Evaluation of clinical and laboratory features of cases with infant anaphylaxis

Öz

Aim: The incidence of infant anaphylaxis has been increasing. The diagnosis of anaphylaxis in this age group is very difficult and there is limited data in the literature. In our study, we aimed to determine the etiology, clinical and laboratory features of anaphylaxis cases observed in the infantile age group. Method: The records of 16 children under two years of age who were followed with the diagnosis of infant anaphylaxis in the Pediatric Immunology and Allergy Clinic of Mersin University Faculty of Medicine between January 2020 and January 2023 were evaluated retrospectively. Results: A total of 16 infant anaphylaxis patients; 10 (62.5%) boys and six (37.5%) girls, were included in the study. The mean age at the onset of anaphylaxis was 5.68±3.75 months. Food was identified as the trigger in 14 patients (87.5%) and drugs in two cases (12.5%). Milk (n=8, 50%) was the most common causative agent. Five (31.2%) of our patients had atopic dermatitis and three (18.7%) had episodic wheezing. Skin and/or mucous membrane involvement were the most common ivolvement (n=15, 93.7%), followed by respiratory system involvement (n=12, 75%). The most common clinical finding was urticaria with a rate of 68.7%, and wheezing (62.5%) and dyspnea (62.5%) were other common findings. All patients with a history of food anaphylaxis had positive skin prick test and/or specific immunglobulin-E with the responsible food. Adrenaline was administered intramuscularly in seven patients (43.7%). Seven patients (43.7%) were prescribed adrenaline auto-injectors as prophylaxis after anaphylaxis. Conclusion: In our study, it was found that the most common triggering agents were cow's milk and egg. The most commonly involved system was the skin, but cardiovascular and neurologic involvement were also possible. Adrenaline administration as the first-line treatment and adrenaline auto-injector prescription rate were low, and the use of auto-injectors by parents was low. There is a need to raise awareness and educate healthcare professionals, parents and caregivers about infant anaphylaxis.

Anahtar Kelimeler

• Infant
• anaphylaxis
• adrenaline

İnfant anafilaksi olgularının klinik ve laboratuvar özelliklerinin değerlendirilmesi

Öz

Amaç: İnfant anafilaksi insidansı giderek artmaktadır. Bu yaş grubunda anafilaksi tanısının konulması oldukça zordur ve literatürde bu konu ile ilgili veriler kısıtlıdır. Çalışmamızda infantil yaş grubunda gözlenen anafilaksi olgularının etiyolojileri, klinik ve laboratuvar özelliklerinin belirlenmesi amaçlanmıştır. Yöntem: Mersin Üniversitesi Tıp Fakültesi Çocuk İmmünoloji ve Alerji Kliniği’nde Ocak 2020-Ocak 2023 tarihleri arasında infant anafilaksisi tanısıyla izlenen iki yaş altı 16 çocuğun dosyaları retrospektif olarak değerlendirildi. Bulgular: Çalışmaya 10 (%62.5) erkek, altı (%37.5) kız olmak üzere toplam 16 infant anafilaksi hastası dahil edildi. Anafilaksi geçirme yaşı ortalama 5.68±3.75 aydı. Hastaların 14’ünde (%87.5) tetikleyici olarak besin, iki olguda ise ilaç (%12.5) olarak belirlendi. Besinlerden ise en sık süt (n=8, %50) nedensel ajan olarak belirlendi. Hastalarımızın beşinde (%31.2) atopik dermatit, üçünde (%18.7) epizodik hışıltı eşlik etmekteydi. Hastalarımızda en sık deri ve/veya mukoza tutulumu görülürken (n=15, %93.7), bunu solunum sistemi tutulumu takip etti (n=12, %75). En sık görülen klinik bulgu %68.7 oranında ürtiker olup, hışıltı (%62.5) ve solunum sıkıntısı (%62.5) diğer sık görülen bulgulardı. Besin anafilaksisi öyküsü olan hastaların tamamında sorumlu besin ile yapılan deri prik testi ve/veya spesifik immünglobulin E pozitifti. Tedavi olarak yedi hastaya (%43.7) adrenalin intramuskuler uygulandı. Profilaksi olarak yedi hastaya (%43.7) anafilaksi sonrası adrenalin oto-enjektör reçete edildiği görüldü. Sonuç: Çalışmamızda en yaygın tetikleyici ajanın inek sütü ve yumurta, en sık tutulan sistemin deri olduğu ancak kardiyovasküler ve nörolojik tutulumunda olabileceği, ilk tedavi olarak adrenalin uygulamasının ve adrenalin oto-enjektör reçeteleme oranlarının düşük olduğu, ebeveynlerde oto-enjektör kullanımının az olduğu saptanmıştır. İnfant anafilaksisi konusunda sağlık çalışanlarının, ebeveynlerin ve diğer bakım verenlerin bilinçlendirilmesi ve eğitilmesi gerekmektedir.

