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Life-threatening Allergic Reactions Increasing Among Children,
Deborah L. McBride, PhD, RN
Samuel Merritt University, Oakland, CA, USA
Anaphylaxis, a sudden and potentially life-threatening allergic reaction, is increasing among children according to a new report by Blue
Cross Blue Shield (2018). The new report looked at U.S. emergency
room visits for anaphylaxis from 2010 to 2016 among their subscribers,
including 9.6 million children 18 years of age and younger. The report
showed that emergency room visits for children for anaphylaxis more
than doubled, from 1.4 visits per 10,000 children in 2010 to 3.5 visits
in 2016. Children diagnosed as at risk for an anaphylaxis episode increased 104% in the seven years of the study, from 23 per 10,000 children in 2010 to 47 per 10,000 in 2016. While anaphylaxis is relatively
rare, children are especially vulnerable to serious allergic reactions
since an allergy is not necessarily known until a reaction occurs. According to the authors of the study, the steep increase in emergency room
visits among children calls for an increased awareness around the dangers of severe allergic reactions.
Nearly 1.7 million, or 18% of the children in the study, suffer one or
more allergy and roughly 25% of children under that age of 3 were diagnosed with one or more allergies, excluding asthma, in 2016. Specific
food allergies were responsible for 47% of the emergency room visits
for anaphylaxis. The most common foods that trigger allergic reactions
were peanuts (22%), tree nuts and seeds (15%), and milk and eggs
(6%). Fish and shellfish (3%) and fruits and vegetables (2%) caused
smaller number of reactions. The other 53% of the visits were attributed
to unknown foods or other unspecified causes, such as insect bites, possibly because the information was collected from insurance claims and
some billing claims charge for anaphylactic shock, unspecified.
An earlier study using administrative claims for 56,212 emergency
room visits for anaphylaxis found that the rate of anaphylaxis emergency room visits increased by 101% from 2005 to 2014 with the largest
increase in children 5 to 17 years (196% increase) (Motosue, Bellolio,
Van Houten, Shah, & Campbell, 2017). Similarly the largest increase in
food-related anaphylaxis was in children aged 5 to 17 years (285% increase) and the highest rates of increase in medication anaphylaxis
was seen among young children aged 0 to 4 years (479%).
The is why there is an increase in allergies among children. Genetics and the environment are both important
factors and may be responsible for the increase. There are several theories. One theory is the hygiene hypothesis, which states that our
improved ability to be clean and avoid germs has thrown our immune
systems off balance. This theory speculates that because the immune
system has less to do, the system that fights allergens overcompensates.
This theory is supported by a study that found that rates of allergies and
asthma are lower for those living on farms, possibly due to exposure to a
specific molecule found in cow manure (Schuijs et al., 2015). Ultimately,
our environment determines whether or not we will be exposed to a
particular allergen, a requirement for developing an allergy, but it is
not clear whether exposure is beneficial.
Another theory credits the rise in childhood allergies to American
parents waiting to , like peanuts.
This theory is based on the observation that cultures where peanuts
are introduced into the diet at an earlier age have a lower incidence of
peanut allergies. A large study called Learning Early About Peanut Allergy (LEAP) was conducted in England to determine if there is any benefit to early exposure to peanuts (Du Toit et al., 2015). It found that
exposing children to peanuts early lowered the chances of a child developing a lifelong allergy.
Another theory hypothesizes that the way food is prepared contributes to allergies. This is based on the observation that roasting peanuts
seems to increase their allergic value relative to boiling them (Verma,
Kumar, Das, & Dwivedi, 2012). There may also be a link between the
prevalence of allergies and climate change. Both the higher global temperatures and the related increase in carbon dioxide in the air allow
plants to grow and propagate faster. More plants leads to more pollen,
which could be linked to higher allergy rates (Katelaris & Beggs, 2018).
Finally, some experts believe that the number of people reporting an
allergy has increased, but the actual number of children affected has
remained the same. Parents may be more aware of the warning signs
and may be seeking care more often than before. In addition, the ability
to identify allergies has improved, so healthcare providers may be
reporting more allergies, which could account for part of the increase
in childhood allergies in the new study (Blue Cross Blue Shield, 2018).
As the rate of allergies rises, there is an increased need for awareness
and education for parents and caregivers to help them recognize and
treat anaphylaxis. Because parents are generally able to make their
homes free of risky substances, most severe reactions occur outside of
the home. This means that parents need to be sure that there is an
awareness of the allergy and how to treat it in all areas that a child
spends time, including at school and after school programs such as
child care and sports programs. It is also important that a child has a
good understanding of their allergy and that they feel empowered to
speak up and ask about the presence of allergens in their food.
Journal of Pediatric Nursing 44 (2019) 127129
The views expressed in this article are the author’s own and not an official position of
The author declares that there are no conflicts of interest.
1611 Allston Way, Berkeley, CA 94703, United States.
E-mail address: [email protected]
0882-5963/ 2018 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Caregivers need to be aware of the signs and symptoms of an anaphylactic reaction, including lip swelling, hives with nausea or
coughing or throat discomfort, tongue swelling, throat tightening,
trouble breathing, dizziness or lightheadedness. The American Academy of Pediatrics (AAP) has a parent information sheet for parents of
children who have had an anaphylactic event and for parents of children who have had a mild allergic event who should be knowledgeable about anaphylaxis because these children are at a higher risk of
having another, more severe attack. In 2017 the AAP released an
emergency plan for allergy and anaphylaxis that can be individualized (http://pediatrics.aappublications.org/content/early/2017/02/
09/peds.2016-4005). Although there are several anaphylaxis action
plans that are available, the AAP version recognizes that allergic reactions can be unpredictable and it outlines multiple pathways to
cover mild to severe reactions. The plan emphasizes that epinephrine should be used promptly if there is any uncertainty about the severity of the reaction. Having a written action plan is only one part of
a comprehensive management of allergy and anaphylaxis. General
community education and planning for prevention, recognition and
management of anaphylaxis is also needed.
