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Presentation of food-induced allergic reactions in infants and toddlers

Published online: January 1, 2021

In recent years, anaphylaxis has become more common for all ages. Studies have identified challenges in recognizing and appropriately treating anaphylaxis in general, but the infant and toddler population poses a special challenge. Infants and toddlers are non-verbal and may not demonstrate the same symptoms and signs as older children or adults. Current diagnostic guidelines (National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network, 2006) and commonly used anaphylaxis action plans are designed for all ages but use terminology difficult to apply to this non-verbal age group; they also lack some symptoms and signs unique to younger children.

In a recent article published in The Journal of Allergy and Clinical Immunology: In Practice, Pistiner and colleagues present the results of a national survey of primary caregivers who were present for their child’s most severe food-induced allergic reaction that occurred when their child was younger than three years of age. This Asthma and Allergy Foundation of America (AAFA) Survey was completed for 374 children. Of these young children, 193 were infants (under 12 months of age) and 181 were toddlers (age 12-35 months). Caregivers were asked about the symptoms and signs they observed. The survey used lay language and was structured similarly to the “Anaphylaxis in America” Survey to allow for comparisons between age groups.

When looked at in general categories, skin involvement was reported in 94% of these young children, respiratory in 63%, gastrointestinal in 51%, neurologic in 34%, and cardiovascular in 23%. Skin reactions, skin mottling, and ear pulling/scratching or putting fingers in ears were more common in infants. Throat itching and coughing/wheezing were more common in toddlers. About half of the surveyed parents reported symptoms or signs that were thought not to be related to an allergic reaction at the time but were later recognized as such. The most common of these later-recognized symptoms were sudden behavioral change (15%), gastrointestinal symptoms (12%), skin reactions (12%), and coughing or wheezing (11%).  Further, the study team compared the number of cases that fulfilled criteria for “probable anaphylaxis” using the currently available criteria versus those criteria with infant and toddler specific modifications and identified additional cases in the younger group (5% absolute increase in anaphylaxis in infants and toddlers; 8% absolute increase in infants; 2% absolute increase in toddlers). Modifying symptoms and signs used to recognize anaphylaxis may assist in identifying some cases that currently are missed.

Overall, this study provides age-specific language that may assist in communicating and identifying difficult-to-recognize symptoms and signs of anaphylaxis in infants and toddlers. Utilization of this language in diagnostic criteria and anaphylaxis action plans may facilitate recognition of anaphylaxis, especially in infants.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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