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Anaphylaxis in children: A nine years retrospective study (2001–2009)
R. Silvaa,
Corresponding author
ruisilva@inbox.com

Corresponding author.
, E. Gomesb, L. Cunhab, H. Falcãob
a Allergy Division, Hospital S. João EPE, Porto, Portugal
b Allergy Division, Centro Hospitalar do Porto, EPE, Hospital Maria Pia, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Anaphylaxis is an acute multisystemic and potentially fatal reaction&#44; resulting from the rapid release of inflammatory mediators by mast cells and basophils&#44; and occurs when a susceptible person is exposed to a certain agent&#46; The severity of the reaction can vary from mild to life threatening and can be rapidly progressive&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The earliest description on record of a fatal allergic reaction is related to Menes&#44; a first dynasty pharaoh&#44; who died in 2621<span class="elsevierStyleHsp" style=""></span>BC&#44; presumably from an anaphylactic shock caused by a bee sting&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Its name comes from the Greek&#58; <span class="elsevierStyleItalic">a</span> &#40;against&#41; and <span class="elsevierStyleItalic">phylaxis</span> &#40;immunity&#44; protection&#41;&#44; and was proposed in 1902 by Portier and Richet&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">According to the latest nomenclature proposed by the World Allergy Organization&#44; it can be classified as&#58; allergic &#40;immunological reaction involving IgE&#44; IgG or immune complexes&#41; and non-allergic &#40;where the mechanisms involved are not immune&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although it may appear that IgE-mediated anaphylaxis occurs upon a first exposure to a food&#44; drug&#44; or insect sting&#44; there must have been a prior&#44; and probably unwitting&#44; sensitisation from a previous exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The patient&#44; however&#44; may not remember an uneventful sting or be aware of &#8220;hidden&#8221; allergens in foods&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The definition of anaphylaxis has only become consensual since 2006&#44; following the completion of the Second Symposium on the Definition and Management of Anaphylaxis&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> allowing the standardisation of diagnostic criteria and comparison of epidemiological data between different countries&#46; The prior absence of a consensual definition contributes to explaining the significant variation in the reported lifetime frequency of anaphylaxis in different countries&#44; ranging from 0&#46;02&#37; to 0&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Its exact prevalence is unknown&#44; being estimated that 1 in 1333 people in the United Kingdom have suffered an episode during their lifetime&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In children&#44; foods &#40;mainly cow&#39;s milk&#44; egg&#44; wheat&#44; peanut&#44; and fish&#41; are the most often involved triggers for IgE-mediated anaphylaxis&#46; Other allergens include drugs &#40;mainly beta-lactam antibiotics&#41;&#44; hymenoptera venom&#44; and administration of specific immunotherapy&#46; Non-IgE triggers include NSAIDs&#44; radiological contrast media&#44; exercise&#44; and cold&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Several reports suggest that almost 20&#37; of all episodes of anaphylaxis are idiopathic&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In 5&#37; to 20&#37; of cases of anaphylaxis&#44; a biphasic reaction can occur&#44; the severity of which may be equal to or higher than the initial reaction&#44; and is generally more refractory to standard treatment&#46; This second reaction can occur between 1 and 72<span class="elsevierStyleHsp" style=""></span>h &#40;generally 8&#8211;12<span class="elsevierStyleHsp" style=""></span>h&#41; after the first one&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Objectives</span><p id="par0030" class="elsevierStylePara elsevierViewall">To characterise the cases of anaphylaxis evaluated in an Allergy Division of a Central Paediatric Hospital and to compare the data with other published studies on this subject&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A retrospective study of all cases of anaphylaxis in children under 18 years of age evaluated in the Allergy Division of Centro Hospitalar do Porto&#44; EPE &#8211; Hospital Maria Pia&#44; Portugal&#44; in the period from 2001 to 2009&#46; Anaphylaxis was defined according to Sampson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; For grading the severity of anaphylactic reactions&#44; three categories were defined&#58; Mild&#44; when there was no respiratory or cardiovascular involvement&#59; Moderate&#44; when respiratory symptoms were present&#44; but without cardiovascular involvement&#59; and Severe&#44; when there was shock&#47;hypotension or cardiovascular collapse&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnostic work up of all children with anaphylaxis evaluated included &#40;1&#41; detailed clinical history&#44; with special emphasis on the events surrounding the episode&#44; the clinical manifestations&#44; the severity of attacks&#44; the response to treatment&#44; and evolution&#59; &#40;2&#41; physical examination&#59; &#40;3&#41; skin tests with the suspect allergen and intradermal tests for drug and hymenoptera venom allergy&#59; &#40;4&#41; specific IgE determination by fluorescence