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Pediatrics, Anaphylaxis: Treatment & Medication
Updated: Oct 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Prehospital care should be directed at stabilization of the airway, breathing, and circulation.
- Epinephrine is the first drug of choice.
- The 1:1000 strength should preferentially be administered intramuscularly (IM) in to the thigh. Subcutaneous administration is no longer recommended.16
- Intravenous (IV) or intraosseous (IO) administration (1:10,000 strength) should be reserved for patients with marked hypotension.
- High-flow oxygen by nonrebreather mask
- In the awake child who is having some difficulty maintaining their airway, a nasopharyngeal (NP) airway is better tolerated than an oropharyngeal (OP) airway.
- Continuous positive airway pressure (CPAP) may be considered prior to using an advanced airway (eg, noninvasive pharyngeal airway, endotracheal intubation) if the child is unable to maintain his or her airway, has decreased oxygen saturation, and/or has decreasing level of consciousness.
- Nebulized albuterol should be administered for cough and wheezing unresponsive to epinephrine.
- Intravenous (IV) access should be obtained. Intraosseous (IO) access should be considered when intravenous access cannot be quickly obtained in unstable patients.
- Patients with signs of poor profusion should be placed in a modified Trendelenburg position with the legs elevated.
- Crystalloid fluids should be given rapidly if the patient is hypotensive or has other signs of shock.
- Diphenhydramine may be given orally (for mild symptoms) via intramuscular or intravenous administration.
Emergency Department Care
Not all patients will present in shock. Most patients present with skin complaints (eg, urticaria, angioedema) along with respiratory or cardiovascular symptoms. Primary attention is directed at the ABCs. If not already given, epinephrine (which acts as a physiologic antagonist) should be administered as soon as the diagnosis is suspected.
- Epinephrine, 1:1000 intramuscularly (IM), is the initial drug of choice. It may be repeated every 5-15 minutes. Administration in the anterolateral thigh appears to provide superior absorption compared with deltoid and subcutaneous injections.17,18 Subcutaneous injection is not recommended.12,16,19
- Because of the risk of potentially lethal dysrhythmias, intravenous/intraosseous (IV/IO) epinephrine (1:10,000) is reserved for the patient with uncompensated shock.
- If the patient is hypoxic or with respiratory complaints, high-flow oxygen (warm, humidified preferred) by nonrebreather mask should be given.
- The use of noninvasive positive pressure (eg, CPAP) may help avoid the need for an advanced airway. In those patients with signs of significant hypoxia, an advanced airway (eg, supraglottic airway device, endotracheal intubation) should be considered. The airway should be secured with an endotracheal tube early in cases of upper airway obstruction.
- Nebulized albuterol (2.5-5 mg/dose) may be used for bronchospasm not responding to epinephrine.
- While the addition of ipratropium to albuterol has been shown to be beneficial in severe asthma exacerbations in children, this combination in anaphylaxis has not been studied.
- Nebulized epinephrine has been used for stridor secondary to laryngeal edema but has not been studied in anaphylaxis.
- An intravenous line should be started in all but the mildest cases. Intraosseous access should be considered when intravenous access cannot be quickly obtained in unstable patients.
- Placing the patient in the modified Trendelenburg position with legs elevated should be used for initial vascular support. Patients with hypotension unresponsive to positioning and epinephrine should receive a rapid crystalloid fluid bolus of (lactated Ringer or isotonic sodium chloride) of 20 mL/kg. Repeat boluses up to 60-80 mL/kg may be necessary for correcting the hypovolemia.
- Recall that children are more likely to have compensated shock where tachycardia and signs of hypoperfusion (eg, decreased peripheral pulses, cool extremities) are present but the blood pressure is normal.20 A systolic pressure of less than the 5th percentile for age would indicate uncompensated shock:
- <70 mm Hg in children aged 1-12 months
- <70 mm Hg + (2X age in years) in children aged 1-10 years
- <90 mm Hg in children ≥10 years of age
- Recall that children are more likely to have compensated shock where tachycardia and signs of hypoperfusion (eg, decreased peripheral pulses, cool extremities) are present but the blood pressure is normal.20 A systolic pressure of less than the 5th percentile for age would indicate uncompensated shock:
- Patients unresponsive to fluid resuscitation should receive vasopressors.
