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Evidence Repository

Anaphylaxis

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Last Updated
Jul 2025

Topic
Anaphylaxis

EVIDENCE REPOSITORIES

This evidence repository is a collection of best available resources and evidence collated by a knowledge synthesis team at Alberta Research for Health Evidence (ARCHE) and the clinical content team. The knowledge synthesis team utilizes a pyramid-shaped framework, built upon the “4S” hierarchy of evidence model, to provide detailed evidence appropriate to meet stakeholders’ needs. They search a combination of databases (Cochrane Library, PubMed, TRIP Database) and web-based search engines (Google, Google Scholar) to locate evidence for the knowledge pyramids. Publication types sought in the initial topic searches are organized into five levels that determine the order in which resources are presented:

  1. Bottom Line Recommendations
  2. Clinical Practice Guidelines And Pathways
  3. Overviews and Summaries of Systematic Reviews
  4. Systematic Reviews
  5. Key Studies

Where applicable resources for families and parents are also listed.

The knowledge synthesis team collaborates with the clinical content team to select the most relevant guidelines, reviews, and key studies, which can be found below. This evidence repository is not intended to be an exhaustive list of resources for a topic, but rather a curated list of current, evidence-based resources, based on expert consensus of relevance and usability for a general emergency department setting. Every effort is made to identify resources that are open access (i.e. publicly available, free of charge, not requiring a subscription).

More information about the creation of our evidence repositories can be found here.

Content Team

Thank you to the following clinical content experts and Knowledge Synthesis team who led the development of this evidence repository.

Waleed Alqurashi, MD, MSc, FAAP, FRCPC; Clinical Investigator, CHEO Research Institute; Pediatric Emergency Physician, Division of Emergency Medicine, CHEO; Assistant Professor, Department of Pediatrics and Emergency Medicine, Faculty of Medicine, University of Ottawa

Anne Ellis, Md Msc Frcpc; Associate Professor, Division Chair, Allergy & Immunology, Queen’s University

Liza Bialy, Bsc, Mph, Knowledge Synthesis Project Coordinator, Alberta Research Centre For Health Evidence, Department of Pediatrics, University of Alberta

Sarah Elliott, PhD, Assistant Director, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta

TREKK developed resources for healthcare providers and parents & families can be found here.

Clinical Practice Guidelines And Pathways

  1. Muraro A, Worm M, Alviani C, et al. EAACI guidelines: Anaphylaxis (2021 update). Allergy. 2022;77(2):357-77.
  2. Frith K, Smith J, Joshi P, Ford LS, Vale S. Updated anaphylaxis guidelines: management in infants and children. Aust  Prescr. 2021;44(3):91-5.
  3. Dodd A, Hughes A, Sargant N, et al. Evidence update for the treatment of anaphylaxis. Resuscitation. 2021;163:86-96.
  4. Cardona V, Ansotegui IJ, Ebisawa M, et al. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J.  2020;13(10):100472.
  5. Turner PJ, Worm M, Ansotegui IJ, et al; WAO Anaphylaxis Committee. Time to revisit the definition and clinical criteria for anaphylaxis? World Allergy Organ J. 2019 Oct 31;12(10):100066.
  6. Fein MN, Fischer DA, O’Keefe AW, et al. CSACI position statement: Newer generation h1-antihistamines are safer than  first-generation h1-antihistamines and should be the first-line antihistamines for the treatment of allergic rhinitis and  urticaria. Allergy, Asthma & Clinical Immunology. 2019.
  7. Canadian Society of Allergy and Clinical Immunology. Anaphylaxis in schools & other settings, 3rd Edition Revised. 2016.
  8. Simons FE, Ebisawa M, Sanchez-Borges M, et al. 2015 update of the evidence base: World allergy organization anaphylaxis  guidelines. World Allergy Organ J. 2015;8(1):32.
  9. Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis–A practice parameter update 2015. Ann Allergy Asthma Immunol. 2015;115(5):341-84.
  10. Halbrich M, Mack DP, Carr S, et al. CSACI position statement: Epinephrine auto-injectors and children < 15 kg. Allergy  Asthma Clin Immunol. 2015;11(1):20.
  11. Muraro A, Roberts G, Worm M, et al. Anaphylaxis: Guidelines from the European academy of allergy and clinical  immunology. Allergy. 2014;69(8):1026-45.
  12. Campbell RL, Li JT, Nicklas RA, et al. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014;113(6):599-608.