enzyme immunoassay &#40;Unicap<span class="elsevierStyleSup">&#174;</span>&#44; Phadia&#44; Sweden&#41;&#59; &#40;5&#41; other specific tests&#44; such as ice cube test for cold-induced anaphylaxis&#44; and complement and basal tryptase levels determination when necessary to exclude other causes&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">As this is a descriptive study&#44; qualitative variables such as sex&#44; symptoms&#44; culprit agent&#44; as well as results of tests are described in frequency and percent&#46; Quantitative variables&#44; such as age&#44; are expressed with medians&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">During the study period&#44; 73 children were consulted for anaphylactic reactions &#40;47 &#9794;&#41;&#44; of whom 64&#37; had a personal history of atopy&#46; The age at the time of the reaction ranged between 17 days and 15 years old&#44; with a median of four years &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; At least 21 of these children had one or more previous episodes of allergic reaction to the agent that caused the anaphylaxis&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Foods were the most frequently identified cause &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>57&#41;&#44; followed by drugs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&#44; hymenoptera venom &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41; and cold &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46; In five cases it was not possible to identify a causal agent after extensive study&#44; and the anaphylaxis was therefore classified as idiopathic&#46; Food anaphylaxis presented at an earlier age than both drug and hymenoptera venom induced anaphylaxis &#40;median ages 3 years&#44; 5&#46;5 years and 8 years&#44; respectively&#41;&#46; Children with idiopathic anaphylaxis had a median age of five years&#46; Among the foods&#44; cow&#39;s milk was the culprit agent in 27 children&#46; Fish&#44; shrimp and mollusc allergy were responsible for 13 cases&#59; cereals and nuts for eight&#59; egg for five&#59; and fruits for four&#46; All drug-induced anaphylactic reactions were attributed to beta-lactams and gentamicin &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The skin tests and&#47;or specific IgE for the culprit allergen were positive in all cases of anaphylaxis due to foods and to hymenoptera venom&#46; The ice test cube was positive in the child with history of cold-induced anaphylaxis&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The most severe reaction was a cardiorespiratory arrest in a milk-allergic child&#46; The most common symptoms were respiratory and cutaneous in 51 cases &#40;of which 17 also had gastrointestinal involvement&#41;&#46; Hypotension occurred in nine cases&#44; with respiratory and&#47;or gastrointestinal and&#47;or cutaneous manifestations&#46; Ten children had gastrointestinal and cutaneous symptoms&#44; and two had respiratory and gastrointestinal symptoms&#46; There were no fatalities in our series&#46; According to the grading system described above&#44; the majority of the reactions were classified as moderate &#40;53 cases&#44; 72&#37;&#41;&#44; with the remaining ones equally divided as mild and severe &#40;10 cases&#44; 14&#37; for each&#41;&#46; Median age of children with severe reactions was lower than those with moderate and mild reactions &#40;1&#46;25 years for severe reactions vs&#46; 4 years for moderate and for mild reactions&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Most reactions were treated in the emergency department with corticosteroids&#44; antihistamines&#44; or both&#46; Aerosolised salbutamol and ipratropium bromide were also used in reactions with respiratory symptoms&#46; Adrenaline was used in the treatment of the acute episode in only one quarter of the children&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Anaphylaxis is diagnosed with high likelihood based on clinical criteria&#44; and there is no <span class="elsevierStyleItalic">gold standard</span> test&#46; In recent years&#44; objective criteria have been proposed for its diagnosis&#44; allowing the comparison of data from different populations and a greater knowledge of the triggering factors&#44; risk factors and other data essential for proper monitoring of these patients&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">According to recent reports&#44; the incidence rate of anaphylaxis is increasing&#44; particularly during the first two decades of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;13&#44;14</span></a> The largest published study of anaphylaxis in paediatric patients included 117 children&#44; and was done at the Royal Children&#39;s Hospital in Melbourne&#44; Australia&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In that article&#44; the median age at diagnosis was 2&#46;4 years&#44; and foods were the most frequent precipitating factor&#44; accounting for 85&#37; of cases&#46; Among foods&#44; peanuts and cashew were the most frequently involved&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Another study from Israel&#44; which reviewed the clinical files of all children who were admitted to the Schneider Children&#39;s Medical Center of Israel with a diagnosis of anaphylaxis over a 12-year period&#44; was recently published&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> During the study period&#44; 92 children with anaphylaxis &#40;50 males&#41;&#44; aged 14 days to 18 years &#40;mean&#58; 7&#46;4 years&#41; were hospitalised&#46; The