- Epinephrine (0.1-1 mcg/kg/min IV) should be considered as the initial vasopressor in children. Doses at <0.3 mcg/kg/min will tend to have more β-activity, whereas α-action becomes more pronounced at higher doses.
- Dopamine (2-20 mcg/kg/min IV) may be used in addition to epinephrine. Greater α-activity is seen at higher doses.
- Norepinephrine (0.1-2 mcg/kg/min IV) is a potent vasopressor. It is usually considered in children unresponsive to epinephrine.
- The combination of H1 and H2 antihistamines appears to be more effective, especially for cutaneous symptoms.12,21 Their onset of activity is slower than epinephrine and are considered next-in-line treatment.
- Diphenhydramine 1 mg/kg (not to exceed 50 mg/dose) may be given IV/IM/PO; oral use should be restricted to mild cases.
- Second-generation H1 antihistamines (eg, cetirizine, loratadine) have not been studied in anaphylaxis.
- Ranitidine 1 mg/kg (not to exceed 50 mg/dose IV or 150 mg/dose PO) has a low side effect profile in children. Oral treatment may be used in mild cases.
- Corticosteroids do not have an immediate effect on the symptoms but may help reduce or prevent a biphasic "late phase" reaction.
- The choice between of methylprednisolone (IV), prednisone, or prednisolone (PO) 1-2 mg/kg should be based on the patient's presentation and condition. The effect and time of onset are similar. Dose may be repeated at 6-hour intervals as indicated.
- No published studies compare dexamethasone with other corticosteroids in the treatment of anaphylaxis. However, based on its use in other allergic conditions, a dose of 0.15-0.6 mg/kg IV would be appropriate.
- Glucagon may help with refractory symptoms in the patient taking a beta-blocker. In children, administer 20-30 mcg/kg (not to exceed a cumulative dose of 1 mg) IV over 5 minutes followed by an IV maintenance infusion and titrated to clinical effect at 5-15 mcg/min.
- Observation and hospitalization
- A delayed or biphasic response may occur in 1-20% of patients.22 The literature is unclear as to which patients are at greatest risk from having this condition. The secondary response may be milder, the same, or more severe than the initial presentation.
- Even patients with mild symptoms should be observed for a minimum period of time. While the time of observation should be individualized to the patient, a minimum of 4-8 hours appears appropriate.
- Patients with greater risk of biphasic response should be observed a minimum of 12-24 hours. Severity of symptoms, delay in receiving epinephrine, and ingested antigen have been implicated as risk factors.
- Children who require fluid resuscitation, multiple doses of epinephrine, or repeated doses of a bronchodilator should be hospitalized.
- At a minimum, children who require vasopressors or glucagon should be admitted to a tertiary pediatric intensive care center.
Consultations
- ED consultation with a pediatric critical care specialist should be obtained in unstable patients and those unresponsive to treatment.
- Outpatient consultation with an allergist is appropriate for most patients with anaphylaxis, especially those with the following:
- Significant clinical presentation or those requiring prolonged treatment
- History of atopic disease
- Unclear trigger or inciting agent
- Recurrent episodes of anaphylaxis
Medication
It cannot be stressed enough that the early use of epinephrine is the most important step in managing anaphylaxis.11,16,23 Antihistamines (H1 and H2 blockers), corticosteroids, crystalloid fluids, and other adrenergic agonists can also be beneficial in the management of this condition.
Adrenergic Agonist Agents
These agents stimulate different adrenergic receptors. Effectiveness in treating anaphylaxis depends on which receptor types are stimulated and on the concentration of receptors in the target tissues.
Epinephrine (Adrenaline, EpiPen, EpiPen Jr.)
DOC for treating anaphylaxis. Elicits alpha-agonist effects that include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. Beta-agonist effects of epinephrine include bronchodilatation, chronotropic cardiac activity, and positive inotropic effects.
IM administration in the anterolateral thigh appears to provide superior absorption compared with deltoid and subcutaneous injections.