Systematic Reviews

  1. Cilona MB, Ramirez GA, Asperti C, et al. Impact of asthma on severe food-induced allergic reactions: a systematic review and meta-analysis. Eur Ann Allergy Clin Immunol. 2024 Jun 26.
  2. Mehta GD, El Zein J, Felippe Baroni I, et al. Epinephrine treatment of food-induced and other cause anaphylaxis in United States and Canadian Emergency Departments: a systematic review and meta-analysis. Expert Rev Clin Immunol. 2023 Jul-Dec;19(9):1171-1181.
  3. Turner PJ, Arasi S, Ballmer-Weber B, et al. Risk factors for severe reactions in food allergy: Rapid evidence review with meta-analysis. Allergy. 2022;77(9):2634-52.
  4. Dreborg S, Walter G, Kim H. International recommendations on epinephrine auto-injector doses often differ from standard weight-based guidance: A review and clinical proposals. Allergy Asthma Clin Immunol. 2022;18(1):102.
  5. Alshajarah HA, Alghamdi HA, Alberi ZA, et al. Peanut-induced anaphylaxis in children: A literature review. Cureus. 2022;14(12):e32946.
  6. Tanno LK, Clark E, Mamodaly M, et al. Food-induced anaphylaxis morbidity: Emergency department and hospitalization data support preventive strategies. Pediatr Allergy Immunol. 2021;32(8):1730-42.
  7. Li LDX, Abrams EM, Lavine E, et al. CSACI position statement: transition recommendations on existing epinephrine autoinjectors. Allergy Asthma Clin Immunol. 2021;17(1):130.
  8. Krishnaswamy G. Critical care management of the patient with anaphylaxis: a concise definitive review. Crit Care Med. 2021;49(5):838-57.
  9. Burrows AG, Ellis AK. Idiopathic anaphylaxis: Diagnosis and management. Allergy Asthma Proc. 2021;42(6):481-8.
  10. Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol. 2020;145(4):1082-123.
  11. Kim TH, Yoon SH, Hong H, et al. Duration of observation for detecting a biphasic reaction in anaphylaxis: a meta-analysis. Int Arch Allergy Immunol. 2019;179(1):31-6.
  12. Greenhawt M, Gupta RS, Meadows JA, et al. Guiding principles for the recognition, diagnosis, and management of infants with anaphylaxis: an expert panel consensus. J Allergy Clin Immunol Pract. 2019;7(4):1148-56.e5.
  13. Gabrielli S, Clarke A, Morris J, et al. Evaluation of prehospital management in a Canadian emergency department anaphylaxis cohort. J Allergy Clin Immunol Pract. 2019;7(7):2232-8.e3.
  14. Cataldi M, Maurer M, Taglialatela M, et al. Cardiac safety of second-generation H(1) –antihistamines when updosed in chronic spontaneous urticaria. Clin Exp Allergy. 2019;49(12):1615-23.
  15. Worm M, Francuzik W, Renaudin JM, et al. Factors increasing the risk for a severe reaction in anaphylaxis: An analysis of data from The European Anaphylaxis Registry. Allergy. 2018;73(6):1322-30.
  16. Dreborg S, Kim L, Tsai G, et al. Epinephrine auto-injector needle lengths: Can both subcutaneous and periosteal/intraosseous injection be avoided? Ann Allergy Asthma Immunol. 2018;120(6):648-53.e1.
  17. Motola D, Donati M, Biagi C, et al. Safety profile of H1-antihistamines in pediatrics: an analysis based on data from  VigiBase. Pharmacoepidemiol Drug Saf. 2017;26(10):1164-71.
  18. Dhami S, Sheikh A, Muraro A, et al. Quality indicators for the acute and long-term management of anaphylaxis: a  systematic review. Clin Transl Allergy. 2017;7:15.
  19. Cohen MB, Saunders SS, Wise SK, et al. Pitfalls in the use of epinephrine for anaphylaxis: patient and provider  opportunities for improvement. Int Forum Allergy Rhinol. 2017;7(3):276-86.
  20. Alqurashi W, Ellis AK. Do corticosteroids prevent biphasic anaphylaxis? J Allergy Clin Immunol Pract. 2017;5(5):1194-205.
  21. Smith PK, Hourihane JO, Lieberman P. Risk multipliers for severe food anaphylaxis. World Allergy Organ J. 2015;8(1):30.
  22. Simons FE, Sampson HA. Anaphylaxis: Unique aspects of clinical diagnosis and management in infants (birth to age 2 years). J Allergy Clin Immunol. 2015;135(5):1125-31.
  23. Lee S, Bellolio MF, Hess EP, et al. Time of onset and predictors of biphasic anaphylactic reactions: A systematic review and  meta-analysis. J Allergy Clin Immunol Pract. 2015;3(3):408-16.e1-2.
  24. Nurmatov UB, Rhatigan E, Simons FE, et al. H2-antihistamines for the treatment of anaphylaxis with and without shock: a  systematic review. Ann Allergy Asthma Immunol. 2014;112(2):126-31.
  25. Sheikh A, Simons FE, Barbour V, et al. Adrenaline auto-injectors for the treatment of anaphylaxis with and without  cardiovascular collapse in the community. Cochrane Database Syst Rev. 2012;2012(8):Cd008935.
  26. Choo KJ, Simons FE, Sheikh A. Glucocorticoids for the treatment of anaphylaxis. Cochrane Database Syst Rev.  2012;2012(4):Cd007596.
  27. Sheikh A, ten Broek V, Brown SG, et al. H1-antihistamines for the treatment of anaphylaxis with and without shock.  Cochrane Database Syst Rev. 2007;2007(1):Cd006160.

