 1.25 [95% CI, 1.02-1.54], respectively). Among children who were assessed by either skin test or specific immunoglobulin E, 36 patients (76.6%) with suspected fish-induced anaphylaxis and 19 patients (51.4%) with suspected shellfish-induced anaphylaxis tested positive. CONCLUSION: Prehospital epinephrine is underused in the management of seafood-induced anaphylaxis. Among children with known seafood allergy, prehospital epinephrine use is more likely if there is a known asthma comorbidity.

The Base Deficit, International Normalized Ratio, and Glasgow Coma Scale (BIG) Score, and Functional Outcome at Hospital Discharge in Children With Traumatic Brain Injury.

OBJECTIVES: To examine the association of the base deficit, international normalized ratio, and Glasgow Coma Scale (BIG) score on emergency department arrival with functional dependence at hospital discharge (Pediatric Cerebral Performance Category ≥ 4) in pediatric multiple trauma patients with traumatic brain injury. DESIGN: A retrospective cohort study of a pediatric trauma database from 2001 to 2018. SETTING: Level 1 trauma program at a university-affiliated pediatric institution. PATIENTS: Two to 17 years old children sustaining major blunt trauma including a traumatic brain injury and meeting trauma team activation criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two investigators, blinded to the BIG score, determined discharge Pediatric Cerebral Performance Category scores. The BIG score was measured on emergency department arrival. The 609 study patients were 9.7 ± 4.4 years old with a median Injury Severity Score 22 (interquartile range, 12). One-hundred seventy-one of 609 (28%) had Pediatric Cerebral Performance Category greater than or equal to 4 (primary outcome). The BIG constituted a multivariable predictor of Pediatric Cerebral Performance Category greater than or equal to 4 (odds ratio, 2.39; 95% CI, 1.81-3.15) after adjustment for neurosurgery requirement (odds ratio, 2.83; 95% CI, 1.69-4.74), pupils fixed and dilated (odds ratio, 3.1; 95% CI, 1.49-6.38), and intubation at the scene or referral hospital (odds ratio, 2.82; 95% CI, 1.35-5.87) and other postulated predictors of poor outcome. The area under the BIG receiver operating characteristic curve was 0.87 (0.84-0.90). Using an optimal BIG cutoff less than or equal to 8, sensitivity and negative predictive value for functional dependence at discharge were 93% and 96%, respectively, compared with a sensitivity of 79% and negative predictive value of 91% with Glasgow Coma Scale less than or equal to 8. In children with Glasgow Coma Scale 3, the BIG score was associated with brain death (odds ratio, 2.13; 95% CI, 1.58-2.36). The BIG also predicted disposition to inpatient rehabilitation (odds ratio, 2.26; 95% CI, 2.17-2.35). CONCLUSIONS: The BIG score is a simple, rapidly obtainable severity of illness score that constitutes an independent predictor of functional dependence at hospital discharge in pediatric trauma patients with traumatic brain injury. The BIG score may benefit Trauma and Neurocritical care programs in identifying ideal candidates for traumatic brain injury trials within the therapeutic window of treatment.

Subarachnoid hemorrhage prevalence and its association with short-term outcome in pediatric severe traumatic brain injury.

BACKGROUND: Subarachnoid hemorrhage (SAH) is an independent prognostic indicator of outcome in adult severe traumatic brain injury (sTBI). There is a paucity of investigations on SAH in pediatric sTBI. The goal of this study was to determine in pediatric sTBI patients SAH prevalence, associated factors, and its relationship to short-term outcome. METHODS: We retrospectively analyzed 171 sTBI patients (pre-sedation GCS ≤8 and head MAIS ≥4) who underwent CT head imaging within the first 24 h of hospital admission. Data were analyzed with both univariate and multivariate techniques. RESULTS: SAH was found in 42 % of sTBI patients (n = 71/171), and it was more frequently associated with skull fractures, cerebral edema, diffuse axonal injury, contusion, and intraventricular hemorrhage (p < 0.05). Patients with SAH had higher Injury Severity Scores (p = 0.032) and a greater frequency of fixed pupil(s) on admission (p = 0.001). There were no significant differences in etiologies between sTBI patients with and without SAH. Worse disposition occurred in sTBI patients with SAH, including increased mortality (p = 0.009), increased episodes of central diabetes insipidus (p = 0.002), greater infection rates (p = 0.002), and fewer ventilator-free days (p = 0.001). In sTBI survivors, SAH was associated with increased lengths of stay (p < 0.001) and a higher level of care required on discharge (p = 0.004). Despite evidence that SAH is linked to poorer outcomes on univariate analyses, multivariate analysis failed to demonstrate an independent association between SAH and mortality (p = 0.969). CONCLUSION: SAH was present in almost half of pediatric sTBI patients, and it was indicative of TBI severity and a higher level of care on discharge. SAH in pediatric patients was not independently associated with increased risk of mortality.

