clinical topic updates

Recognizing and Responding to Anaphylactic Food Reactions

by Aikaterini Anagnostou, MD, PhD

Overview

One of the most important aspects of anaphylaxis is its rapid progression. Knowledge of the potential symptoms of anaphylactic food reactions and familiarity with the use of an epinephrine autoinjector help parents and caregivers to take prompt, appropriate action during emergencies.

Expert Commentary

Aikaterini Anagnostou, MD, PhD

Professor of Pediatrics
Director, Food Immunotherapy Program
Director, Food Challenge Program
Co-Director, Food Allergy Program
Lead, Adolescent Transition for Allergy
Texas Children’s Hospital
Baylor College of Medicine
Houston, TX

“The potential variation in initial symptoms might cause some hesitancy or a delay in the use of epinephrine; however, following consistent training and education, patients and families are able to recognize reactions, especially in food-induced anaphylaxis.”

Aikaterini Anagnostou, MD, PhD

Symptoms of anaphylactic reactions vary from person to person and also from one episode to another in the same person. Allergic reactions are not identical to each other. A patient may develop hives and vomiting on one occasion, but, on another occasion, the hives may be accompanied by wheezing. This uncertainty can create anxiety, but what is most important in this scenario is that caregivers and patients become familiar with the possible symptoms of anaphylaxis and consider the possibility of an exposure to a food allergen when symptoms develop. The potential variation in initial symptoms might cause some hesitancy or a delay in the use of epinephrine; however, following consistent training and education, patients and families are able to recognize reactions, especially in food-induced anaphylaxis.

One of the most important things to remember about anaphylaxis is its progression, which is typically rapid. Most patients may develop skin or mucosal symptoms initially. These may be followed by gastrointestinal or respiratory symptoms, such as vomiting or wheezing. Anaphylaxis can be life threatening, but, fortunately, fatalities are rare.

A common misconception is that anaphylaxis only affects older children and adults. It is important to note that infants and toddlers may also present with an anaphylactic food reaction, and recognizing symptoms in these age groups may be particularly challenging. Very young children are nonverbal and are unable to communicate subjective symptoms such as itchiness of the mouth or nausea. Additionally, early symptoms of food-induced anaphylaxis may be nonspecific in these age groups. Fussiness, spitting up, and vomiting may occur within the normal spectrum for the infant’s/toddler’s age, which complicates matters. And symptoms such as hives or wheezing may be caused by a viral illness. The combination of symptom variability and a lack of specificity can complicate the recognition of anaphylaxis in the very young. Parents and caregivers find it easier to recognize anaphylaxis in older children. 

The first-line treatment for anaphylaxis is the administration of epinephrine. This action should be followed by a call to emergency services to transport the child to the Emergency Department. Some caregivers may be fearful or reluctant to inject the child and would prefer to simply wait for emergency services and/or to give an antihistamine while waiting, neither of which is recommended. To counter this, we encourage parents to practice using an autoinjector training device so that they become familiar with the process and are prepared if their child experiences an anaphylactic reaction. The prompt use of epinephrine in emergencies has the potential to protect patients from undesired outcomes.

References

American College of Allergy Asthma & Immunology. Anaphylaxis. Accessed November 9, 2021. https://acaai.org/allergies/symptoms/anaphylaxis/ 

Carlisle A, Lieberman J. Clinical management of infant anaphylaxis. J Asthma Allergy. 2021;14:821-827. doi:10.2147/JAA.S286692

Greenhawt M, Gupta RS, Meadows JA, et al. Guiding principles for the recognition, diagnosis, and management of infants with anaphylaxis: an expert panel consensus. J Allergy Clin Immunol Pract. 2019;7(4):1148–1156.e5. doi:10.1016/j.jaip.2018.10.052 

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(1):162-8.e1-3. doi:10.1016/j.jaci.2011.09.018

Rudders SA, Banerji A, Clark S, Camargo CA Jr. Age-related differences in the clinical presentation of food-induced anaphylaxis. J Pediatr. 2011;158(2):326-328. doi:10.1016/j.jpeds.2010.10.017

Simons FER, Sampson HA. Anaphylaxis: unique aspects of clinical diagnosis and management in infants (birth to age 2 years). J Allergy Clin Immunol. 2015;135(5):1125-1131. doi:10.1016/j. jaci.2014.09.014

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