Epinephrine underused in treating children with sesame-induced anaphylaxis

Sesame-induced anaphylaxis, usually due to hummus ingestion, common represented the first manifestation of sesame allergy among children in Canada, according to a study published in Annals of Allergy, Asthma & Immunology.

Also, epinephrine tended to be underutilized in these cases at home, by emergency medical services and in the ED, the researchers wrote.

“Our Cross-Canada Anaphylaxis Registry (C-CARE) study included a 10-year nationwide investigation of pediatric sesame-induced anaphylaxis,” Carly Sillcox, BSc, of the division of allergy and clinical immunology in the department of pediatrics at Montreal Children’s Hospital, McGill University Health Centre, told Healio.

Carly Sillcox

“As cases of sesame anaphylaxis rise in North America due to factors such as food globalization, so does the need for research on the management and clinical presentation of sesame as a food allergen,” Sillcox said.

C-CARE reported 3,279 cases of children with food-induced anaphylactic reactions presenting to seven EDs in four Canadian provinces and one regional emergency medical service between April 2011 and January 2021.

Sesame accounted for 130 (mean age, 5 years; 61.5% boys) of these cases. Of these patients, 37.7% had a known sesame allergy, whereas the remaining 62.3% had sesame-induced anaphylaxis as their presenting symptom. 

The researchers defined anaphylaxis as the involvement of at least two organ systems or hypotension in response to an allergen, and they categorized 33.8% of cases as mild, 60.8% as moderate and 5.4% as severe.

Angioedema was a symptom in 66.2% of cases, followed by urticaria in 63.9%, pruritis in 45.4%, gastrointestinal symptoms in 36.9% and breathing difficulties in 26.9%.

Hummus, made with a sesame paste called tahini, caused 68.8% of cases, although bagel sesame grains were the culprit in 4.4% and bread and cookies each caused 3.5% of events.

Reactions occurred within 5 minutes in 48.3% of cases, between 5 minutes and 2 hours after exposure in 46.7% of cases and between 2 hours and 8 hours after exposure in 3.3% of reactions. The researchers attributed these later reactions to late recognition and recall or to rare cases of delayed anaphylaxis.

Home was the setting for 60% of these reactions, followed by 12.5% at school or daycare, 12.5% at a public location and 11.7% at restaurants.

Before reaching the ED, 32.3% of these patients received epinephrine, 50.8% were given antihistamines, 4.6% received inhaled beta agonists, 0.1% received corticosteroids and 30% were not treated.

Once reaching the ED, treatment included epinephrine in 47.7% of cases, antihistamines in 40.8%, beta agonists in 3.8% and corticosteroids in 29.2%, whereas 15.4% were not treated.

Also, the researchers found that one out of five children presenting with sesame-induced anaphylaxis were not treated with epinephrine before or after reaching the ED, although multiple doses of epinephrine were administered to four patients in the ED. None of the patients in the study were admitted to the hospital.

Boys (adjusted OR = 1.27; 95% CI, 1.08-1.5) and patients with a known food allergy (aOR = 1.36; 95% CI, 1.11-1.68) were more likely to receive epinephrine before reaching the ED. The researchers also found likelihood for receiving multiple doses of epinephrine in the ED increased with age (aOR = 1; 95% CI, 1-1.02).

Providers prescribed epinephrine autoinjectors (EAIs) in 67.7% of cases after ED visits, and 50.8% of these children were referred to an allergist for evaluation.

“Our study emphasizes the concern that epinephrine remains underutilized in pediatric patients suffering with sesame anaphylaxis,” Sillcox said.

The researchers attributed this underuse to a lack of prior allergy diagnosis, inaccessibility of epinephrine at the time of the reaction and inability to recognize the child’s symptoms.

Additional obstacles to EAI use include delays between sesame ingestion and reaction, the researchers continued. Plus, only approximately half of patients carry an unexpired EAI regularly. 

To counteract these barriers, Sillcox said, doctors need to continue to educate families aboutrecognizing the signs and symptoms of anaphylaxis and the prompt use of EAIs as first-line treatment.

“Physicians should encourage parents and guardians to practice prompt auto-injector use, demonstrate how to properly administer an auto-injector,and reinforce its safety and efficacy,” Sillcox said.

Also, Sillcox said, doctors need to promote consistent epinephrine carriage and prompt administration to manage pediatric sesame anaphylaxis.

Physicians additionally should help empower parents to use EAIs promptly when indicated, the researchers continued, adding that there is a need for ongoing management and awareness of sesame-induced anaphylaxis cases in the community.

The researchers plan on continuing their studies of sesame anaphylaxis as well as their educational efforts.

“Our aim is toraiseawarenessthat sesame, in the form of tahini, is a common ingredient inhummus andtrigger of anaphylaxis in those with a sesame allergy,” Sillcox said. “As sesame-induced anaphylaxis heightens in Canada, so does our responsibility to increase management and consciousness in the community.”

Over the next several years, Sillcox said that research should reinvestigate pediatric sesame anaphylaxis to determine if awareness regarding epinephrine usage and administration has helped to control instances of sesame anaphylaxis.

“In addition, as sesame allergen becomes increasingly prominent in North America, future studies are needed to consider associated factors of sesame anaphylaxis and discover how to diminish such anaphylactic scenarios,” Sillcox said.

For more information:

Carly Sillcox, BSc, can be reached at carly.sillcox@mail.mcgill.ca.