Asia Pac Allergy.  2013 Apr;3(2):106-114. 10.5415/apallergy.2013.3.2.106.

Clinical evaluation of pediatric anaphylaxis and the necessity for multiple doses of epinephrine

• Inoue N
• Yamamoto A

• KMID: 2400406
• DOI: http://doi.org/10.5415/apallergy.2013.3.2.106

Abstract

BACKGROUND
Epinephrine administered intramuscularly is the treatment of choice for anaphylaxis, and more than 1 dose is occasionally required.
OBJECTIVE
To determine clinical background of anaphylaxis for improving the treatment, management, and prognosis of anaphylaxis.
METHODS
Children who had satisfied the diagnostic criteria for anaphylaxis according to the National Institute of Allergy and Infectious Disease Food Allergy and Anaphylaxis Network were selected from our hospital from April 1, 2009 to March 31, 2012.
RESULTS
We analyzed 61 patients from the ages of 2 months to 14 years who satisfied the diagnostic criteria for anaphylaxis. Parents of 32 children (52.5%) reported that they had been administered single dose of epinephrine, and 3 children (4.9%) reported receiving multiple doses of epinephrine. The latter group experienced syncope more often (p = 0.049) than the former and suffered more often from comorbid allergic diseases (p = 0.043) that included either bronchial asthma, allergic rhinitis, or atopic dermatitis. Two (3.3%) children experienced biphasic reactions. Patients who experienced a biphasic reaction were more likely to have experienced syncope (p = 0.033), vomiting (p = 0.02), and administration of multiple doses of epinephrine (p = 0.0016).
CONCLUSION
Our findings lead us to recommend that children receiving more than 1 injection of epinephrine should be observed for 24 hours, because it seems that children with requiring more than 1 injection of epinephrine might be have biphasic reactions.

Keyword

Epinephrine; Children; Biphasic anaphylaxis; Anaphylaxis

MeSH Terms

Anaphylaxis*
Asthma
Child
Communicable Diseases
Dermatitis, Atopic
Epinephrine*
Food Hypersensitivity
Humans
Hypersensitivity
Parents
Prognosis
Rhinitis, Allergic
Syncope
Vomiting
Epinephrine

Reference

1. Simons FE, Ardusso LR, Biló MB, El-Gamal YM, Ledford DK, Ring J, Sanchez-Borges M, Senna GE, Sheikh A, Thong BY. World Allergy Organization. World Allergy Organization anaphylaxis guidelines: summary. J Allergy Clin Immunol. 2011; 127:587–593.e1-22. PMID: 21377030.

2. Lieberman P, Camargo CA Jr, Bohlke K, Jick H, Miller RL, Sheikh A, Simons FE. Epidemiology of anaphylaxis: findings of the American College of Allergy, Asthma and Immunology Epidemiology of Anaphylaxis Working Group. Ann Allergy Asthma Immunol. 2006; 97:596–602. PMID: 17165265.

3. Decker WW, Campbell RL, Manivannan V, Luke A, St Sauver JL, Weaver A, Bellolio MF, Bergstralh EJ, Stead LG, Li JT. The etiology and incidence of anaphylaxis in Rochester, Minnesota: a report from the Rochester Epidemiology Project. J Allergy Clin Immunol. 2008; 122:1161–1165. PMID: 18992928.

4. Sheikh A, Hippisley-Cox J, Newton J, Fenty J. Trends in national incidence, lifetime prevalence and adrenaline prescribing for anaphylaxis in England. J R Soc Med. 2008; 101:139–143. PMID: 18344471.

5. Liew WK, Williamson E, Tang ML. Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol. 2009; 123:434–442. PMID: 19117599.

6. Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001; 107:191–193. PMID: 11150011.

7. NIAID-Sponsored Expert Panel. Boyce JA, Assa'ad A, Burks AW, Jones SM, Sampson HA, Wood RA, Plaut M, Cooper SF, Fenton MJ, Arshad SH, Bahna SL, Beck LA, Byrd-Bredbenner C, Camargo CA Jr, Eichenfield L, Furuta GT, Hanifin JM, Jones C, Kraft M, Levy BD, Lieberman P, Luccioli S, McCall KM, Schneider LC, Simon RA, Simons FE, Teach SJ, Yawn BP, Schwaninger JM. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010; 126:S1–S58. PMID: 21134576.

