Location of anaphylaxis episode influences epinephrine use in children
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Children who experienced food-induced anaphylaxis at school received epinephrine administered via an autoinjector before going to the hospital more often than those experiencing anaphylaxis at home or at restaurants, data showed.
These findings suggest a need for setting-specific interventions to increase prompt recognition and management of food-induced anaphylaxis (FIA), Connor Prosty, BS, a student in the division of allergy and clinical immunology at Montreal Children’s Hospital, McGill University Health Centre, and colleagues wrote.
Published in The Journal of Allergy and Clinical Immunology: In Practice, the study involved 3,604 cases of children (60.2% boys; median age, 5 years; interquartile range, 1.8-11) with FIA enrolled from 11 EDs in five Canadian provinces between February 2011 and February 2022.
According to the researchers, among the 85% of FIA cases with known locations, 68.1% occurred at home; 12.8% at school or daycare; 11.4% at other settings such as at parks, parties or in the car; 7.4% at restaurants and 0.3% at the workplace.
Also, 62.3% of these patients had been diagnosed with a food allergy before the FIA episode, with 63.4% of those diagnosed with an allergy to the suspected FIA trigger.
Ingestion triggered 92.1% of these FIA cases across all settings. Triggers were most often unknown in restaurants (34.4%), whereas peanuts were the most common triggers at home (19.5%) and at school or daycare (18.6%).
Additionally, 73.6% of reactions were moderate, with 2.2% requiring hospitalization.
Prior to these patients reaching the hospital, 66.7% of the reactions at school or daycare were treated with epinephrine autoinjectors (EAI), followed by 50% of those reactions at work, 44.5% of those at restaurants, 40.2% of those at other locations and 36.7% at home.
Once these patients reached the ED, clinicians administered intramuscular epinephrine in 50% to 60% of the cases involving reactions at work, in restaurants and in other settings and in 33.6% of cases where the reaction happened at school or daycare.
Additionally, 19.8% of these patients with FIA did not receive any intramuscular epinephrine before or after reaching the hospital, including 9.9% of the cases at school or daycare and 16% to 21% of all other settings.
The use of EAI before reaching the hospital was less likely when reactions occurred at home (adjusted OR = 0.8; 95% CI, 0.76-0.84), in restaurants (aOR = 0.81; 95% CI, 0.75-0.87) or in other settings (aOR = 0.77; 95% CI, 0.73-0.83) than at school or daycare.
The use of EAI also was more likely among children with a previously known food allergy (aOR = 1.4; 95% CI, 1.36-1.45).
The researchers found associations between moderate to severe anaphylaxis and asthma (aOR = 1.07; 95% CI, 1.02-1.11) and age (aOR = 1.02; 95% CI, 1.01-1.02), but FIA setting did not appear to impact reaction severity or outcome.
Although most reactions occurred at home, the researchers noted, EAI was used less frequently there than in other settings. The researchers suggested that parents may be afraid of misusing the EAI or of hurting their child. Educational programs for parents may help improve these rates, the researchers continued.
Similarly, the researchers emphasized the high rates of EAI use when incidents occur at school or daycare, adding that perhaps they are due to policies requiring mandatory EAI stocking and training in anaphylaxis management.
Such policies and training would benefit patients who experience FAI at restaurants as well, with some restaurant chains already implementing their own, the researchers continued.
Perspective
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This is an interesting article that examines the location in which FIA takes place, the resultant frequency of the use of EAI, as well as outcomes in a large Canadian study.
From this study, we learn that home was the most common location for FIA to occur, followed by school, “other places” and restaurants, yet school is the most common place in which EAI is used. With that said, there appeared to be no significant signal of difference in reaction severity or hospitalization.
The authors suggest that the greater use of EAI in the school setting may be explained by proactive policies and laws for that setting. They note that this may be a call to demand more of restaurants regarding anaphylaxis policy.
These findings are like those seen in the United States regarding location of anaphylaxis. They reinforce the fact that anaphylaxis can occur anywhere, but certainly home and school/daycare settings are the most common.
But, with regard to use of EAI, several questions arise. For example, do parents have more insight into their children’s illness, or are schools overusing epinephrine? Although the amount of more than 3,000 anaphylaxis episodes in this study is quite large, we may need greater numbers to really answer this very important question. Also, the authors’ suggestion that restaurants need more stringent policies in the treatment of anaphylaxis is an important one and would be a great step forward for food allergy sufferers and their families.
Certainly, in my care of patients, FIA most often occurs at home, but can occur anywhere. I do find it interesting that the most common use of epinephrine occurred in the school setting, and I agree with the authors’ conclusion that this is likely due to stringent policies. However, I do think that it is interesting to note that there was no difference in signal of ultimate outcomes.
We know that early use of epinephrine in anaphylaxis has translated to decreases in hospitalizations, yet we saw no such finding in this study. The reasons for this disconnect could include too small a number of patients to demonstrate signal, or possibly that there is an overuse of epinephrine in the school setting. Further data are definitely needed. But until we have a better understanding, it makes sense to be proactive in treatment vs. delaying the use of epinephrine.
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