Adult
Pediatric
Initial treatment: 0.01 mg/kg/dose (ie, 0.01 mL/kg/dose 1:1000 [1 mg/mL]) IM q5-15min (dose range, 0.1-0.5 mg/dose)
Significant hypoperfusion evident: 0.01 mg/kg/dose IV/IO (ie, 0.1 mL/kg/dose 1:10,000 [0.1 mg/mL])
Auto-injectors for IM administration by patient or caregiver into (clothed or unclothed) anterolateral thigh:
10-20 kg:
EpiPen Jr (1:2000 [0.5 mg/mL]): Delivers 0.15 mg/dose (0.3 mL)
>20 kg:
EpiPen (1:1000; 1 mg/mL): Delivers 0.3 mg/dose (0.3 mL)
Increases toxicity of beta-blocking and alpha-blocking agents and of halogenated inhalational anesthetics; TCAs enhance pressor response
Documented hypersensitivity; cardiac arrhythmias or angle-closure glaucoma; local anesthesia in areas such as fingers or toes because vasoconstriction may produce sloughing of tissue; do not use during labor (may delay second stage of labor)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in elderly patients, prostatic hypertrophy, hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias
Dopamine (Intropin)
Stimulates both adrenergic and dopaminergic receptors. Hemodynamic effect is dependent on the dose. Lower doses (<5 mcg/kg/min) predominantly stimulate dopaminergic receptors that, in turn, produce renal and mesenteric vasodilation. Cardiac stimulation and renal vasodilation produced by higher doses.
Adult
Pediatric
1-20 mcg/kg/min IV; titrate to effect; not to exceed 50 mcg/kg/min
MAO inhibitors may prolong effects of dopamine; beta-adrenergic blockers may antagonize peripheral vasoconstriction caused by high doses of dopamine; butyrophenones (eg, haloperidol) and phenothiazines can suppress dopaminergic renal and mesenteric vasodilation induced with low-dose dopamine infusion; concurrent administration of diuretic agents with low-dose dopamine may produce additive effects on urine flow; hypotension and bradycardia may occur with phenytoin; dopamine may decrease effects of phenytoin
Documented hypersensitivity; pheochromocytoma; ventricular fibrillation
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Closely monitor urine flow, cardiac output, pulmonary wedge pressure, and blood pressure during infusion; prior to infusion, correct hypovolemia with either whole blood or plasma, as indicated; monitoring central venous pressure or left ventricular filling pressure may be helpful in detecting and treating hypovolemia
Norepinephrine (Levophed)
For protracted hypotension following adequate fluid-volume replacement. Stimulates beta1- and alpha-adrenergic receptors, which, in turn, increases cardiac muscle contractility and heart rate as well as vasoconstriction. As a result, systemic blood pressure and coronary blood-flow increases.
After obtaining a response, the rate of flow should be adjusted and maintained at a low normal blood pressure, such as 80-100 mm Hg systolic, sufficient to perfuse vital organs.
Adult
Pediatric
0.1-2 mcg/kg/min IV, titrate to effect
Effects increase when administered concurrently with tricyclic antidepressants, MAO inhibitors, antihistamines, guanethidine, methyldopa, ergot alkaloids; atropine may block reflex tachycardia caused by norepinephrine and enhances pressor response
Documented hypersensitivity; peripheral or mesenteric vascular thrombosis because ischemia may be increased and the area of infarct extended
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Correct blood-volume depletion, if possible, before giving norepinephrine therapy; extravasation may cause severe tissue necrosis and, thus, should be administered into a large vein; caution in occlusive vascular disease
Antihistamines
Antihistamines decrease histamine activity by reversible competitive blockade of the histamine receptor. H 1 -receptor stimulation can lead to bronchial smooth muscle constriction and capillary leakage. H 2 -receptor activity increases gastric acid secretion and pacemaker rate. Stimulation of histamine H 1 and H 2 receptors may produce vasodilation and dysrhythmias. Therefore, use of H 1 and H 2 blockers should be considered.
Diphenhydramine (Benadryl)
Competes with histamine for H 1 -receptor sites in GI tract, blood vessels, and respiratory tract. Preferred agent when IV antihistamine is required.
