In the JournalsPerspective

Less than half of children immediately receive epinephrine for anaphylaxis

Melissa Robinson, MD
Melissa Robinson

Less than 50% of children who experience anaphylaxis receive epinephrine before treatment in an ED or urgent care center, despite the medication being the first line of defense against the condition, according to a study published in the Annals of Allergy, Asthma and Immunology.

“Despite the availability of multiple published guidelines regarding anaphylaxis management, there continue to be deficiencies in treatment, particularly for children,” Melissa Robinson, DO, from the Section of Allergy and Immunology at National Jewish Hospital, and colleagues wrote. “Research has shown poor understanding of indications for the use of epinephrine among families with food allergic children, school nurses and emergency responders, likely contributing to the underuse of epinephrine before the arrival at the ED.”

To assess how anaphylaxis is managed before arrival to an ED or urgent care center (UCC) for children, the researchers conducted a retrospective review of electronic medical records for people between the ages of 0 and 25 years. All had presented to the ED or UCC within a pediatric academic referral center between 2009 and 2013 with anaphylaxis.

The average age of the 408 patients included was 7.25 years, and 62% were male. Epinephrine was administered to only 36.3% of those included in the study before arrival for treatment. Children were more likely to receive epinephrine if their reaction occurred at school (n = 30/49) than if anaphylaxis occurred in the home (n = 36/114).

When one organ system was involved with anaphylaxis, children were more likely to receive epinephrine before treatment than they were if two-organ (OR = 0.50; 95% CI = 0.30-0.85) or three-organ systems (OR = 0.41; 95% CI = 0.21-0.81) were affected. Patients were most likely to have a reaction catalyzed by a food allergy (83.8%) — usually peanuts or tree nuts — and those who did not receive epinephrine before treatment were less likely to be discharged (OR = 0.56; 95% CI = 0.37-0.86; P = 0.01)

“Multiple past studies have corroborated the finding that epinephrine is reported as not always available or, worse, available and not used, a finding in particular associated with food allergy fatality in teenagers and young adults,” Robinson and colleagues wrote. “The circumstances of why this finding persists are beyond the scope of this study but may relate to social disparities, access to specialty care or multiple physician-related factors that have [an] influence on how subsequent reactions are managed.” by Katherine Bortz

Disclosure: The researchers report no relevant financial disclosures.

Melissa Robinson, MD
Melissa Robinson

Less than 50% of children who experience anaphylaxis receive epinephrine before treatment in an ED or urgent care center, despite the medication being the first line of defense against the condition, according to a study published in the Annals of Allergy, Asthma and Immunology.

“Despite the availability of multiple published guidelines regarding anaphylaxis management, there continue to be deficiencies in treatment, particularly for children,” Melissa Robinson, DO, from the Section of Allergy and Immunology at National Jewish Hospital, and colleagues wrote. “Research has shown poor understanding of indications for the use of epinephrine among families with food allergic children, school nurses and emergency responders, likely contributing to the underuse of epinephrine before the arrival at the ED.”

To assess how anaphylaxis is managed before arrival to an ED or urgent care center (UCC) for children, the researchers conducted a retrospective review of electronic medical records for people between the ages of 0 and 25 years. All had presented to the ED or UCC within a pediatric academic referral center between 2009 and 2013 with anaphylaxis.

The average age of the 408 patients included was 7.25 years, and 62% were male. Epinephrine was administered to only 36.3% of those included in the study before arrival for treatment. Children were more likely to receive epinephrine if their reaction occurred at school (n = 30/49) than if anaphylaxis occurred in the home (n = 36/114).

