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Chapter 143 Anaphylaxis

Anaphylaxis is defined as a serious allergic reaction that is rapid in onset and may cause death. Anaphylaxis in children, particularly infants, is frequently underdiagnosed. It occurs when there is a sudden release of potent biologically active mediators from mast cells and basophils, leading to cutaneous (urticaria, angioedema, flushing), respiratory (bronchospasm, laryngeal edema), cardiovascular (hypotension, dysrhythmias, myocardial ischemia), and gastrointestinal (nausea, colicky abdominal pain, vomiting, diarrhea) symptoms.


The most common causes of anaphylaxis in children are different for hospital and community settings. Anaphylaxis occurring in the hospital results primarily from allergic reactions to medications and latex. Food allergy is the most common cause of anaphylaxis occurring outside the hospital, accounting for about one half of the anaphylactic reactions reported in pediatric surveys from the USA, Italy, and South Australia (Table 143-1). Peanut allergy is an important cause of food-induced anaphylaxis, accounting for the majority of fatal and near-fatal reactions. In the hospital, latex is a particular problem for children undergoing multiple operations, such as patients with spina bifida and urologic disorders, and has prompted many hospitals to switch to latex-free products. Patients with latex allergy may also experience food-allergic reactions from homologous proteins in foods such as bananas, kiwi, avocado, chestnut, and passion fruit.


Food: peanuts, tree nuts (walnut, hazelnut, cashew, pistachio, Brazil nut), milk, eggs, fish, shellfish (shrimp, crab, lobster, clam, scallop, oyster), seeds (sesame, cottonseed, pine nuts, psyllium), fruits (apples, banana, kiwi, peaches, oranges, melon), grains (wheat)

Drugs: penicillins, cephalosporins, sulfonamides, nonsteroidal anti-inflammatory agents, opiates, muscle relaxants, vancomycin, dextran, thiamine, vitamin B12, insulin, thiopental, local anesthetics

Hymenoptera venom: honeybee, yellow jacket, wasp, hornet, fire ant


Allergen immunotherapy

Exercise: food-specific exercise, postprandial (non–food-specific) exercise

Vaccinations: tetanus, measles, mumps, influenza

Miscellaneous: radiocontrast media, gamma globulin, cold temperature, chemotherapeutic agents (asparaginase, cyclosporine, methotrexate, vincristine, 5-fluorouracil), blood products, inhalants (dust and storage mites, grass pollen)


* In order of frequency.

From Leung DYM, Sampson HA, Geha RS, et al: Pediatric allergy principles and practice, St Louis, 2003, Mosby, p 644.


A National Institutes of Health (NIH)–sponsored expert panel has recommended an approach to the diagnosis of anaphylaxis (Table 143-2). The differential diagnosis includes other forms of shock (hemorrhagic, cardiogenic, septic), vasopressor reactions including flush syndromes such as carcinoid syndrome, excess histamine syndromes (systemic mastocytosis), and ingestion of monosodium glutamate (MSG), scombroidosis, and heriditary angioedema. In addition, panic attack, vocal cord dysfunction, pheochromocytoma, and red man syndrome (due to vancomycin) should be considered.


Anaphylaxis is highly likely when any one of the following three criteria is fulfilled:

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