Adult
Pediatric
1 mg/kg/dose PO/IV/IM q6h prn; not to exceed 300 mg/d
Potentiates effect of CNS depressants; because of alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions
Documented hypersensitivity; use with MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause paradoxical excitation; may exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction
Cetirizine (Zyrtec)
Competitive H1-receptor blocker similar to diphenhydramine. Metabolite of hydroxyzine. May be used as part of discharge post-ED or hospital care.
This medication has not been studied in the treatment of acute anaphylaxis.
Adult
Pediatric
<2 years: Not established
2-5 years: 2.5 mg once daily
>5 years: 5-10 mg PO qd or divided bid
Increases CNS toxicity of depressants
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic or renal dysfunction; doses higher than 10 mg/d may cause drowsiness
Loratadine (Alavert, Claritin)
Competitive H1-receptor blocker similar in activity to diphenhydramine. May be used as part of discharge post-ED or hospital care.
This medication has not been studied in the treatment of acute anaphylaxis.
Adult
10 mg PO qd on empty stomach
Pediatric
<2 years: Not established
2-5 years: 5 mg PO qd
>5 years: Administer as in adults
Ketoconazole, erythromycin, procarbazine, and alcohol may increase loratadine levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Initiate therapy at lower dose in liver impairment
Ranitidine (Zantac)
H 2 antagonist (DOC) which, when combined with an H 1 type, may be useful in treating allergic reactions that do not respond to H 1 antagonists alone.
Adult
Pediatric
IV: 1 mg/kg/dose IV, not to exceed 50 mg/dose; may repeat IV dose q6-8h, not to exceed 200 mg/d
PO: 1 mg/kg/PO, not to exceed 150 mg/dose PO; may repeat PO dose q12h, not to exceed 300 mg/d
May decrease effects of ketoconazole and itraconazole; may alter serum levels of ferrous sulfate, diazepam, nondepolarizing muscle relaxants, and oxaprozin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Bronchodilators
Bronchodilators provide relief of bronchial smooth muscle contraction.
Albuterol (AccuNeb, Proventil)
DOC that relaxes bronchial smooth muscle and may decrease mediator release from mast cells and basophils. May inhibit airway microvascular leakage. Although not FDA-approved for children younger than 2 years, standard of care data support use in this age group.
Adult
Pediatric
<15 kg: 2.5 mg via nebulizer q20-30min
>15 kg: 5 mg via nebulizer q20-30min
As clinically indicated or for convenience, multiple treatments may be given by continuous nebulization
<15 kg: 5-7.5 mg over 1 h via nebulizer
≥15 kg: 10-15 mg over 1 h via nebulizer
Alternatively, 0.5 mg/kg/h via continuous nebulization; not to exceed 2-3 mg/kg/h or 15 mg/h
Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; cardiovascular effects may increase with MAOIs, inhaled anesthetics, TCAs, and sympathomimetic agents
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, diabetes mellitus, hypokalemia, muscle tremors, and cardiovascular disorders
Corticosteroids
Anti-inflammatory activity counters actions caused by histamine and other inflammatory mediators. Also potentiates the effect of beta-agonists.
Prednisolone (Millipred, Prelone)
Decreases inflammatory reactions by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Adult
Pediatric
Initial dose: 1-2 mg/kg/d PO
Subsequent doses: 1-2 mg/kg/d PO qd or divided bid for 3-7 d; not to exceed 80 mg/d
Note: Children who have used systemic corticosteroid within the previous 60 d may require a longer tapering regimen over 7-21 d
This medication is available both as a liquid and orally disintegrating tablets
Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects of corticosteroids
Documented hypersensitivity; viral, fungal or tubercular skin lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis
Prednisone (Sterapred, Prednisone Intensol Concentrate)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Blocks the release of inflammatory mediators by inhibition of phospholipase A2.
Adult
Pediatric
Initial dose: 1-2 mg/kg/d PO
Subsequent doses: 1-2 mg/kg/d PO qd or divided bid for 3-7 d; not to exceed 80 mg/d
Note: Children who have used systemic corticosteroid within the previous 60 d may require a longer tapering regimen over 7-21 d
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, tubercular skin, or connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI bleeding or ulceration
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in varicella, measles, and diabetes mellitus; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Methylprednisolone (Medrol) or methylprednisolone sodium succinate (Solu-Medrol)
Steroids ameliorate delayed effects of anaphylactoid reactions and may limit biphasic anaphylaxis.