main causes were foods &#40;43&#37;&#41;&#44; mainly milk and nuts&#44; drugs &#40;22&#37;&#41;&#44; and hymenoptera venom &#40;11&#37;&#41;&#46; In five children&#44; the cause could not be identified&#46; There was history of atopy in more than half of children&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In a questionnaire-based survey done to Paediatricians in Germany regarding episodes of anaphylaxis in infants and children below 12 years of age&#44; 103 cases were reported&#46; Median age was five years&#44; and 58&#37; were boys&#46; Foods were the most common causal allergen &#40;57&#37;&#41;&#44; followed by insect stings &#40;13&#37;&#41;&#44; and specific immunotherapy &#40;12&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However&#44; since this study was done before the current definition of anaphylaxis was proposed&#44; several cases not currently considered as such were included&#44; which difficult the analysis and possibly explains the relatively high number of cases attributed to insect stings and specific immunotherapy&#46; Another limitation lies in the fact that the suspected aetiological agent of anaphylaxis was reported by the physicians in the questionnaire&#44; and was not proven by allergy tests in the majority of cases&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Ours is the largest European study published to date using the current definition of anaphylaxis&#44; with 73 children studied&#46; Similarly to most studies published in the literature&#44; the most frequently involved agents in anaphylaxis in children are foods&#44; mainly cow&#39;s milk&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;18&#44;19</span></a> Also in agreement with previous studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;20</span></a> the prevalence of anaphylaxis until adolescence was higher in males&#46; Atopy was also present in two thirds of the children in our study&#46; According to the literature&#44; atopic individuals have a higher predisposition to anaphylactic episodes&#44; and dominate series of all causes of anaphylaxis&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;18&#44;21&#44;22</span></a> A possible explanation is that the extracellular cytokine milieu associated with atopic diseases may account for the increased risk of atopic individuals to an anaphylactic reaction&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> It should also be noted that several studies have reported an association of anaphylaxis with several gene groups&#44; including genes that affect the anatomic barrier&#44; and genes associated with the innate and adaptive immune systems&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Idiopathic anaphylaxis is a diagnosis of exclusion and therefore extensive labwork and testing are required to rule out possible culprit allergens and the numerous diseases that may appear as idiopathic anaphylaxis &#40;such as a carcinoid syndrome&#44; cutaneous or visceral mastocytosis&#44; deficiency of C1 esterase inhibitor&#44; among others&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In our study&#44; five cases &#40;7&#37;&#41; were classified as idiopathic after full diagnostic work-up&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The existing grading systems for severity of anaphylaxis are based on outdated definitions of anaphylaxis&#44; which included some systemic hypersensitivity reactions currently not considered as anaphylaxis&#46; For our grading on the severity of anaphylactic reactions&#44; we defined three categories &#40;mild&#44; moderate and severe&#41;&#44; detailed in the &#8220;Material and methods&#8221; section&#46; The most common symptoms were respiratory and cutaneous and&#44; according to the grading system described&#44; the majority of the reactions were classified as moderate&#46; It is probable that a selection bias is present in this population&#44; since mild cases of anaphylaxis are more frequently underdiagnosed&#44; and therefore not referred to an allergy division for study and follow-up&#46; Also&#44; hypotension sometimes goes undocumented&#44; especially in infants and young children&#44; which may explain the relatively low number of cases classified as severe&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The primary and most important treatment for anaphylaxis is adrenaline&#44; at a dose of 0&#46;01<span class="elsevierStyleHsp" style=""></span>mg&#47;kg of a 1<span class="elsevierStyleHsp" style=""></span>mg&#47;mL &#40;1&#58;1000&#41; dilution to a maximum dose of 0&#46;3<span class="elsevierStyleHsp" style=""></span>mg in a child&#44; which can be repeated if necessary&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;32</span></a> Despite being recommended in all anaphylaxis management guidelines as the mainstay of treatment for anaphylaxis&#44; adrenaline is still used in only a minority of these cases&#44; meaning that three-quarters of these children did not receive adequate treatment&#46; Even after the complete resolution of symptoms&#44; a period of observation at the Hospital for a minimum of 8 or 10<span class="elsevierStyleHsp" style=""></span>h is recommended&#44; in order to monitor the recurrence of symptoms and a possible biphasic reaction&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;28&#44;33</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">A recent review has shown that food allergy&#44; particularly in cases of severe reactions such as anaphylaxis&#44; has a very significant impact on the quality of life of