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

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

“Epinephrine is underused in the treatment of anaphylaxis, which reflects the challenges in diagnosing anaphylaxis and understanding its correct treatment,” So Lim Kim, MD, allergist and immunologist at University of Chicago, and colleagues wrote. “This pattern is concerning because delayed epinephrine administration has been associated with higher mortality.”

Kim and colleagues also noted that delayed epinephrine is associated with higher risk for hospitalization. Physician barriers to underuse can include the complexity of diagnosis, lack of knowledge and misconceptions regarding epinephrine administration.

To evaluate patterns of epinephrine administration for food-induced anaphylaxis at pediatric EDs in the U.S., researchers evaluated data from 15,318 ED visits of 13,917 children (mean age, 6.3 years; 21.2% aged younger than 2 years; 59.7% male).

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

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

The most common triggers for food-induced anaphylaxis were peanuts (29.9%) and tree nuts and seeds (19.3%). These together accounted for half of all visits; however, 27.9% of cases did not have an identified trigger. Other causes included 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, likelihood of receiving epinephrine for anaphylaxis in the pediatric ED increased by 4% each year (OR = 1.04; 95% CI, 1.03-1.05), which remained significant after adjusting for age, sex, race, insurance and severity of illness (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 in the West (OR = 1.14; 95% CI, 1.1-1.18), after adjusting for age, sex, race, insurance and severity of illness. There was no significant increase in the Midwest or South.

Kim and colleagues noted data were limited to reactions treated in the ED, and therefore do not reflect the rates of epinephrine administration in other settings.

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

“These data also raise the question as to the correct rate of epinephrine use in pediatric EDs,” they added. “If food-allergy advocacy has been effective as hypothesized, many children will have been successfully treated with epinephrine prior to their arrival in the ED and only require monitoring for delayed reactions. Therefore, we would not expect that 100% of children arriving in the ED need to receive epinephrine.”

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