For children who do have an allergy, parents and teachers need to be
vigilant about the signs of anaphylaxis and to begin treatment quickly.
According to the AAP, it is better to over-treat than to under-treat anaphylaxis. In the Blue Cross Blue Shield report many of the children who
came to the emergency room for anaphylaxis did not have a previous diagnosis of anaphylaxis (Blue Cross Blue Shield, 2018). This means that it
is a diagnosis that everyone caring for children should be prepared to
recognize and treat, whether there is a history of an allergic reaction
or not. The Centers for Disease Control and Prevention (CDC) has a
tool kit for managing food allergies in schools as part of their Healthy
Schools campaign (https://www.cdc.gov/healthyschools/foodallergies/
index.htm). In addition, a School Nurses Tool Kit is available from the
National Association of School Nurses (NASN) to provide guidance for
food allergy and anaphylaxis management in the school setting
There has been a substantial increase in the most severe anaphylactic allergic reactions in children, largely triggered by foods. This increase coincides with a steep rise in emergency room visits. The National
Institute of Allergy and Infectious Diseases guidelines for peanut allergies, the most common cause of fatal anaphylaxis from a food, include
introducing earlier than previously recommended (Greenhawt, 2017). Children with severe eczema or egg allergy
need to be evaluated for peanut allergy, and depending on results,
peanut-containing foods (although not peanuts) may be introduced at
4 to 6 months of age (Togias et al., 2017).
Until we can figure out the causes, parents should know the
warning signs and talk to their healthcare providers about what to
do if an allergic reaction occurs. Previous studies have found that
more than half of the individuals who had anaphylaxis were not
equipped with life-saving epinephrine (Greenberger, Wallace,
Lieberman, & Gregory, 2017). In addition, only half of those who
had an auto-injector of epinephrine used it prior to arrival in the
emergency department (Hochstadter et al., 2016). Anaphylaxis can
occur within seconds or minutes of exposure to an allergen. It is important for caregivers and healthcare providers to work together to
ensure the timely use of epinephrine auto-injectors in the case of
Successful management of anaphylaxis in the emergency department also plays a crucial part in the care of children with allergies.
Fear of biphasic anaphylaxis, the recurrence of symptoms after a period
of resolution without re-exposure to the allergen, has prompted minimum observation periods ranging from 3 h to 24 h. This range of observation periods led to a variation in clinical decision-making, more
hospitalizations or prolonged emergency department stays, increased
costs, and inconsistent discharge care and caregiver confusion. Recent
research has shown that biphasic anaphylaxis is uncommon and that
decreasing the recommended length of observation from 8 to 4 h can result in a 60% reduction hospital admissions (Lee et al., 2018). In 2011
consensus guidelines were created by the National Institute for Allergy
and Infectious Diseases that recommended an observation period of 4
to 6 h for most anaphylaxis patients and that patients with oral food
challenge could be discharged 2.5 h after epinephrine administration,
provided that symptoms had resolved (Burks et al., 2011).
The Blue Cross Blue Shield (2018) study notes that the chances of a
positive outcome are increased if necessary medications are on hand
during a . The availability of medication is a
particularly important topic given the recent controversy about the
high cost of the epinephrine auto-injectors, commonly prescribed for
children at risk, so that they have emergency treatment available at
home and school. Epinephrine auto-injector medications alleviate severe allergy symptoms and are available as both name brand and generic drugs. According to the authors of the study, the steep increase
in price of the most commonly prescribed Mylan EpiPen over the
past several years (from $129 in 2010, to $645 in 2016 for a pack of
two auto-injectors) motivated parents and health care workers to
work to ensure that these medications continue to be available in case
of an emergency. Several generic versions of the medication are now
available, including the Adrenaclinck auto-injector, which now costs
$234. Work has been done to make epinephrine in schools, parks and
other places, but more work needs to be done to ensure that this medication is available in emergency situations. Parents are more likely to
use an auto-injector if cost is not an issue. The authors of the Blue
Cross Blue Shield study noted that the increase in emergency room
visits may be good, because it indicates that parents are more aware
of possible anaphylaxis and are using their epinephrine auto-injectors
more often and subsequently taking their children to emergency
Continued focus on proper identification and diagnosis of childhood
allergies remains an important step to help keep children safe. The
availability and access to epinephrine auto-injectors should remain a
matter of concern for health care workers. As more children suffer
from allergies and potentially life-threatening anaphylactic reactions,
access to these medications and to emergency room care is essential
to safeguarding the health of children.
Blue Cross Blue Shield (2018). Childhood allergies in America. https://www.bcbs.com/
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NEJMoa1414850 (Epub 2015 Feb 23).
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future bring? Annals of Allergy, Asthma, and Immunology, 119(4), 333338. https://
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Katelaris, C. H., & Beggs, P. J. (2018). Climate change: Allergens and allergic diseases.
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Lee, J., Rodio, B., Lavelle, J., Lewis, M. O., English, R., Hadley, S., … Brown-Whitehorn, T.
(2018). Improving anaphylaxis care: The impact of a clinical pathway. Pediatrics,
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Motosue, M. S., Bellolio, M. F., Van Houten, H. K., Shah, N. D., & Campbell, R. L. (2017). Increasing emergency department visits for anaphylaxis, 20052014. Journal of Allergy
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128 D.L. McBride / Journal of Pediatric Nursing 44 (2019) 127129
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(2015). Farm dust and endotoxin protect against allergy through A20 induction in
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