D1.10 - Underrecognition of Anaphylaxis in Children: Gaps in Diagnosis and Management

Pediatric anaphylaxis may be life-threatening, but is often underrecognized and undertreated. We aimed to assess recognition, diagnosis and management of severe allergic reactions in children and adherence to guideline-recommended IM adrenaline use in a tertiary center in Sarajevo, Bosnia and Herzegovina.

We retrospectively reviewed health care records of children (0–18 years) presenting to a Pediatric Assessment and Admissions Unit (PAAU) of the Pediatric clinic between January 2023 and December 2025, who fulfilled EAACI criteria for anaphylaxis and were admitted to hospital. Patients discharged without admission were excluded due to the insufficient granularity of available information. We extracted demographics, clinical features, management, and outcomes, evaluating anaphylaxis recognition and treatments used.

Twenty-eight anaphylaxis episodes occurred in 24 children (median [IQR] age 10 [1-15] years; 70.8% male). Despite meeting the diagnostic criteria, none were admitted as anaphylaxis. Common admission diagnoses included allergic reaction (16/28, 57.1%), acute urticaria (6/28, 21.4%), Quincke edema (4/28, 14.3%), and insect bite or milk allergy (1/28 each, 3.6%). Six of 28 cases presented directly to the PAAU, and none received IM adrenaline. The remaining 22 were initially assessed in other healthcare settings; among them, 11 had persistent anaphylaxis symptoms on PAAU arrival, and only one received IM adrenaline. Overall, IM adrenaline was administered in 6/28 (21.4%) cases. Systemic corticosteroids were used in 23/28 (82.1%), antihistamines in 17/28 (60.7%), and inhaled bronchodilators in 6/28 (21.4%) cases. Five patients had adrenaline auto-injectors (AAI), which were used in three cases (one by a parent, two by emergency physicians). Although 24/28 (85.7%) patients were discharged with AAI prescriptions, only 8/28 (28.6%) were discharged with a diagnosis of anaphylaxis.

Anaphylaxis remains underdiagnosed and mislabeled despite accurate clinical symptom documentation. This diagnostic hesitancy likely contributed to low adherence to guideline-recommended treatment, including underuse of IM adrenaline and overuse of systemic corticosteroids. These findings reveal gaps in recognition and treatment, highlighting the need for targeted education and standardized protocols to improve outcomes and prevent potential life-threatening delays.