Among 155 patients aged 0 to 24 months, 96.1% of episodes were food-triggered and 90.4% of epinephrine recipients received only 1 dose.
Colleen M. Shannon, MD, MPH, from Children's Hospital of Philadelphia, and colleagues designed the study to characterize the clinical presentation and emergency management of anaphylaxis in patients aged 0 to 24 months.¹ Cases were confirmed using the 2006 National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) clinical criteria, which apply across age groups without infant-specific modifications.² The analysis captured presenting symptoms, administered treatments, and disposition for each confirmed case.¹
The investigators retrospectively screened encounters at a pediatric emergency department between June 2019 and June 2022 using anaphylaxis-associated International Classification of Diseases, Ninth and 10th Revision codes.¹ Using electronic medical records, the team reviewed each patient’s presenting symptoms, the treatments they received, and whether they were discharged or admitted.
Of 225 potentially eligible encounters identified by diagnostic code, 155 patients met inclusion criteria on chart review.¹ The median age was 10.8 months (interquartile range [IQR], 8.4 to 15.6), and food triggered 96.1% (149/155) of episodes.¹
Skin and mucosal symptoms were the most common presentation, occurring in 99.4% of patients.¹ Gastrointestinal symptoms were documented in 74.2% and respiratory symptoms in 57.4%.¹ Cardiovascular symptoms occurred in 5.8% of patients.¹
Intramuscular epinephrine was administered to 87.1% of patients, and 90.4% of those treated received a single dose.¹ The remaining 12.9% of patients did not receive epinephrine in the emergency department.¹ The investigators also tracked use of antihistamines, corticosteroids, albuterol, and intravenous fluids as treatments of interest.¹
Most patients, 88.4%, were discharged home from the emergency department. None of the admitted patients required additional epinephrine after admission.¹
In their conclusions, the investigators described the typical reaction in this age group as food-triggered and mucocutaneous, with gastrointestinal and/or mild-to-moderate respiratory involvement.¹ Severe respiratory or cardiovascular involvement was uncommon.¹ Symptoms tended to resolve after 1 epinephrine dose, and most patients did not require hospitalization.¹
The findings provide emergency and allergy clinicians with age-specific data on symptom distribution, epinephrine response, and disposition for patients younger than 2 years presenting with suspected anaphylaxis.¹ Mild-to-moderate respiratory involvement and gastrointestinal symptoms accompanied mucocutaneous findings in most reactions, a pattern clinicians can weigh when applying NIAID/FAAN criteria to patients unable to report subjective symptoms.¹,²
Because the cohort included only reactions prompting emergency department evaluation, the findings describe the presentations clinicians are most likely to encounter in acute care settings rather than the full spectrum of infant reactions managed at home.¹ The investigators also noted that the data was analyzed descriptively.
The findings build on recent HCPLive coverage of anaphylaxis recognition in young children. In an August 2026 Q&A, Jay Lieberman, MD, professor at the University of Tennessee Health Science Center, discussed atypical presentations in infants and toddlers and persistent epinephrine underuse.³
Lieberman pointed to fussiness, inconsolable crying, putting a finger in the mouth, and ear tugging as possible signs of oral, throat, or ear canal itching in patients unable to describe their symptoms.³ He also noted clinicians may dismiss vomiting as a minor illness. This point is relevant here, since 74.2% of patients in the Pediatric Emergency Care cohort presented with gastrointestinal involvement.¹,³
“Infants shouldn’t be treated any differently,” Lieberman said. “If we think they’re having anaphylaxis, they should get epinephrine.”
References
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