Key Studies

  1. Short HB, Walters B, Fabi M, et al. Evaluating practice patterns of observation periods following epinephrine administration for anaphylaxis among pediatric patients. Cureus. 2024 Sep 14;16(9):e69419.
  2. Wang J, Lieberman JA, Wallace DV, et al. Anaphylaxis in practice: a guide to the 2023 practice parameter update. J Allergy Clin Immunol Pract. 2024 Sep;12(9):2325-2336.
  3. Thomas A, Delic J, Hudson P, et al. A retrospective audit of adult and paediatric anaphylaxis management from two Australian metropolitan mixed emergency departments. BMC Emerg Med. 2024 Apr 17;24(1):67.
  4. Mori F, Saretta F, Giovannini M, et al. Pediatric idiopathic anaphylaxis: practical management from infants to adolescents. Ital J Pediatr. 2024 Aug 9;50(1):145.
  5. Patel N, Isaacs E, Duca B, et al. Optimal dose of adrenaline auto-injector for children and young people at risk of anaphylaxis: A phase IV randomized controlled crossover study. Allergy. 2023 Jul;78(7):1997-2006.
  6. Clark E, Kase Tanno L, Vo T, et al. Anaphylaxis management in a French pediatric emergency department: Lessons from the ANA-PED study. Clin Transl Allergy. 2023 Aug;13(8):e12289.
  7. Turgay Yagmur I, Kulhas Celik I, et al. The etiology, clinical features, and severity of anaphylaxis in childhood by age groups. Int Arch Allergy Immunol. 2022;183(6):600-10.
  8. Serbes M, Sasihuseyinoglu AS, Ozcan D, et al. Clinical features of anaphylaxis in children. Allergy Asthma Proc. 2022;43(1):50-6.
  9. Nunes FA, Zanini F, Braga CS, et al. Incidence, triggering factors, symptoms, and treatment of anaphylaxis in a pediatric hospital. World Allergy Organ J. 2022;15(9):100689.
  10. Narchi H, Elghoudi A, Al Dhaheri K. Barriers and challenges affecting parents’ use of adrenaline auto-injector in children with anaphylaxis. World J Clin Pediatr. 2022;11(2):151-9.
  11. Gaffney LK, Porter J, Gerling M, et al. Safely reducing hospitalizations for anaphylaxis in children through an evidence-based guideline. Pediatrics. 2022;149(2).
  12. Dribin TE, Schnadower D, Wang J, et al. Anaphylaxis knowledge gaps and future research priorities: A consensus report. J Allergy Clin Immunol. 2022;149(3):999-1009.
  13. Dondi A, Calamelli E, Scarpini S, et al. Triage grading and correct diagnosis are critical for the emergency treatment of anaphylaxis. Children (Basel). 2022;9(12).
  14. Cha LM, Lee WS, Han MY, et al. The timely administration of epinephrine and related factors in children with anaphylaxis. J Clin Med. 2022;11(19).
  15. Uppala R, Phungoen P, Mairiang D, et al. Pediatric anaphylaxis: etiology and predictive factors in an emergency setting. Glob Pediatr Health. 2021;8.
  16. Sokoloff WC, O’Connell NC, Olson PG, et al. Fill rates and access to self-injectable epinephrine prescribed in a pediatric emergency department. Am J Emerg Med. 2021;44:378-82.
  17. Ruiz-Garcia M, Bartra J, Alvarez O, et al. Cardiovascular changes during peanut-induced allergic reactions in human subjects. J Allergy Clin Immunol. 2021;147(2):633-42.
  18. Robinson LB, Arroyo AC, Cash RE, et al. Emergency department revisits and rehospitalizations among infants and toddlers for acute allergic reactions. Allergy Asthma Proc. 2021;42(3):247-56.
  19. Lieberman JA, Camargo CA, Jr., Pistiner M, et al. Pediatrician perspectives on symptom presentation and treatment of acute allergic reactions. Ann Allergy Asthma Immunol. 2021;126(3):273-7.
