Age-Specific Criteria Improve Anaphylaxis Detection in Infants

Two newly published reviews outline barriers to timely epinephrine use in anaphylaxis among infants and toddlers and support incorporating age-specific signs into recognition criteria.^1,2

Current National Institutes of Health anaphylaxis criteria have not been updated to include infant-specific presentations for frontline clinicians, even as newer international definitions already incorporate them.

"Children, specifically infants and toddlers, can have different reactions or can look different during severe allergic reactions," said Jay Lieberman, MD, professor at the University of Tennessee Health Science Center and program director of the Allergy/Immunology Fellowship Program at Le Bonheur Children's Hospital, in an interview with HCPLive.

Recognizing Atypical Anaphylaxis Signs in Infants and Toddlers

Infants and toddlers cannot verbalize early symptoms such as oral or throat itching the way older children and adults can, which often delays recognition, Lieberman said. Because of this, clinicians and caregivers need to watch for nonverbal cues signaling a systemic allergic reaction. These cues include increased fussiness, inconsolable crying, clinging to a caregiver, placing a finger in the mouth to indicate oral or throat itching, and tugging at an ear to indicate itching inside the ear canal, according to Lieberman.

The plain language review by Pistiner et al, published in Expert Review of Clinical Immunology, identifies additional age-specific signs worth incorporating into recognition criteria, including drooling, back arching, belly breathing, and tongue-thrusting or licking behaviors.¹ Gastrointestinal symptoms such as vomiting are also commonly overlooked in this age group, as clinicians and caregivers may attribute them to a minor illness rather than an allergic reaction, Lieberman said.

Impact of Age-Specific Criteria on Anaphylaxis Detection

The review by Leeds et al. found modified age-specific anaphylaxis criteria improved detection by 23% in infants and 10% in toddlers compared with standard criteria.2 In practice, Lieberman said allergists and emergency physicians often rely on clinical judgment rather than a strict checklist when deciding to give epinephrine. Awareness of these additional presenting signs makes clinicians more likely to identify a reaction as anaphylaxis and to use epinephrine sooner, he said.

Leeds and colleagues analyzed more than a decade of literature to identify barriers behind delayed or missed epinephrine use in this age group.² Investigators point to gaps in caregiver recognition and confidence, rather than epinephrine access alone, as key drivers of delayed or missed treatment among infants and toddlers.

“If you're doing a food challenge or you have a patient with a food allergic reaction in the community, if it's an older kid or an adult, they can usually tell you, ‘Oh, I'm starting to have some itching in my mouth, or my throat feels a little funny,’ whereas an infant or toddler may not be able to tell you that,” Lieberman said, “and so, they're doing other things or behaving differently as that first sign.”

References

1. Pistiner et al. Recognizing and Treating Serious Allergic Reactions (Anaphylaxis) in Infants and Toddlers: A Plain Language Review of Four Studies. Expert Rev Clin Immunol. 2026. doi:10.1080/1744666X.2026.2695166

2. Leeds et al. Epinephrine Underuse for Anaphylaxis in Infants and Toddlers: A Practical Review for Pediatricians. Pediatr Drugs. 2026. doi:10.1007/s40272-026-00752-7