​One of the biggest challenges is that this age group is mostly nonverbal. Infants cannot talk about their symptoms, so parents/caregivers and health care providers may not notice or identify the signs of an allergic reaction. Our research also suggests infants and toddlers might have different symptoms than older children.

Another challenge is how doctors diagnose anaphylaxis in infants and toddlers. Doctors use certain criteria to diagnose anaphylaxis, but the current guidelines are not validated for children under 2 years old. These guidelines also rely on vital signs that can be difficult to get from infants, such as blood pressure.

A similar issue exists for anaphylaxis action plans. Action plans help caregivers recognize and respond to a severe allergic reaction. However, these action plans might list symptoms that are different from what is seen in infants. This can make it difficult for caregivers to know what to look for and can delay the use of life-saving epinephrine.

If a child doesn’t have an anaphylaxis action plan, they are less likely to be treated with epinephrine.

New Research on Allergic Reactions in Infants and Toddlers

The Asthma and Allergy Foundation of America (AAFA) and its Kids with Food Allergies (KFA) division recently partnered with leading food allergy researchers to better understand how parents (and primary caregivers) of young children recognize the signs of allergic reactions and treat them. Results from AAFA’s Infants and Toddlers with Anaphylaxis (ITA) study have now been published in the Journal of Allergy and Clinical Immunology: In Practice.

We surveyed 374 caregivers of children who had an allergic reaction to food. The children were under 5 at the time of the study, and under 3 when they had a severe allergic reaction.

Key Findings

Important key findings came from the study:

Signs and Symptoms of Anaphylaxis in Infants and Toddlers

We asked about the signs caregivers noticed during their child’s most severe allergic reaction. We categorized these signs into five organ systems:

• Skin
• Respiratory (airways)
• Cardiovascular (heart, blood vessels, blood pressure)
• Gastrointestinal (stomach, gut)
• Neurological (brain, behavior)

The most common symptoms in infants and toddlers were skin reactions, swelling, vomiting, and diarrhea. Signs related to the cardiovascular system – like blue-grey-white appearance and poor head control – were not as common as skin or gastrointestinal issues. However, these symptoms are important to look for.

 

 

Researchers compared the infant and toddler symptoms to a previous study by AAFA of the general population (Anaphylaxis in America 2014). The comparison found that infants are more likely than other ages to have skin and gastrointestinal-related reactions, and less likely to have problems with breathing.

Some symptoms such as hoarse voice/cry are also more common in infants and toddlers. Because babies can’t talk and express what they are feeling, certain symptoms like itchy throat are more common in older populations.

Compared to older children and adults, infants and toddlers are more likely to have:

• Itching
• Rash
• Hives
• Vomiting
• Diarrhea
• Hoarse voice/cry
• Sudden behavioral change

Compared to older children and adults, infants and toddlers are less likely to have:

• Increase breathing rate
• Trouble breathing
• Itchy throat

This study identifies signs and symptoms of anaphylaxis that are specific to infants and toddlers and reported by the primary caregivers. More research is underway to look at what doctors see in emergency rooms and food challenges. Then experts can create age-specific diagnostic criteria and guidelines to improve anaphylaxis recognition and response.

The language this research uses can help doctors better diagnose anaphylaxis in infants by identifying symptoms and signs that caregivers observed. These observed signs and symptoms can then be used to improve caregiver education. If doctors and caregivers use similar words, it can improve communications and decision-making. The table below shows AAFA’s recommendations on how language in the current guidelines can change to be more accurate and easier to understand.

 

 

Itchiness (Pruritis)

Signs of itchiness in infants and toddlers include:

• Tongue thrusting and tongue pulling
• Throat itching
• Repetitive licking of lips, hands, or objects
• Ear pulling, scratching, or putting fingers in ears
• Eye rubbing, eye itching

Trouble Breathing (Dyspnea or Shortness of Breath)

Signs of breathing difficulty in infants and toddlers include:

• Belly breathing
• Fast breathing
• Chest or neck “tugging”
• Nasal flaring (nostrils open wide)

Noisy Breathing (Stridor)

Signs of noisy breathing in infants and toddler include:

• High-pitched sound while breathing (whistling sound)
• Hoarse voice, hoarse cry
• Barky/croup-like cough
• Noisy breathing, especially when inhaling

Shock (Reduced Blood Pressure)

Signs of shock in infants and toddlers include:

• Wobbly appearance
• Lethargic
• Floppy or limp
• Poor head control
• Difficult to wake up
• Crankiness
• Withdrawn or clingy
• Inconsolable crying
• Subdued or less active
• Lace-like appearance of the skin
• Blue/grey skin around mouth/lips or hands/feet

Poor Muscle Tone or Fainting (Hypotonia, or Syncope)

Signs of poor muscle tone and fainting in infants and toddlers include:

• Wobbly appearance
• Lethargic
• Floppy or limp
• Poor head control
• Difficult to wake up
• Crankiness
• Withdrawn or clingy
• Inconsolable crying
• Less active

Gastrointestinal Symptoms That Are Significant (Persistent Gastrointestinal Symptoms)

Signs of significant gastrointestinal symptoms in infants and toddlers include:

• Abdominal pain
• Diarrhea
• Hiccups
• Spitting up
• Back arching
• Vomiting

Finally, half of the caregivers said they observed signs they later recognized were part of the allergic reaction. This highlights the need for more education on symptoms that are specific to infants and toddlers.

For more information, read the original article in The Journal of Allergy and Clinical Immunology: In Practice titled, “Caregiver-Reported Presentation of Severe Food-Induced Allergic Reactions in Infants and Toddlers.”​

The Importance of Anaphylaxis Action Plans

AAFA’s ITA study also looked at whether previous diagnosis of a food allergy and anaphylaxis action plans are associated with epinephrine use. The results show that epinephrine is more likely to be used in infants and toddlers with a previously diagnosed food allergy, compared to children without a diagnosis.

In children diagnosed with food allergy, the study found that 89% of children with anaphylaxis action plans were given epinephrine during their allergic reaction. Only 50% of children without a plan were given epinephrine.

For more information, read the original article in The Journal of Allergy and Clinical Immunology: In Practice titled, “Factors Associated with Epinephrine Use in the Treatment of Anaphylaxis in Infants and Toddlers.”

Acknowledgments

This study was authored in partnership with the following experts:

• Michael Pistiner, MD, MMSc, MassGeneral Hospital for Children, Harvard Medical School
• Jose Mendez-Reyes, MD, MassGeneral Hospital for Children, Harvard Medical School
• Sanaz Eftekhari, Chief Business Development Officer and Vice President of Research, Asthma and Allergy Foundation of America
• Melanie Carver, Chief Mission Officer, Asthma and Allergy Foundation of America
• Jay Lieberman, MD, LeBonheur Children’s Hospital, University of Tennessee
• Julie Wang, MD, Icahn School of Medicine at Mount Sinai
• Carlos Camargo, Jr., MD, DrPH, Massachusetts General Hospital, Harvard Medical School

The authors thank Wayne Shreffler, MD, PhD, and Lacey Robinson, MD, for review and comments on the survey and Hannah Jaffee of AAFA for editorial support on study publications.

This AAFA-led collaborative research was funded by kaléo, Inc.