Anahtar Kelimeler

• İnfant
• anafilaksi
• adrenalin

Kaynakça

1. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. 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. Feb 2006;117:391-397. doi:10.1016/j.jaci.2005.12.1303
2. Cardenas-Morales M, Hernandez-Trujillo V. Infant Anaphylaxis: A Diagnostic Challenge. Curr Allergy Asthma Rep. Feb 23 2021;21:12. doi:10.1007/s11882-021-00990-4
3. Simons FE, Sampson HA. Anaphylaxis: Unique aspects of clinical diagnosis and management in infants (birth to age 2 years). J Allergy Clin Immunol. May 2015;135:1125-1131. doi:10.1016/j.jaci.2014.09.014
4. Motosue MS, Bellolio MF, Van Houten HK, Shah ND, Campbell RL. National trends in emergency department visits and hospitalizations for food-induced anaphylaxis in US children. Pediatr Allergy Immunol. Aug 2018;29:538-544. doi:10.1111/pai.12908
5. Andrew E, Nehme Z, Bernard S, Smith K. Pediatric Anaphylaxis in the Prehospital Setting: Incidence, Characteristics, and Management. Prehosp Emerg Care. Jul-Aug 2018;22:445-451. doi:10.1080/10903127.2017.1402110
6. Dosanjh A. Infant anaphylaxis: the importance of early recognition. J Asthma Allergy. 2013;6:103-107. doi:10.2147/jaa.S42694
7. Muraro A, Worm M, Alviani C, et al. EAACI guidelines: Anaphylaxis (2021 update). Allergy. Feb 2022;77:357-377. doi:10.1111/all.15032
8. Dibek Misirlioglu E, Vezir E, Toyran M, et al. Clinical diagnosis and management of anaphylaxis in infancy. Allergy Asthma Proc. Jan 1 2017;38:38-43. doi:10.2500/aap.2017.38.4009