Temporal trends in anaphylaxis ED visits over the last decade and the effect of COVID-19 pandemic on these trends.

BACKGROUND: Anaphylaxis is an acute systemic and potentially fatal allergic reaction. We evaluated trends in yearly rates of anaphylaxis in a pediatric Emergency Department (ED) in Montreal, Canada. METHODS: A prospective and retrospective recruitment process was used to find families of children who had presented with anaphylaxis at the Montreal Children's Hospital between April 2011 and April 2021. Using a uniform recruitment form, data were collected. Anaphylaxis patterns were compared to clinical triggers using descriptive analysis. RESULTS: Among 830,382 ED visits during the study period, 2726 (26% recruited prospectively) presented with anaphylaxis. The median age was 6 years (IQR: 0.2, 12.00), and 58.7% were males. The relative frequency of anaphylaxis cases doubled between 2011-2015, from 0.22% (95% CI, 0.19, 0.26) to 0.42 March 2020, the total absolute number of anaphylaxis cases and relative frequency declined by 24 cases per month (p < 0.05) and by 0.5% of ED visits (p < 0.05). CONCLUSIONS: The rate of anaphylaxis has changed over the years, representing modifications in food introduction strategies or lifestyle changes. The decrease in the frequency of anaphylaxis presenting to the ED during the COVID pandemic may reflect decreased accidental exposures with reduced social gatherings, closed school, and reluctance to present to ED.

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.

Fruit-Induced Anaphylaxis: Clinical Presentation and Management.

BACKGROUND: Data are sparse regarding the clinical characteristics and management of fruit-induced anaphylaxis. OBJECTIVE: To assess clinical characteristics and management of patients with fruit-induced anaphylaxis and determine factors associated with severe reactions and epinephrine use. METHODS: Over 9 years, children and adults presenting with anaphylaxis to seven emergency departments in four Canadian provinces and patients requiring emergency medical services in Outaouais, Quebec were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting symptoms, triggers, and management was collected. Multivariate logistic regression was used to identify factors associated with severe reactions and epinephrine treatment in the pre-hospital setting. RESULTS: We recruited 250 patients with fruit-induced anaphylaxis, median age 10.2 years (interquartile range, 3.6-23.4 years); 48.8% were male. The most common fruit triggers were kiwi (15.6%), banana (10.8%), and mango (9.2%). Twenty-three patients reported having eczema (9.3%). Epinephrine use was low in both the pre-hospital setting and the emergency department (28.4% and 40.8%, respectively). Severe reactions to fruit were more likely to occur in spring and among those with eczema (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI], 1.03-1.23; and 1.17, 95% CI, 1.03-1.34, respectively). Patients with moderate and severe reactions (aOR = 1.23; 95% CI, 1.06-1.43) and those with a known food allergy (aOR = 1.38; 95% CI, 1.24-1.54) were more likely to be treated with epinephrine in the pre-hospital setting. CONCLUSIONS: Severe anaphylaxis to fruit is more frequent in spring. Cross-reactivity to pollens is a potential explanation that should be evaluated further.

Solar urticaria in a 1-year-old infant: diagnosis and management.

Solar urticaria is a type of inducible urticaria triggered by sun exposure resulting in hives on exposed skin as well as risk of developing systemic symptoms. Most cases are reported in the adult population. However, cases do occur in children. We present a case of visible light induced urticaria in a 12-month-old girl that demonstrates the need for accurate diagnosis and appropriate management.

Cold-induced urticaria: challenges in diagnosis and management.

Cold-induced urticaria (CU) is a chronic physical urticaria that can be hard to diagnose and manage. Symptoms of CU can vary from mild localised urticaria, angio-oedema to anaphylaxis. CU may be induced by a wide range of cold triggers from aquatic activities to ingestions of cold substances. This exemplifies the importance of accurate diagnosis and management of patients with CU. We present three cases of CU that demonstrate the variability in triggers and clinical presentation.