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We thank Grigoletto et al for their thoughtful letter regarding our report. We agree with the authors' conclusion that clinicians should consider history of asthma and asthma control status when managing children with anaphylaxis. In support of their conclusions, the authors cite a study evaluating anaphylactic reactions from peanuts and tree nuts in an outpatient allergy center.1Summers C.W. Pumphrey R.S. Woods C.N. McDowell G. Pemberton P.W. Arkwright P.D. Factors predicting anaphylaxis to peanuts and tree nuts in patients referred to a specialist center.J Allergy Clin Immunol. 2008; 121: 632-638.e2Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar In contrast to our report, this study includes limited allergens and may represent a more severe cohort of patients with a greater predilection for asthma and/or severe anaphylaxis based on their referral to an allergy center. Thus, it is difficult to compare their findings with our own, or generalize them to the care of children presenting to emergency departments (EDs) with anaphylaxis. In our study, we accounted for potential differences in asthma severity and control status by performing a subanalysis to determine whether children with a history of asthma receiving inhaled corticosteroids were more likely to have severe anaphylactic reactions than children with a history of asthma not receiving inhaled corticosteroids (OR 1.14; 95% CI 0.68-1.94). We believe this was the best approach to evaluate the potential effect of asthma control on anaphylaxis severity within the limitations of our retrospective study design, in which we could not accurately assess the level of asthma control (eg, nighttime awakenings, interference with normal activity, frequency of use of short-acting inhaled beta agonists for symptom control) in the electronic health record.2Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma–summary report 2007.J Allergy Clin Immunol. 2007; 120: S94-S138PubMed Google Scholar Based on the letter by Grigoletto et al, we performed an additional subanalysis to determine whether children with asthma with potential surrogates of asthma control status, including previous ED encounters for asthma exacerbations (n = 128), severe ED encounters for asthma exacerbations (defined as emergency severity index levels 1 and 2; n = 51), or previous intensive care unit admissions for asthma exacerbations (n = 12), were more likely to have severe anaphylactic reactions. Children with these asthma-specific covariates were not more likely to have severe anaphylactic reactions (52.3% vs 63.1% [P = .11]; 51.0% vs 58.9% [P = .34]; 75.0% vs 56.2% [P = .24], respectively). We believe that it is important to manage children with anaphylaxis based on the severity of symptoms and physical examination findings. Thus, it is imperative that clinicians recognize the early signs of severe and potentially fatal anaphylactic reactions (eg, upper airway obstruction, severe bronchospasm, cardiovascular collapse) and to initiate prompt treatment to prevent sequelae.3Campbell R.L. Li J.T.C. Nicklas R.A. Sadosty A.T. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter.Ann Allergy Asthma Immunol. 2014; 113: 599-608Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar However, we also propose that for patients with anaphylaxis and a history of asthma who do not have severe reaction features, decision-making about the need for prolonged observation or hospitalization should not be made solely based on a history of asthma. Finally, we reinforce that before our findings can be applied in clinical care, they require further validation to accurately assess and account for clinical features that may affect anaphylaxis severity, including history of asthma and asthma control status. Poor asthma control remains a risk factor for severe anaphylaxisThe Journal of PediatricsVol. 224PreviewWe have read with interest the report by Dribin et al investigating the association between history of asthma and anaphylaxis severity in children.1 The authors concluded that children hospitalized for anaphylaxis with a medical history of asthma were not more likely to have severe anaphylactic reactions compared with children without asthma. However, we noticed that asthma control status at the time of anaphylaxis was not determined in the study. As mentioned by the authors, a position paper from the European Academy of Allergy and Clinical Immunology identifies asthma as a risk factor for fatal anaphylaxis, but it does also specify that this mainly concerns “severe and uncontrolled asthma.”2 Previous observations from independent series pointed out that asthma control status at the time of the event was of primary importance. Full-Text PDF