Anaphylaxis (Pediatric) Initial Assessment

Clinical Presentation

Signs and Symptoms  

The patient’s age is not correlated with reaction severity and initial reaction to an allergen leading to anaphylaxis is unlikely when it comes to infants and toddlers. Age-specific symptoms are less often seen in older children and adults may be seen in infants and toddlers. It must be noted that the longer the symptoms develop, the less severe the overall reaction. Grading the severity of clinical symptoms as 1 to 5 based on the organ system affected may be helpful in the diagnosis and timely administration of Epinephrine.  

Cutaneous  

The most common manifestation of anaphylaxis is cutaneous, occurring in more than 90% of cases. However, it must be noted that cutaneous manifestations may be delayed or absent in rapidly progressive anaphylactic reaction. Cutaneous manifestations include urticaria, angioedema (including periorbital edema, conjunctival swelling), flushing, and pruritus (may begin on the palms and soles).  

Respiratory  

Respiratory manifestations of anaphylaxis occur in up to 85% of episodes. Respiratory manifestations include rhinorrhea, nasal congestion, throat tightness, hoarseness, sudden or ‘barky’ cough, stridor, wheeze, dyspnea, and chest tightness.  

Gastrointestinal  

Gastrointestinal manifestations of anaphylaxis occur in up to 45% of episodes. These include oral pruritus, nausea, vomiting, dysphagia, diarrhea, and crampy abdominal pain.  

Cardiovascular  

Cardiovascular manifestations of anaphylaxis occur in up to 45% of episodes. These include dizziness, tachycardia, chest pain, hypotension, and collapse.  

Neurological  

Neurological manifestations of anaphylaxis include restlessness, withdrawal behavior, dizziness, lightheadedness, sense of impending doom, confusion, loss of consciousness, headache, and seizure. 

Anaphylaxis (Pediatric)_Initial Assesment

History

History taking is a key part of the diagnostic work-up. It is important to identify risk and predisposing factors for possible recurrence (eg history of previous anaphylactic reactions, history of atopy, asthma even if well-controlled, adolescence, family history of any type of allergic reaction). Family history remains the most practical and useful tool in identifying allergy-prone infants. The presence of allergic diseases in one or both parents and in a sibling increases the likelihood of allergy in a child. The time of the onset of symptoms and the circumstances prior to the reaction are determined and recorded, including the treatments given. A detailed history of all the food and drugs taken, and all the patient’s activities, including history of sting or bite is obtained within a 2-hour period of the episode. 

Diagnosis or Diagnostic Criteria

Clinical Criteria for the Diagnosis of Anaphylaxis  

Diagnosis of anaphylaxis is highly likely when any one of the following is fulfilled:

• Acute onset of illness minutes to several hours' duration involving the skin, mucosal tissue, or both (eg pruritus, flushing, generalized hives, edema of the lips, tongue and uvula)
• Plus at least one of the following:
  • Respiratory compromise (eg dyspnea, stridor, bronchospasms, wheezing, hypoxia, decreased peak expiratory flow [PEF])
  • Reduced blood pressure (BP) or end-organ dysfunction symptoms (eg collapse, syncope, incontinence)

Two or more of the following that occur rapidly after exposure to a likely allergen of minutes to several hours:

• Skin or mucosal tissue involvement (eg pruritus, flushing, generalized hives, edema of the lips, tongue and uvula)
• Respiratory compromise (eg dyspnea, stridor, wheeze, bronchospasm, hypoxia, decreased PEF)
• Reduced BP or associated symptoms (eg collapse, syncope, incontinence)
• Gastrointestinal symptoms that are persistent (eg crampy abdominal pain, vomiting)

Decreased BP after exposure to known allergen of minutes to several hours’ duration. Hypotension is defined as:

• Systolic BP (SBP) <60 mmHg for term neonates (0 to 28 days)
• SBP <70 mmHg for 1 month to 1 year of age
• SBP <(70 mmHg + [2 x age]) for 1 to 10 years of age
• SBP <90 mmHg for 11 to 17 years of age
• >30% decrease in SBP for all ages