children and their parents&#46; The burden of responsibility and the constant vigilance needed to avoid allergens&#44; as well as the uncertainty associated with the possibility of accidental exposures&#44; are major contributing factors&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In a study by Ferreira and Alves&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> which used a multiple-choice questionnaire to evaluate the practical knowledge of diagnostic and therapeutic aspects of anaphylaxis among general practitioners in Portugal&#44; the authors found a percentage of correct answers ranging from 36&#37; to 46&#37; regarding the diagnostic questions&#44; and from 18&#37; to 22&#37; regarding the anaphylaxis treatment&#46; This lack of knowledge and misconceptions about the treatment of an anaphylactic reaction among the medical community constitute a major concern since this can be a life-threatening condition&#46; There is an urgent need to increase knowledge and awareness regarding the treatment of anaphylaxis and the importance of referring the patient to an allergist for appropriate follow-up&#46; The complete study of all cases of anaphylaxis is required in order to allow to identify the cause&#44; and to help prevent future reactions&#46; In cases of food allergy&#44; the child and the parents must be clearly informed about dietary restrictions&#44; including foods with known cross-reactivity&#44; the possibility of its presence as a &#8220;hidden allergen&#8221;&#44; and instructed to always read the food labels to avoid possible untoward reactions&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a> Parents of children considered to be &#8220;at risk&#8221; of anaphylaxis are advised to inform schools of their children&#39;s allergies and what to do in case of a reaction&#46; An adrenaline &#40;epinephrine&#41; auto-injector should be prescribed to all patients with a history of anaphylaxis&#44; according to the recommendations of the European Academy of Allergy and Clinical Immunology<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> and the American Academy of Allergy Asthma and Immunology&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> with detailed instructions on how to proceed in the event of future reactions&#46; Specific immunotherapy with hymenoptera venoms is effective in preventing future episodes of anaphylaxis caused by these agents&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;38&#44;39</span></a> Oral desensitisation is effective for many foods&#44; and can be proposed in certain cases of food induced reactions&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;24&#44;40&#8211;42</span></a> For anaphylaxis triggered by a drug&#44; if that drug is indispensable for treatment &#40;such as chemotherapic agents&#41; and there is no alternative drug&#44; a tolerance induction protocol can generally be used to obtain temporary tolerance&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;43&#44;44</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; the most important causes of anaphylaxis in our study are foods&#44; particularly cow&#39;s milk&#44; and the most common symptoms were respiratory and cutaneous&#46; The prevalence of anaphylaxis was higher in males and&#44; in two-thirds of the patients there was a history of atopy&#46; Adrenaline was used in only one quarter of the children&#44; meaning that the majority of the cases did not meet the recommended standards of care with regard to administration of intramuscular adrenaline&#46; There is an urgent need to increase knowledge and awareness regarding the treatment of anaphylaxis and its follow-up among the general medical community&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2010-11-11"
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        "titulo" => "Summary"
        "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Anaphylaxis is an acute multisystemic and potentially fatal reaction&#44; resulting from the rapid release of inflammatory mediators&#46; Its exact prevalence is unknown&#46; In children&#44; foods are the most significant triggers for IgE-mediated anaphylaxis&#46;</p> <span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To characterise the cases of anaphylaxis evaluated in an Allergy Division of a Central Paediatric Hospital&#46;</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A review of all cases of anaphylaxis evaluated from 2001 to 2009&#46; Anaphylaxis was defined according to Sampson&#39;s 2006 criteria&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Seventy-three children had anaphylactic reactions &#40;47 male&#41;&#44; of which 64&#37; had history of atopy&#46; Age at time of reaction ranged between 17 days and 15 years old &#40;median&#58; four years&#41;&#46; Food was the most frequently identified cause &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>57&#41;&#44; followed by drugs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>8&#41;&#44; hymenoptera venom &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; and cold &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46; In five cases there was no identifiable cause&#46; Among foods&#44; cow&#39;s milk was the culprit agent in 27 children&#46; The most severe reaction was a cardiorespiratory arrest&#46; The most frequent symptoms were respiratory and cutaneous in 51 cases&#46; Hypotension was present in nine cases&#46; There were no fatalities&#46; Most acute reactions were treated with corticosteroids and&#47;or antihistamines&#46; Adrenaline