A working group of the American College of Allergy, Asthma and Immunology (ACAAI) and the American Academy of Allergy, Asthma and Immunology (AAAI) has updated recommendations for the management of children and adults with anaphylaxis. The document discusses diagnostic criteria for anaphylaxis, specific symptoms of pathology in children and adolescents, indications for the use of epinephrine, beta blockers and ACE inhibitors, and determination of mast cell status.
AAAAI/ACAAI experts have developed updated guidelines for the diagnosis and treatment of anaphylactic reactions in children and adults. The recommendations were published in the journal Annals of Allergy, Asthma & Immunology.
The document revised the diagnostic criteria for anaphylaxis and identified patterns of its development. The use of updated criteria from the World Allergy Organization (WAO), Brighton and Delphi Consensus Groups is recommended. Biphasic anaphylaxis is associated with greater severity of the initial reaction, persistence of the reaction, and use of more than one dose of epinephrine, the guidelines note.
Experts emphasize the importance of measuring serum tryptase to diagnose anaphylaxis and detect mast cell disorders. Experts recommend measuring baseline serum tryptase levels in patients with a history of recurrent, idiopathic or severe anaphylaxis, hymenoptera venom anaphylaxis, or suspected mastocytosis. If the level of serum tryptase exceeds 8 ng/ml, it is necessary to exclude the diagnosis of hereditary α-tryptasemia and mastocytosis.
Diagnosis and treatment of anaphylaxis in children presents special challenges. Experts noted that in newborns and preschool children, the severity of anaphylaxis does not correlate with age and may present symptoms that are rarely identified in older children and adults. In these patients, anaphylaxis is unlikely to be the initial reaction to the allergen upon first exposure.
Previously, it was believed that in patients with a high risk of anaphylaxis, the use of beta blockers and ACE inhibitors was contraindicated due to an increased likelihood of more severe anaphylactic reactions. However, experts noted that the risk associated with stopping or replacing beta blockers and ACE inhibitors may exceed the risk of developing severe anaphylaxis while continuing to take the drugs, especially among patients with insect sting anaphylaxis. The use of cardioselective beta blockers is recommended whenever possible. It is also noted that the use of these drugs in combination with immunotherapy is not an absolute contraindication. For patients with insect sting allergies and reactions to environmental allergens, it is suggested that venom immunotherapy and appropriate allergen immunotherapy be considered.
After perioperative anaphylaxis, re-anesthesia can be performed after shared decision-making based on the history and diagnostic evaluation using immediate skin testing for hypersensitivity (transcutaneous and intradermal) and/or specific IgE in vitro testing (if available). If necessary, allergen challenge tests can be performed in cases of negative results of skin tests and/or in vitro tests.