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Tree Nut-Induced Anaphylaxis in Canadian Emergency Departments: Rate, Clinical Characteristics and Management.

Authors: Ducharme, L., Gabrielli, S., Clarke, A. E., Morris, J., Gravel, J., Lim, R., Chan, E. S., Goldman, R. D., O'Keefe, A., Gerdts, J., Chu, D. K., Upton, J., Hochstadter, E., Bretholz, A., McCusker, C., Zhang, X., & Ben-Shoshan, M. Journal: Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Year: 2022
Fruits: Tree nuts
Subject: Allergy

Background: Data are sparce regarding tree nut-induced anaphylaxis (TNA). Objective: We aimed to characterize rate, clinical characteristics, and management of TNA in children (0-17 years old) across Canada, and assess factors associated with severe reactions and epinephrine use. Methods: Between April 2011 and May 2020, data were collected on children presenting to five emergency departments (EDs) in Canada. Multivariate logistic analysis was used to evaluate factors associated with severe reactions (stridor, cyanosis, circulatory collapse, or hypoxia) and epinephrine use. Results: Among 3096 cases of anaphylaxis, 540 (17%) were induced by tree nut. The median age was 5.2 years [Interquartile range (IQR): 2.5-9.5] and 65.4% were males. Among all reactions, 7.0% were severe. The major tree nuts accounting for anaphylaxis were cashew (32.8%), hazelnut (20.0%) and walnut (11.5%). Cashew-induced anaphylaxis was more common in British Columbia [14.0% difference (95% CI, 1.6%-27.6%)] versus Ontario and Quebec, whereas pistachio-induced anaphylaxis was more common in Ontario and Quebec [6.3% difference (95% CI, 0.5%-12.2%)]. Pre-hospital and ED intramuscular (IM) epinephrine administration was documented in only 35.2% and 52.4% of cases, respectively. Severe reactions were more likely among males [adjusted Odds Ratio (aOR) 1.05 (95% CI, 1.01-1.10)] older children [aOR 1.00 (95% CI, 1.00-1.01)], and in reactions triggered by macadamia [aOR 1.27 (95% CI, 1.03-1.57)]. Conclusion: Different TNA patterns in Canada may be due to differences in lifestyle (higher prevalence of Asian ethnicity in British Columbia versus Arabic ethnicity in Ontario and Quebec). IM epinephrine underutilization urges for EAI stocking in schools and restaurants, patient education, and consistent policies across Canada.

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