8. Muraro A, Roberts G, Clark A, Eigenmann PA, Halken S, Lack G, Moneret-Vautrin A, Niggemann B, Rancé F. EAACI Task Force on Anaphylaxis in Children. The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology. Allergy. 2007; 62:857–871. PMID: 17590200.

9. Rudders SA, Banerji A, Corel B, Clark S, Camargo CA Jr. Multicenter study of repeat epinephrine treatments for food-related anaphylaxis. Pediatrics. 2010; 125:e711–e718. PMID: 20308215.

10. Oren E, Banerji A, Clark S, Camargo CA Jr. Food-induced anaphylaxis and repeated epinephrine treatments. Ann Allergy Asthma Immunol. 2007; 99:429–432. PMID: 18051213.

11. Kelso JM. A second dose of epinephrine for anaphylaxis: how often needed and how to carry. J Allergy Clin Immunol. 2006; 117:464–465. PMID: 16461150.

12. Uguz A, Lack G, Pumphrey R, Ewan P, Warner J, Dick J, Briggs D, Clarke S, Reading D, Hourihane J. Allergic reactions in the community: a questionnaire survey of members of the anaphylaxis campaign. Clin Exp Allergy. 2005; 35:746–750. PMID: 15969665.

13. Banerji A, Rudders SA, Corel B, Garth AM, Clark S, Camargo CA Jr. Repeat epinephrine treatments for food-related allergic reactions that present to the emergency department. Allergy Asthma Proc. 2010; 31:308–316. PMID: 20819321.

14. Webb LM, Lieberman P. Anaphylaxis: a review of 601 cases. Ann Allergy Asthma Immunol. 2006; 97:39–43. PMID: 16892779.

15. Järvinen KM, Sicherer SH, Sampson HA, Nowak-Wegrzyn A. Use of multiple doses of epinephrine in food-induced anaphylaxis in children. J Allergy Clin Immunol. 2008; 122:133–138. PMID: 18547626.

16. Manivannan V, Campbell RL, Bellolio MF, Stead LG, Li JT, Decker WW. Factors associated with repeated use of epinephrine for the treatment of anaphylaxis. Ann Allergy Asthma Immunol. 2009; 103:395–400. PMID: 19927537.

17. Huang F, Chawla K, Järvinen KM, Nowak-Węgrzyn A. Anaphylaxis in a New York City pediatric emergency department: triggers, treatments, and outcomes. J Allergy Clin Immunol. 2012; 129:162–168.e1-3. PMID: 22018905.

18. Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, Brown SG, Camargo CA Jr, Cydulka R, Galli SJ, Gidudu J, Gruchalla RS, Harlor AD Jr, Hepner DL, Lewis LM, Lieberman PL, Metcalfe DD, O'Connor R, Muraro A, Rudman A, Schmitt C, Scherrer D, Simons FE, Thomas S, Wood JP, Decker WW. Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol. 2006; 117:391–397. PMID: 16461139.

19. Pawankar R, Canonica GW, Holgate ST, Lockey RF. WAO white book on allergy 2011-2012: executive summary [Internet]. 2012. Milwaukee, WI: World Allergy Organization;Available from: http://www.worldallergy.org/publications/wao_white_book.pdf.

20. Simons FE. Apparent lack of response to epinephrine in anaphylaxis. J Allergy Clin Immunol. 2005; 115:640. PMID: 15753921.

21. Lee JM, Greenes DS. Biphasic anaphylactic reactions in pediatrics. Pediatrics. 2000; 106:762–766. PMID: 11015520.

22. Mehr S, Liew WK, Tey D, Tang ML. Clinical predictors for biphasic reactions in children presenting with anaphylaxis. Clin Exp Allergy. 2009; 39:1390–1396. PMID: 19486033.

23. Lieberman P. Biphasic anaphylactic reactions. Ann Allergy Asthma Immunol. 2005; 95:217–226. PMID: 16200811.