Acute urticaria in children: from pediatric Emergency Department to allergology consultation at a Central Hospital

Abstract

Background. Acute urticaria is a common condition in the pediatric emergency department (ED) and no data is available in Portugal.Objective. We aimed to characterize the prevalence, etiology and management of acute urticaria in children presenting at an ED of a portuguese central hospital and report the followup investigation when drug or food allergy was suspected. Methods.Retrospective study of clinical records from children admitted to the ED with acute urticaria during one year period.Results. 250 children were included, mean age of 7.4 ± 4.9 years (0-17 years). The most frequently suspected etiological factors were infections (22%), foods (12%), insect bites (9%) and drugs (8%), of which, upper respiratory tract infections, seafood and β-lactam antibiotics were the most frequent. In 44% of cases, the etiology of urticaria was not determined. After ED discharge, of the 50 patients with suggestive drug or food allergy, only 48% were sent to allergological workup and the allergy confirmed in 6 of them (2.4% of the 250 children). Conclusion.These data suggest that allergy is not the main trigger of acute urticaria in ED children, but when suspected, reference to an allergy department to complete allergological workup was insufficient.M a n u s c r i p t a c c e p t e d f o r p u b l i c a t i o n 5) Highlights boxAcute urticaria in children can be caused by a wide variety of factors, such as infections, food or drug hypersensitivity, physical triggers, insect bites and idiopathic causes. There is a lack of childhood acute urticaria detailed information in Portugal, with no data available. In our study we characterize the prevalence, etiology and management of acute urticaria in children presenting at an emergency department of a portuguese central hospital and reported the follow-up investigation when drug or food allergy was suspected.This study supports the opinion that allergy is not the main trigger of acute urticaria in children, representing 2.4% of the children admitted to the ED with acute urticaria. Most importantly, we found that in 52% of patients with suspected drug or food allergy, reference to an allergy department to complete allergological work-up was not performed.It is important that physicians practising emergency medicine provide appropriate aftercare instructions to patients with suspected allergy and refer these patients for allergological evaluation, in order to provide a complete and careful diagnostic work-up that is essential for a correct diagnosis. In fact, underestimated allergy diagnosis could lead to an increased risk in truly allergic patients, and overestimated diagnosis of allergy could contribute to an overrated avoidance measures in non-allergic children.

The common triggers of urticaria in children admitted to the pediatric emergency room

“…In this study, exact triggers could be identified in 27.3% of patients despite further evaluation. Infection was found to be the most common trigger in children with AU in line with previous studies 8,13–15 . A systematic review indicated viral infection as a potential trigger for both AU and CU, and Herpesviridae was the most frequently reported infectious agent in the pediatric age group 16 .…”

“…The main approach to urticaria is the elimination of the underlying causes; however, the exact trigger usually may remain unknown in AU and CU 4 . The success of identifying causes of AU in childhood varied between 21% and 68% 5–8 . Unlike adults, infections and non‐allergic causes are commonly suspected triggers for AU in children 9 .…”

“…4 The success of identifying causes of AU in childhood varied between 21% and 68%. [5][6][7][8] Unlike adults, infections and non-allergic causes are commonly suspected triggers for AU in children. 9 On the other hand, the triggers of CU, which are mainly immune mediated, are often not identified.…”

The international WAO/EAACI guideline for the management of hereditary angioedema—The 2021 revision and update

“…Nonsedating antihistamines, at standard or higher than standard doses, alone or in combination with omalizumab or immune modulators such as cyclosporine can prevent wheals and angioedema in CSU patients 86,90 . Because mast cell‐mediated angioedema is far more common than HAE‐1/2, on‐demand therapy with antihistamines and, if necessary, with epinephrine and corticosteroids, is indicated when the diagnosis is not yet determined and the history seems to be inconsistent with HAE 91–93 …”

The international WAO/EAACI guideline for the management of hereditary angioedema – The 2021 revision and update

“… 86 , 90 Because mast cell-mediated angioedema is far more common than HAE-1/2, on demand therapy with antihistamines and, if necessary, with epinephrine and corticosteroids, is indicated when the diagnosis is not yet determined and the history seems to be inconsistent with HAE. 91 , 92 , 93 …”