COMMENTARY

Anaphylaxis in Kids: Clinical Pearls From The Cribsiders

Christopher J. Chiu, MD; Justin L. Berk, MD, MPH, MBA

Disclosures

November 16, 2020

This transcript has been edited for clarity.

Christopher J. Chiu, MD: Welcome. This is Chris Chiu. I'm with The Cribsiders. Joining me today is my co-host, Dr Justin Berk.

Justin L. Berk, MD, MPH, MBA: We are here recapping our podcast episode with Julie Brown, MD, a pediatric emergency medicine attending physician at Seattle Children's Hospital, on anaphylaxis. It was a great episode and it's definitely worth checking out.

Chiu: The first pearl we're talking about is the three scenarios in which anaphylaxis is likely. The first scenario is when there is no known allergen exposure but there are skin/mucosa changes plus respiratory symptoms and/or low blood pressure symptoms. The second scenario is when there is a likely allergen exposure. Then, you could have involvement of two of four systems, including skin/mucosa, GI tract, respiratory, or low blood pressure symptoms. The last scenario is when you have a known allergy exposure. Here, just having low blood pressure symptoms or associated symptoms is likely.

Berk: A lot of those skin changes, rashes, can present in lots of different [ways]. But one of the ones that Dr Julie Brown taught us about was diffuse erythroderma. It's a sign of rapid mast cell release and can be an early sign of skin involvement in anaphylaxis. It looks like a really bad sunburn.

Whenever any kid comes in with any of these anaphylaxis scenarios or things like diffuse erythroderma, one of the big takeaways I got was just epinephrine, epinephrine, epinephrine. Epinephrine is lifesaving. It's one of the only evidence-based treatments for anaphylaxis. Even if they don't meet full criteria, we should be giving epinephrine early on in the case of a severe allergic response.

Anytime parents come in having given their children epinephrine, we should acknowledge that that is a difficult thing to do. We should congratulate them and say, "You did it, this is great. See, the fear is gone. You are able to give epinephrine." Help them overcome the fear of giving the injection to their own kid.

Chiu: Justin, in terms of treatment for these patients, there was another pearl about third spacing in anaphylaxis. Do you want to explain that?

Berk: Yes. That was something I had not heard before, but I think it made sense. The idea is that because patients have severe anaphylaxis, they experience third spacing. Placing patients in the supine position can actually optimize their circulation and the epinephrine delivery. So, if they are coming in to the emergency room in anaphylaxis, it's important to lay them down flat, and that can actually help with their circulation.

Chiu: Last, I want to leave you with the top eight food allergies in children. Milk, wheat, egg, and soy can present early in childhood and usually resolve. In contrast, peanuts, tree nuts, fish, and shellfish usually present late in childhood, but they usually become lifelong allergies.

Make sure you check out our full episode on anaphylaxis with Dr Julie Brown.

Berk: You can find out more on our website. You can also send us an email. We'd love to hear from you. And you can find The Cribsiders pediatric podcast on any podcast app: Apple, Stitcher, Overcast, Spotify — you name it.

Chris Chiu, MD, is assistant professor at The Ohio State University, where he is also the physician lead at OSU's Outpatient Care East Clinic and serves as the assistant clinical director for the internal medicine residency. He is an Air Force veteran and a self-proclaimed gadget geek. Follow him on Twitter

Justin Berk, MD, MPH, MBA, is assistant professor of medicine and pediatrics at the Warren Alpert School of Medicine at Brown University. He is a clinical educator active in ambulatory and inpatient care and pediatrics. He enjoys coffee, thinking about hiking, and being a generalist. Follow him on Twitter

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