Development and Evaluation of Modified Criteria for Infant and Toddler Anaphylaxis

Current diagnostic criteria for anaphylaxis, such as the 2006 National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) criteria, were designed primarily for older children and adults. Infants and toddlers often present with unique, age-specific signs and symptoms of anaphylaxis not captured by current diagnostic criteria, which could lead to underdiagnosis or delayed treatment. This study aimed to identify and incorporate features of infant/toddler anaphylaxis to create modified criteria to improve recognition of anaphylaxis in this age group.The study included a medical record review of 337 pediatric patients younger than 6 years who presented to a single tertiary pediatric emergency department (ED) over a 41-month period with suspected allergic or anaphylactic reactions.This was a retrospective medical record review that coded patients as having anaphylaxis based on any of 3 criteria: NIAID/FAAN criteria, documentation by the ED physician, or by the modified criteria developed by the authors. The authors’ modified criteria included age-related symptoms and signs, such as swollen ears, eyes, lips, or face, tongue thrusting/licking, drooling, hoarse cry, back arching, increased work of breathing, retractions, nasal flaring, mottling, being floppy or limp, having poor head control, and others. The modified criteria were applied to all cases and compared with classifications based on the existing guidelines. The primary outcome was the difference in the proportion of likely anaphylaxis cases identified using each set of criteria across different age groups.A total of 175 participants were classified as having anaphylaxis (57 were infants and 68 were aged 12-36 months). The modified criteria identified 98% of cases, compared with the NIAID/FAAN criteria that identified 85% (P < .001), representing a 22.8% improvement in identifying infant anaphylaxis and a 10.3% improvement in identifying toddler anaphylaxis. There was no significant difference in detection rates among older children, suggesting that the modified criteria enhanced detection in younger populations without increasing false positives in older children.The study demonstrated that incorporating age-appropriate, nonverbal signs and symptoms that are unique to infants and toddlers into diagnostic criteria significantly improved the classification of anaphylaxis in this age group.This study addresses a critical diagnostic gap regarding the unique presentations of anaphylaxis in infants and toddlers. The modified criteria may be a potentially lifesaving improvement for prompt diagnosis and treatment of anaphylaxis with epinephrine by health professionals and caregivers. However, the retrospective design and single-center setting limit generalizability, and these findings need to be validated in other settings. Some of the signs and symptoms included in the modified criteria may occur in nonanaphylaxis medical conditions, such as infections, cardiac disease, and others, making it important to have context such as the timing of symptom onset, potential exposure to an allergic trigger, and exclusion of other causes of symptoms. Nonetheless, the incorporation of unique age-specific behavioral cues in this diagnostic framework may improve care. If confirmed in other populations, these criteria could meaningfully improve early recognition and management of anaphylaxis in younger children.