Underuse of Intramuscular Adrenaline in Pediatric Anaphylaxis: A Retrospective Cohort Study

Anaphylaxis is a potentially life-threatening systemic hypersensitivity reaction for which prompt intramuscular adrenaline is the recommended first-line treatment.

We aimed to describe the triggers, clinical characteristics, severity, and treatment patterns of pediatric anaphylaxis in children at a single tertiary allergy center, with particular focus on adherence to guideline-recommended adrenaline use.

This single-center retrospective cohort study included 51 children aged 0-18 years diagnosed with anaphylaxis at the Pediatric Allergy and Immunology Clinic, Alanya Alaaddin Keykubat University, between 2020 and 2025. Severity was graded using the 2024 World Allergy Organization (WAO) classification. Associations between demographic, clinical, and treatment variables were assessed using appropriate non-parametric tests.

Fifty-one children were included (32 male [62.7%] and 19 female [37.3%]; mean age 6.38 ± 5.16 years). Food was the leading trigger (52.9%), followed by Hymenoptera venom (17.6%), drugs (13.7%), and idiopathic reactions (13.7%), with a significant age gradient across trigger categories (food-induced reactions occurring in younger children; p<0.001). Cutaneous (92.2%) and respiratory (82.4%) symptoms predominated. Adrenaline was administered in only 49.0% of reactions overall and was markedly less frequent in food-induced (25.9%) than in drug- (100%) or venom-induced (77.8%) anaphylaxis (p=0.001). Increasing WAO severity grade was significantly associated with cardiovascular involvement (p=0.016) and inversely associated with the use of antihistamines as the initial treatment (p=0.013). Sixteen patients (31.4%) were hospitalized and only 14 (27.5%) were prescribed an adrenaline auto-injector at discharge.

In this pediatric cohort, anaphylaxis triggers and treatment patterns showed clear age-related differences. Adrenaline was underused, particularly in food-induced reactions among young children, potentially reflecting difficulties in early symptom recognition. These findings highlight the need for improved anaphylaxis recognition and timely adrenaline use, particularly in young children, as well as appropriate adrenaline auto-injector prescription at discharge, accompanied by training in its use and reinforcement of the importance of carrying the prescribed device.