Pediatric EDs report increase in epinephrine administration for food-induced anaphylaxis

Nov 04, 2021

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disclosures:
Kim does not report any relevant financial disclosures. See the study for the relevant financial disclosures from all other authors.

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Cases of epinephrine administration for food-induced anaphylaxis in U.S. pediatric ERs increased by 4% each year between 2007 and 2015, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

“Epinephrine is underutilized in the treatment of anaphylaxis, reflecting the challenges in diagnosing anaphylaxis and understanding appropriate treatment,” said Lim Kim, MD, an allergist and immunologist at the University of Chicago, and colleagues. “This pattern is worrisome because delayed epinephrine administration has been associated with higher mortality.”

Data are derived from Kim SL, et al. J Allergy Clin Immunol Pract. 2021;doi:10.1016/j.jaip.2021.09.024.

Kim and colleagues also noted that delayed epinephrine is associated with a higher risk of hospitalization. Physicians’ barriers to under-use may be the complexity of diagnosis, lack of knowledge, and misconceptions about epinephrine administration.

To evaluate patterns of epinephrine administration for food-induced anaphylaxis in pediatric emergency departments in the US, researchers evaluated data from 15,318 emergency room visits of 13,917 children (mean age 6.3 years; 21.2% under 2 years; 59.7% male) .

Nearly half of the patients (49.6%) had at least one dose of epinephrine administered in the ED.

Compared to patients who did not receive epinephrine during a visit, patients who did receive it were more likely to be black (52% vs. 48%), government insurance or self-pay (53% vs. 47%) or more severe illness (85% vs. 15%). ;P < .01 for everyone). The researchers found no significant difference in epinephrine administration by gender (female, 49.7% vs. male, 50.3%).

The most common triggers for food-induced anaphylaxis were peanuts (29.9%) and nuts and seeds (19.3%). These together accounted for half of all visits; However, 27.9% of cases had no identified trigger. Other causes were fish (6.5%), milk (5.7%), eggs (4.6%) and shellfish (3%).

Patients diagnosed with shellfish allergy were more likely to receive epinephrine in the ED (56% vs. 44%; P < .01).

From 2007 to 2015, the odds of receiving epinephrine for anaphylaxis in the pediatric ED increased by 4% per year (OR = 1.04; 95% CI, 1.03-1.05), which remained significant after adjusting for age, sex, race, insurance and disease severity (OR = 1.06; 95% CI, 1.04-1.07).

The odds of receiving epinephrine increased significantly each year in the Northeast (OR = 1.18; 95% CI 1.13-1.33) and the West (OR = 1.14; 95% CI 1.1- 1.18), after adjusting for age, sex, race, insurance and disease severity. There was no significant increase in the Midwest or South.

Kim and colleagues noted that the data were limited to responses treated in the emergency room and therefore do not reflect the rate of epinephrine administration in other settings.

Overall, these findings may reflect physicians’ increasing awareness of the use of epinephrine for anaphylaxis, Kim and colleagues wrote.

“These data also raise the question of the appropriate rate of epinephrine use in pediatric emergency departments,” she added. “If the food allergy advocacy has been effective as presumed, many children will have been successfully treated with epinephrine prior to their arrival in the ED and only need to be monitored for delayed reactions. Therefore, we would not expect 100% of children arriving in the ED to require epinephrine.”

The researchers advise that further research is needed to better understand overtreatment and undertreatment, especially through demographic factors.

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