When one organ system was involved with anaphylaxis, children were more likely to receive epinephrine before treatment than they were if two-organ (OR = 0.50; 95% CI = 0.30-0.85) or three-organ systems (OR = 0.41; 95% CI = 0.21-0.81) were affected. Patients were most likely to have a reaction catalyzed by a food allergy (83.8%) — usually peanuts or tree nuts — and those who did not receive epinephrine before treatment were less likely to be discharged (OR = 0.56; 95% CI = 0.37-0.86; P = 0.01)

“Multiple past studies have corroborated the finding that epinephrine is reported as not always available or, worse, available and not used, a finding in particular associated with food allergy fatality in teenagers and young adults,” Robinson and colleagues wrote. “The circumstances of why this finding persists are beyond the scope of this study but may relate to social disparities, access to specialty care or multiple physician-related factors that have [an] influence on how subsequent reactions are managed.” by Katherine Bortz

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    Melanie Makhija

    Melanie Makhija

    Robinson et al. have done a nice job of elucidating factors associated with anaphylaxis that occur prior to arrival in the ED. These study findings are important for all physicians who look after patients who are at risk for anaphylaxis because of their IgE-mediated allergies (trigged by food, venom or other). Physicians who see patients with IgE-mediated allergies – including primary care physicians and ED/urgent care physicians – should always ask families if they have up-to-date prescriptions for their self-injectable epinephrine and if they keep it with them at all times. It is also important to review with patients and parents how and when to use their self-injectable epinephrine.

    • Melanie Makhija, MD
    • Attending physician, Allergy & Immunology Ann & Robert H. Lurie Children’s Hospital of Chicago Assistant professor of allergy/immunology Northwestern University Feinberg School of Medicine

    Disclosures: Dr. Makhija reports no relevant financial disclosures.

    Perspective
    Jennifer A. Sherman

    Jennifer A. Sherman

    Anaphylaxis is a severe, rapidly progressing, potentially life-threatening allergic reaction. The most common trigger of anaphylaxis in children is food allergens, with additional triggers including medications, venom and latex. Prompt administration of epinephrine is first-line therapy in the treatment of anaphylaxis, with poor outcomes consistently linked to the delayed administration of epinephrine.

    Robinson, et al reviewed 408 patient records of children seen in an acute care (emergency department or urgent care) setting for anaphylaxis and found that 50% of the children received epinephrine prior to arrival despite a known history of anaphylaxis in 65% of those patients. Only half had been prescribed an epinephrine auto-injector and just two-thirds of those had their device available at the time of symptom onset. Patients were less likely to receive epinephrine for the treatment of an acute allergic reaction in the home versus school setting and in the absence of skin symptoms. Additionally, patients with symptoms affecting more than one organ system were less likely to receive epinephrine – a finding that Robinson describes as “ominous and illogical.”

    This study effectively highlights the discord between known anaphylaxis protocols and the actual management of acute anaphylactic emergencies, and underscores the importance of the need for further patient and caregiver education in terms of symptom recognition and prompt administration of epinephrine. Additional management should include referral to an allergist for further evaluation, the provision of a written anaphylaxis treatment plan, and epinephrine auto-injector training.

    • Jennifer A. Sherman, DO
    • Allergy & Immunology The Valley Hospital

    Disclosures: Dr. Sherman reports no relevant financial disclosures.

    Perspective
    Purvi Parikh

    Purvi Parikh

    The findings of this study are very alarming as it shows how those with more severe anaphylactic reactions (two or more organ systems) did not use epinephrine prior to arrival in the ED. While food allergy was the most common cause of anaphylaxis, many patients had not been prescribed an auto injector prior to arrival in the ED or did not have it accessible. 

    I feel this raises the issue of increased education on behalf of both clinicians and patients regarding appropriate prescribing and use of epinephrine. If a patient has a pre-existing food allergy, simply avoiding the foods may not be enough counseling – especially if the patient also has asthma, which is a risk factor for anaphylaxis. Clinicians should be prescribing and educating their patients on appropriate use of epinephrine auto injectors, and clinicians themselves may need additional education on what truly constitutes anaphylaxis. 

    In addition, the study found that that auto injectors were not used when skin symptoms were not present; I think more time spent educating patients on all the signs and symptoms of anaphylaxis could possibly empower them to use the medication more appropriately. To confront the pervasive misconception that the autoinjector itself is dangerous, additional education may be warranted to emphasize that delay in use of autoinjector is actually far more detrimental to patient health than using it improperly.

    • Purvi Parikh, MD
    • Allergist/immunologist Allergy & Asthma Network

    Disclosures: Parikh provide no relevant financial disclosures.