Neta Cohen1, Tali Capua2, Dikla Pivko2, Moshe Ben-Shoshan3, Shira Benor4, Ayelet Rimon2. 1. Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel. Electronic address: netarab81@gmail.com. 2. Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel. 3. Montreal Children's Hospital, Montreal, Quebec, Canada. 4. Allergy and Clinical Immunology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel.
Abstract
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 to compare correctly diagnosed and misdiagnosed cases. METHODS: All records of patients presenting to a tertiary care PED between 2013 and 2016 with a final diagnosis of anaphylaxis or allergic reaction were reviewed. RESULTS: The rate of anaphylaxis increased from 0.1% between 2013 and 2014 and 0.24% between 2015 and 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 study periods (88% in 2013-2014 and 91% in 2015-2016), with milk (20% in 2013-2014 and 28% in 2015-2016) and tree nuts (23.1% in 2013-2014 and 23.7% in 2015-2016 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 throughout the study. Referral to an allergist increased from 68% in 2013 to 2014 to 90% in 2015 to 2016. CONCLUSION: The rate of visits attributable 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.
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 to compare correctly diagnosed and misdiagnosed cases. METHODS: All records of patients presenting to a tertiary care PED between 2013 and 2016 with a final diagnosis of anaphylaxis or allergic reaction were reviewed. RESULTS: The rate of anaphylaxis increased from 0.1% between 2013 and 2014 and 0.24% between 2015 and 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 study periods (88% in 2013-2014 and 91% in 2015-2016), with milk (20% in 2013-2014 and 28% in 2015-2016) and tree nuts (23.1% in 2013-2014 and 23.7% in 2015-2016 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 throughout the study. Referral to an allergist increased from 68% in 2013 to 2014 to 90% in 2015 to 2016. CONCLUSION: The rate of visits attributable 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.
Authors: Mélanie Leung; Ann E Clarke; Sofianne Gabrielli; Judy Morris; Jocelyn Gravel; Rodrick Lim; Edmond S Chan; Ran D Goldman; Paul Enarson; Andrew O'Keefe; Jennifer Gerdts; Derek Chu; Julia Upton; Xun Zhang; Greg Shand; Moshe Ben-Shoshan Journal: CMAJ Date: 2020-09-21 Impact factor: 8.262