was used in only about one quarter of children&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The most important causes of anaphylaxis in our study were foods&#44; and the most common symptoms were respiratory and cutaneous&#46; The prevalence of anaphylaxis was higher in males and&#44; in two thirds of patients there was a history of atopy&#46; Despite being the primary and most important treatment for anaphylaxis&#44; adrenaline is still used in only a minority of these cases&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Age at time of reaction in years&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Examples&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Allergic</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Foods&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Milk&#44; egg&#44; peanut&#44; fish&#44; shrimp&#44; cereals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">penicillin&#44; cephalosporins&#44; anesthetics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hymenoptera venom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bee&#44; wasp&#44; polistes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vaccines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Specific immunotherapy&#44; tetanus toxoid&#44; vaccines containing egg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Latex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Gloves&#44; balloons&#44; condoms&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Drugs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">NSAIDs &#40;aspirin&#44; nimesulide&#44; ibuprofen&#41;&#44; muscle relaxants&#44; gammaglobulin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Radiological contrast media&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Preservatives&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Sulphites&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Physical&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Exercice&#44; cold&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Idiopathic&nbsp;\t\t\t\t\t\t\n
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        "fuente" => "<span class="elsevierStyleItalic">Source&#58;</span> Adapted from Ref&#46; <a class="elsevierStyleCrossRef" href="#bib0030">6</a>&#46;"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Clinical criteria for the diagnosis of anaphylaxis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Anaphylaxis is highly likely when <span class="elsevierStyleUnderline">any one of the following three</span> criteria are fulfilled</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; Acute onset of an illness &#40;minutes to several hours&#41; with involvement of the skin&#44; mucosal tissue&#44; or both and at least one of the following&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>a&#46; Respiratory compromise &#40;e&#46;g&#46; dyspnoea&#44; bronchospasm&#44; stridor&#44; hypoxia&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>b&#46; Cardiovascular compromise or associated symptoms of end-organ dysfunction &#40;e&#46;g&#46; hypotension&#44; collapse&#44; syncope&#44; incontinence&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Two or more of the following that occur after exposure to a likely allergen for that patient &#40;minutes to several hours&#41;&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>a&#46; Involvement of the skin or mucosal tissue &#40;e&#46;g&#46; generalized hives&#44; itch&#44; flushing&#44; swelling&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>b&#46; Respiratory compromise &#40;e&#46;g&#46; dyspnoea&#44; bronchospasm&#44; stridor&#44; hypoxia&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>c&#46; Cardiovascular compromise or associated symptoms of end-organ dysfunction &#40;e&#46;g&#46; hypotension&#44; collapse&#44; syncope&#44; incontinence&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>d&#46; Persistent gastrointestinal symptoms &#40;e&#46;g&#46; crampy abdominal pain&#44; vomiting&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; Hypotension after exposure to known allergen for that patient &#40;minutes to several hours&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Infants and children&#58; low systolic BP &#40;age-specific&#41; or greater than 30&#37; decrease in systolic BP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adults&#58; systolic BP of less than 90<span class="elsevierStyleHsp" style=""></span>mm Hg or greater than 30&#37; decrease from that person&#39;s baseline&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Milk &#8211; 27Fish&#44; shrimp and mollusc &#8211; 13Cereals and nuts &#8211; 8Egg &#8211; 5Fruit &#8211; 4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Beta-lactams and gentamicin &#8211; 8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Bee &#8211; 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Cold &#8211; 1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Unknown &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "Symposium on the definition and management of anaphylaxis&#58; summary report"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;A&#46; Sampson"
                            1 => "A&#46; Munoz-Furlong"
                            2 => "S&#46;A&#46; Bock"
                            3 => "C&#46; Schmitt"
                            4 => "R&#46; Bass"
                            5 => "B&#46;A&#46; Chowdhury"
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ISSN: 03010546
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos