Anaphylaxis is a common diagnosis in the Pediatric Emergency Department. We know that the risk of biphasic reaction exists, and that it can occur as far out as 72 -hours after the initial reaction. Many will observe children for up to 4 to 6 hours after the initial presentation and treatment in the ED and if symptoms persist or recur admit to an inpatient ward. But what happens to those patients? Are we admitting too many of them? How van we know which kids have a higher risk of progression to more serious disease and need more interventions on an inpatient setting? A paper recently published in PLOS ONE by Dribin et al. attempted to answer these very questions.

Identification of children with anaphylaxis at low risk of receiving acute inpatient therapies
Dribin  TE, Michelson  KA, Monuteaux  MC, Stack  AM, Farbman  KS, et al. 
PLOS ONE, 2019

What does this study show? 

This was a retrospective look at a single center’s admissions for anaphylaxis. The authors then created rules to predict children at low risk for acute intervention as inpatients. Acute intervention was defined widely as inhaled beta agonists, epinephrine, magnesium, terbutaline, intravenous fluid boluses, vasopressors, non-invasive ventilation, intubation, or central line placement 

  • For children under 36 months, those with no wheezing and no cardiac involvement (defined as hypotension, hypotonia, syncope, incontinence, wide pulse pressure) were unlikely to receive acute inpatient therapy (NPV 98.3%, 95% CI 94.1-99.8%).  
  • For children 36 months or older, those with no wheezing, no cardiac involvement, and presence of GI involvement were unlikely to receive inpatient therapy (NPV 92.4%, 95% CI 85.6-96.7%). 

The bottom line

We may be able to use clinical indicators in the emergency department to discern children at low risk of needing admission after anaphylaxis 

A prospective study is needed to prove the efficacy and safety of these rules 

Read the article from Dribin et al. right here! 


Campbell RL, Li JTC, Nicklas RA, Sadosty AT. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Annals of Allergy, Asthma & Immunology. 2014;113(6):599-608. doi:10.1016/j.anai.2014.10.007. 

Dribin TE, Michelson KA, Monuteaux MC, Stack AM, Farbman KS, et al. (2019) Identification of children with anaphylaxis at low risk of receiving acute inpatient therapies. PLOS ONE 14(2): e0211949.