Adult
Pediatric
1-2 mg/kg/dose PO/IM; may repeat q6h prn
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics; grapefruit juice increases prednisolone concentrations; methylprednisolone and cyclosporine mutually inhibit one another resulting in increased plasma levels of each drug
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Dexamethasone (Decadron)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. Blocks release of inflammatory mediators by inhibition of phospholipase A2. Administer IM as an alternative to IV. Current liquid products have a high percentage of alcohol and are not very concentrated; therefore, a large volume (ie, 30 mL) is typically required to provide the dose. Additionally, the liquid form is not very palatable. To circumvent this problem, some practitioners have administered the IV solution orally with a flavoring agent (off-label use).
Adult
Pediatric
0.15-0.6 mg/kg IV/IM; not to exceed 20 mg
PO administration not ideal but possible in emergency; may administer IV solution by PO route if needed
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; active bacterial or fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use
Adenyl Cyclase Activator
Glucagon has been used to reverse bradycardia and hypotension associated with beta-adrenergic blocker overdose. Proposed mechanism of action is increased cyclic adenosine monophosphate production resulting in positive ionotropic and chronotropic effects.
Glucagon
DOC for severe anaphylaxis in patients taking beta-blockers (should be used in addition to epinephrine, not as a substitute).
Pancreatic alpha cells of the islets of Langerhans produce glucagon, a polypeptide hormone. Exerts opposite effects of insulin on blood glucose. Glucagon elevates blood glucose levels by inhibiting glycogen synthesis and enhancing formation of glucose from noncarbohydrate sources, such as proteins and fats (gluconeogenesis). Increases hydrolysis of glycogen to glucose (glycogenolysis) in liver in addition to accelerating hepatic glycogenolysis and lipolysis in adipose tissue. Glucagon also increases force of contraction in heart and has a relaxant effect on GI tract.
Dose used for anaphylaxis is higher than usual dose of 1 mg (1 U) IV/IM/SC used to treat hypoglycemia.
Adult
Pediatric
20-30 mcg/kg IV infused over 5 min; not to exceed 1 mg; followed by 5-15 mcg/min continuous IV infusion
Effects of anticoagulants may be enhanced by glucagon (although onset may be delayed); monitor prothrombin activity and for signs of bleeding in patients receiving anticoagulants; adjust dose accordingly
Documented hypersensitivity; pheochromocytoma
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor blood glucose levels in hypoglycemic patients until they are asymptomatic; glucagon is effective in treating hypoglycemia only if sufficient liver glycogen is present; since liver glycogen availability is necessary to treat hypoglycemic patients, glucagon has virtually no effect on patients in states of starvation, adrenal insufficiency, or chronic hypoglycemia
More on Pediatrics, Anaphylaxis |
| Overview: Pediatrics, Anaphylaxis |
| Differential Diagnoses & Workup: Pediatrics, Anaphylaxis |
 Treatment & Medication: Pediatrics, Anaphylaxis |
| Follow-up: Pediatrics, Anaphylaxis |
| References |
| Further Reading |
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References
Simons EFR. Advances in H1-antihistamines. N Engl J Med. Nov 2004;351 (21):2203-17. [Medline].
Ogawa Y, Grant JA. Mediators of anaphylaxis. Immunol Allergy Clin North Am. May 2007;27(2):249-60, vii. [Medline].
Vadas P, Gold M, Perelman B, Liss GM, Lack G, Blyth T. Platelet-activating factor, PAF acetylhydrolase, and severe anaphylaxis. N Engl J Med. Jan 3 2008;358(1):28-35. [Medline].
Neugut AI, Ghatak AT, Miller RL. Anaphylaxis in the United States: an investigation into its epidemiology. Arch Intern Med. Jan 8 2001;161(1):15-21. [Medline]. [Full Text].