9. Muraro A, Roberts G, Worm M, et al. Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology. Allergy. Aug 2014;69:1026-1045. doi:10.1111/all.12437
10. Dinakar C. Anaphylaxis in children: current understanding and key issues in diagnosis and treatment. Curr Allergy Asthma Rep. Dec 2012;12:641-649. doi:10.1007/s11882-012-0284-1
11. Rudders SA, Banerji A, Clark S, Camargo CA, Jr. Age-related differences in the clinical presentation of food-induced anaphylaxis. J Pediatr. Feb 2011;158:326-328. doi:10.1016/j.jpeds.2010.10.017
12. Topal E, Bakirtas A, Yilmaz O, et al. Anaphylaxis in infancy compared with older children. Allergy Asthma Proc. May-Jun 2013;34:233-238. doi:10.2500/aap.2013.34.3658
13. Kahveci M, Akarsu A, Koken G, Sahiner UM, Soyer O, Sekerel BE. Food-induced anaphylaxis in infants, as compared to toddlers and preschool children in Turkey. Pediatr Allergy Immunol. Nov 2020;31:954-961. doi:10.1111/pai.13320
14. Samady W, Trainor J, Smith B, Gupta R. Food-induced anaphylaxis in infants and children. Ann Allergy Asthma Immunol. Sep 2018;121:360-365. doi:10.1016/j.anai.2018.05.025
15. 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. Apr 2019;7:1148-1156.e1145. doi:10.1016/j.jaip.2018.10.052
16. Simons FE. Anaphylaxis in infants: can recognition and management be improved? J Allergy Clin Immunol. Sep 2007;120:537-540. doi:10.1016/j.jaci.2007.06.025
17. Orhan F, Civelek E, Şahiner ÜM, et al. Anaphylaxis: Turkish national guideline 2018. 2018; Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol. Nov 2015;115:341-384. doi:10.1016/j.anai.2015.07.019
18. Rajani PS, Martin H, Groetch M, Järvinen KM. Presentation and Management of Food Allergy in Breastfed Infants and Risks of Maternal Elimination Diets. J Allergy Clin Immunol Pract. Jan 2020;8:52-67. doi:10.1016/j.jaip.2019.11.007
19. Belhocine W, Ibrahim Z, Grandné V, et al. Total serum tryptase levels are higher in young infants. Pediatr Allergy Immunol. Sep 2011;22:600-607. doi:10.1111/j.1399-3038.2011.01166.x
20. Lee S, Sadosty AT, Campbell RL. Update on biphasic anaphylaxis. Curr Opin Allergy Clin Immunol. Aug 2016;16:346-351. doi:10.1097/aci.0000000000000279
21. Arıkoğlu T, Ozhan AK, Kuyucu S. Management of Anaphylaxis in Pediatric Population. Curr Pharm Des. 2023;29:209-223. doi:10.2174/1381612829666221021154032
22. Mehr S, Liew WK, Tey D, Tang ML. Clinical predictors for biphasic reactions in children presenting with anaphylaxis. Clin Exp Allergy. Sep 2009;39:1390-1396. doi:10.1111/j.1365-2222.2009.03276.x
23. Robinson M, Greenhawt M, Stukus DR. Factors associated with epinephrine administration for anaphylaxis in children before arrival to the emergency department. Ann Allergy Asthma Immunol. Aug 2017;119:164-169. doi:10.1016/j.anai.2017.06.001
24. Jeon YH, Lee S, Ahn K, et al. Infantile Anaphylaxis in Korea: a Multicenter Retrospective Case Study. J Korean Med Sci. Apr 8 2019;34:e106. doi:10.3346/jkms.2019.34.e106
25. Pouessel G, Jean-Bart C, Deschildre A, et al. Food-induced anaphylaxis in infancy compared to preschool age: A retrospective analysis. Clin Exp Allergy. Jan 2020;50:74-81. doi:10.1111/cea.13519
26. Erdem SB, Karaman S, Nacaroğlu HT, et al. Anafilakside Riskli Grup: İnfant Anafilaksisi. Asthma Allergy Immunology/Astim Allerji Immunoloji. 2016;14
27. Serbes M, Sasihuseyinoglu AS, Ozcan D, Ufuk Altıntas D. Clinical features of anaphylaxis in children. Allergy Asthma Proc. Jan 1 2022;43:50-56. doi:10.2500/aap.2022.43.210089
28. Fazıl Orhan EC, Ümit Murat Şahiner, Mustafa Arga, Demet Can, Ahmet Zafer Çalışkaner,Feyzullah Çetinkaya. Anaphylaxis: Turkish National Guideline 2018. Asthma Allergy Immunol. 2018 2018;16:1-62.
29. Carlisle A, Lieberman J. Clinical Management of Infant Anaphylaxis. J Asthma Allergy. 2021;14:821-827. doi:10.2147/jaa.S286692
30. Halbrich M, Mack DP, Carr S, Watson W, Kim H. CSACI position statement: epinephrine auto-injectors and children < 15 kg. Allergy Asthma Clin Immunol. 2015;11:20. doi:10.1186/s13223-015-0086-9
31. Wright CD, Longjohn M, Lieberman PL, Lieberman JA. An analysis of anaphylaxis cases at a single pediatric emergency department during a 1-year period. Ann Allergy Asthma Immunol. Apr 2017;118:461-464. doi:10.1016/j.anai.2017.02.002
32. Chad L, Ben-Shoshan M, Asai Y, et al. A majority of parents of children with peanut allergy fear using the epinephrine auto-injector. Allergy. Dec 2013;68:1605-1609. doi:10.1111/all.12262
33. Alvarez-Perea A, Ameiro B, Morales C, et al. Anaphylaxis in the Pediatric Emergency Department: Analysis of 133 Cases After an Allergy Workup. J Allergy Clin Immunol Pract. Sep-Oct 2017;5:1256-1263. doi:10.1016/j.jaip.2017.02.011
34. Esenboga S, Ocak M, Cetinkaya PG, et al. Physicians prescribe adrenaline autoinjectors, do parents use them when needed? Allergol Immunopathol (Madr). Jan-Feb 2020;48:3-7. doi:10.1016/j.aller.2019.07.009
35. Simons FE, Ardusso LR, Bilò MB, et al. International consensus on (ICON) anaphylaxis. World Allergy Organ J. 2014;7:9. doi:10.1186/1939-4551-7-9