  20. Jung WS, Kim SH, Lee H. Missed diagnosis of anaphylaxis in patients with pediatric urticaria in the emergency department. Pediatr Emerg Care. 2021;37(4):199-203.
  21. Cohen JS, Agbim C, Hrdy M, et al. Epinephrine autoinjector prescription filling after pediatric emergency department discharge. Allergy Asthma Proc. 2021;42(2):142-6.
  22. Arroabarren E, Alvarez-Garcia J, Anda M, et al. Quality of the triage of children with anaphylaxis at the emergency department. Pediatr Emerg Care. 2021;37(1):17-22.
  23. Liu X, Lee S, Lohse CM, et al. Biphasic reactions in emergency department anaphylaxis patients: a prospective cohort study. J Allergy Clin Immunol Pract. 2020;8(4):1230-8.
  24. Kraft M, Scherer Hofmeier K, et al. Risk factors and characteristics of biphasic anaphylaxis. J Allergy Clin Immunol Pract. 2020;8(10):3388-95.e6.
  25. Casale TB, Wang J, Nowak-Wegrzyn A. Acute at home management of anaphylaxis during the covid-19 pandemic. J Allergy Clin Immunol Pract. 2020;8(6):1795-7.
  26. Alqurashi W, Awadia A, Pouliot A, et al. The Canadian anaphylaxis action plan for kids: development and validation. Patient Educ Couns. 2020;103(1):227-33.
  27. Shaker M, Wallace D, Golden DBK, et al. Simulation of health and economic benefits of extended observation of resolved anaphylaxis. JAMA Netw Open. 2019;2(10):e1913951.
  28. Shaker M, Kanaoka T, Feenan L, et al. An economic evaluation of immediate vs non-immediate activation of emergency medical services after epinephrine use for peanut-induced anaphylaxis. Ann Allergy Asthma Immunol. 2019;122(1):79-85.
  29. O’Keefe A, Clarke A, St Pierre Y, et al. The risk of recurrent anaphylaxis. J Pediatr. 2017;180:217- 21.
  30. Institute for Safe Medication Practices Canada. Epinephrine use for anaphylaxis – a multi-incident analysis. 2017.
  31. Hochstadter E, Clarke A, De Schryver S, et al. Increasing visits for anaphylaxis and the benefits of early epinephrine administration: A 4-year study at a pediatric emergency department in Montreal, Canada. J Allergy Clin Immunol. 2016;137(6):1888-90.e4.
  32. Dreborg S, Wen X, Kim L, et al. Do epinephrine auto-injectors have an unsuitable needle length in children and adolescents at risk for anaphylaxis from food allergy? Allergy Asthma Clin Immunol. 2016;12:11.
  33. Brown JC, Tuuri RE, Akhter S, et al. Lacerations and embedded needles caused by epinephrine autoinjector use in children. Ann Emerg Med. 2016;67(3):307-15.e8.
  34. Umasunthar T, Procktor A, Hodes M, et al. Patients’ ability to treat anaphylaxis using adrenaline autoinjectors: a randomized controlled trial. Allergy. 2015;70(7):855-63.
  35. Fleming JT, Clark S, Camargo CA, Jr., et al. Early treatment of food-induced anaphylaxis with epinephrine is associated with a lower risk of hospitalization. J Allergy Clin Immunol Pract. 2015;3(1):57-62.
  36. Alqurashi W, Stiell I, Chan K, et al. Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis. Ann Allergy Asthma Immunol. 2015;115(3):217-23.e2.
  37. Church MK, Maurer M, Simons FE, et al. Risk of first-generation H(1)-antihistamines: a GA(2)LEN position paper. Allergy. 2010;65(4):459-66.

Resources For Families

  1. Food Allergy Canada. Caring for a child with food allergy: A guide on what you need to know. 2023.
  2. Food Allergy Canada. National food allergy action plan: charting the path forward. 2019.
  3. Alqurashi W, Children’s Hospital of Eastern Ontario (CHEO). Canadian anaphylaxis action plan for kids. 2018.