Lieberman P, Camargo CA Jr, Bohlke K, et al. Epidemiology of anaphylaxis: findings of the American College of Allergy, Asthma and Immunology Epidemiology of Anaphylaxis Working Group. Ann Allergy Asthma Immunol. Nov 2006;97(5):596-602. [Medline].
Yocum MW, Butterfield JH, Klein JS, Volcheck GW, Schroeder DR, Silverstein MD. Epidemiology of anaphylaxis in Olmsted County: A population-based study. J Allergy Clin Immunol. Aug 1999;104(2 Pt 1):452-6. [Medline].
Decker WW, Campbell RL, Manivannan V, Luke A, St Sauver JL, Weaver A, et al. The etiology and incidence of anaphylaxis in Rochester, Minnesota: a report from the Rochester Epidemiology Project. J Allergy Clin Immunol. Dec 2008;122(6):1161-5. [Medline].
Sheikh A, Alves B. Age, sex, geographical and socio-economic variations in admissions for anaphylaxis: analysis of four years of English hospital data. Clin Exp Allergy. Oct 2001;31(10):1571-6. [Medline].
Simons FE, Peterson S, Black CD. Epinephrine dispensing patterns for an out-of-hospital population: a novel approach to studying the epidemiology of anaphylaxis. J Allergy Clin Immunol. Oct 2002;110(4):647-51. [Medline].
Bohlke K, Davis RL, DeStefano F, Marcy SM, Braun MM, Thompson RS. Epidemiology of anaphylaxis among children and adolescents enrolled in a health maintenance organization. J Allergy Clin Immunol. Mar 2004;113(3):536-42. [Medline].
[Guideline] Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology; American College of Allergy,Asthma and Immunology and Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol. Mar 2005;115(3 Suppl 2):S483-523. [Medline].
Sampson HA, Munoz-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(2):391-7. [Medline]. [Full Text].
Kobrynski LJ. Anaphylaxis. Clin Ped Emerg Med. 2007;8:110-16. [Full Text].
Sicherer SH, Sampson HA. Peanut allergy: emerging concepts and approaches for an apparent epidemic. J Allergy Clin Immunol. Sep 2007;120(3):491-503. [Medline].
Schwartz LB, Irani AM. Serum tryptase and the laboratory diagnosis of systemic mastocytosis. Hematol Oncol Clin North Am. Jun 2000;14(3):641-57. [Medline].
Sheikh A, Shehata YA, Brown SG, Simons FE. Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock. Cochrane Database Syst Rev. Oct 8 2008;CD006312. [Medline]. [Full Text].
Simons FE, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol. Jan 1998;101(1 Pt 1):33-7. [Medline].
Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. Nov 2001;108(5):871-3. [Medline].
[Guideline] Muraro A, Roberts G, Clark A, Eigenmann PA, Halken S, Lack G. The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology. Allergy. Aug 2007;62(8):857-71. [Medline]. [Full Text].
American Heart Association. Part 12: Pediatric Advanced Life Support. Circulation. 2005;112(Suppl 1):IV-167-87. [Full Text].
Lin RY, Curry A, Pesola GR, Knight RJ, Lee HS, Bakalchuk L. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med. Nov 2000;36(5):462-8. [Medline].
Lieberman P. Biphasic anaphylactic reactions. Ann Allergy Asthma Immunol. Sep 2005;95(3):217-26. [Medline].
Kemp SF, Lockey RF, Simons FE. Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization. Allergy. Aug 2008;63(8):1061-70. [Medline].
Further Reading
AAAAI Board of Directors. Position Statement: Anaphylaxis in schools and other child-care settings. American Academy of Allergy Asthma & Immunology. Available at http://www.aaaai.org/media/resources/academy_statements/position_statements/ps34.asp. Accessed August 19, 2007.
AAAAI School Tools: Allergy & Asthma Resources for Professionals. Available at http://www.aaaai.org/professionals/school_tools.stm. Accessed April 30, 2009.
Keywords
anaphylaxis, anaphylaxis symptoms, anaphylaxis in children, allergic reaction, treating anaphylaxis, anaphylaxis syndrome, bee sting, drug allergy, food allergens, food allergy, latex allergy, peanut anaphylaxis, severe allergic reaction, venomous sting/bite
