Children at risk for food-related anaphylaxis should carry two doses of epinephrine
Article Outline
- Question
- Design
- Setting
- Participants
- Intervention
- Outcomes
- Main Results
- Conclusions
- Commentary
- References
- Copyright
Rudders SA, Banerji A, Corel B, Clark S, Camargo CA, Jr. Multicenter study of repeat epinephrine treatments for food-related anaphylaxis. Pediatrics 2010;125:e711-8.
Question
Among children who present to the emergency department (ED) with food-related anaphylaxis, how many require more than one dose of epinephrine?
Design
Retrospective cohort.
Setting
Pediatric emergency departments at both Massachusetts General Hospital and Children's Hospital Boston.
Participants
605 cases of children (median age 5.8 years, 62% male) presenting to the ED for food-related acute allergic reactions between January 1, 2001, and December 31, 2006 were reviewed. Through random sampling and appropriate weighting, this represents a study cohort of 1255 patients.
Intervention
A structured chart review was performed to collect information about causative foods, clinical presentations, and emergency treatments.
Outcomes
The percentage of participants who required more than one dose of epinephrine.
Main Results
A variety of foods provoked the allergic reactions, including peanuts (23%), tree nuts (18%), and milk (15%). Approximately half (52% [95% confidence interval, 48 to 57]) of the children met diagnostic criteria for food-related anaphylaxis. Among those with anaphylaxis, 31% received 1 dose and 3% received >1 dose of epinephrine before their arrival to the ED. In the ED, patients with anaphylaxis received antihistamines (59%), corticosteroids (57%), and epinephrine (20%). Over the course of their reaction, 44% of patients with food-related anaphylaxis received epinephrine, and among this subset of patients, 12% (95% CI, 9 to 14) received >1 dose. Risk factors for repeat epinephrine use included older age and transfer from an outside hospital. Most patients (88%) were discharged from the hospital. On ED discharge, 43% were prescribed self-injectable epinephrine, and only 22% were referred to an allergist.
Conclusions
Among children with food-related anaphylaxis who received epinephrine in the ED, 12% received a second dose. Results of this study support the recommendation that children at risk for food-related anaphylaxis carry 2 doses of epinephrine.
Commentary
This retrospective study represents the largest review of ED management and clinical features of food related anaphylaxis in children. Among children receiving epinephrine for food-related anaphylaxis in the ED, 12% received repeat epinephrine, similar to previous data demonstrating an incidence of additional dosing at 16-19%.1, 2 This data supports recommendations that children at risk for food related anaphylaxis carry two doses of self-injectable epinephrine. Limitations include the urban ED patient population that excludes anaphylaxis treated in outpatient clinics and could overestimate epinephrine requirements. Studies in similar non-rural settings showed the second dose of epinephrine was given by a healthcare professional in 94% of reactions.3 Given the authors' recommendation that at-risk patients carry multiple doses of epinephrine, particularly when emergency care access is limited, a study in a rural setting may further support the need for self-carried multidose epinephrine.3 In addition, even though limited data exists, research exploring similar recommendations for patients with other triggers of anaphylaxis is important. Further understanding of risk factors and long-term outcomes of these children will help predict who requires multiple doses of epinephrine. Until then, this study further supports recommendations for children at risk for food-related anaphylaxis to carry two doses of self-injectable epinephrine.
References
- . Use of multiple doses of epinephrine in food-induced anaphylaxis in children. J Allergy Clin Immunol. 2008;122:133–138
- . A second dose of epinephrine for anaphylaxis: how often needed and how to carry. J Allergy Clin Immunol. 2006;117:464–465
- . Access to emergency care in the United States. Ann Emerg Med. 2009;54:261–269
PII: S0022-3476(10)00779-1
doi:10.1016/j.jpeds.2010.09.019
© 2010 Mosby, Inc. All rights reserved.
