Trend in the Diagnosis and Management of Anaphylaxis in Tertiary Care Pediatric Emergency Department

Background: Underdiagnosis of anaphylaxis is a major concern in the pediatric emergency department (PED), leading to failure to administer and prescribe intramuscular epinephrine treatment.

Objective: To examine the clinical features, triggers and management of anaphylaxis in the PED, with a special focus on the rate of cases diagnosed and treated correctly over time, and compare between correctly diagnosed and misdiagnosed cases.

Methods: All records of patients presenting to a tertiary care PED between 2013-2016 with a final diagnosis of anaphylaxis or allergic reaction were reviewed.

Results: The rate of anaphylaxis increased from 0.1% between 2013-2014 and 0.24% between 2015-2016. Symptoms such as breathing difficulties and wheezing were found significantly less among misdiagnosed patients compared with patients correctly diagnosed with anaphylaxis. Food was the most common causative agent in both of the time periods (88% and 91% respectively), with milk (20% and 28% respectively) and tree nuts (23.1% and 23.7 % respectively (as the most prevalent identified triggers. Intramuscular epinephrine treatment in the prehospital and hospital settings and the automatic epinephrine injector prescription rate did not change significantly over the years. Referral to an allergist increased from 68% in 2013-2014 to 90% in 2015-2016.

Conclusion: The rate of visits due to anaphylaxis in our PED doubled during the study period, with milk allergy as the most common trigger. Most cases of misdiagnosed and undertreated anaphylaxis had no respiratory signs and symptoms. Novel methods to improve recognition of anaphylaxis and adherence to treatment guidelines are needed