Caregivers respond well after administering epinephrine during child oral food challenge

Key takeaways:

• Caregivers reported feeling more confident to administer epinephrine autoinjectors in the future.
• Caregivers also noted a need for more information on what to do after a positive OFC.

Giving young children an epinephrine autoinjection can be a positive and confidence-boosting experience for families, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

“With relatively recent guidelines and evidence supporting early introduction of allergens like peanuts, the management of food allergy in infancy has become increasingly important,” Michael Pistiner, MD, MMSc, director of food allergy advocacy, education and prevention, Mass General for Children, Harvard Medical School, told Healio.

Oral food challenges, performed in a monitored environment, are used to differentiate a patient with a clinically relevant sensitization or allergy from a patient who has positive allergy testing but tolerates the food without a reaction and are key in food allergy management, Pistiner continued.

However, he added, OFCs have an inherent risk for reactions and potential anaphylaxis.

“Our team set out to conduct a study with dual purposes,” Pistiner said.

First, the researchers wanted to document and share the experience of caregivers of infants and toddlers with food allergies that participated in an OFC.

“Secondly, we wanted to learn from the parents about their experience in administering an epinephrine autoinjector to their young child,” Pistiner said. “We set out to see if with education and support, even if a child experiences a reaction, can caregivers be equipped to administer an autoinjector and feel more confident in the context of potential future reactions?”

Methods

This mixed-methods sub-study collected prospective data on clinically indicated infant and toddler OFCs from September 2020 to August 2022.

All participants had at least one caregiver trained to administer an epinephrine autoinjector (EAI) prior to the OFC in the study. If a reaction happened during the OFC, the caregiver would administer the EAI with staff supervision. Caregivers were given pre-interview surveys before discharge, and qualitative interviews were given 48 to 72 hours after an EAI was used.

The pre-interview surveys used a 0-4 Likert scale to examine attitudes, beliefs and confidence levels when it came to food allergy management and anaphylactic treatment in clinical and home settings.

The interviews that were given after an EAI was used were conducted by a pediatric psychologist. They included open-ended questions about caregivers’ experiences during the OFC, the EAI administration and emotions in relation to these events as well as potential future instances.

Results

In total, 343 infants and toddlers participated in the larger study and took an OFC. Among them, nine experienced a reaction that required the use of an EAI administered by a caregiver. Caregivers then shared their experiences in this sub-study.

Pre-interview surveys were completed by eight parents prior to patient discharge, whereas nine interviews were conducted after. Researchers noticed three primary themes in the data collected from interviews.

The first was that caregivers found the experience to be positive and helpful despite anxiety. The second was that caregivers gained confidence for future instances where an EAI needs to be administered. This included confidence in the EAI procedures as well as symptom recognition. The third finding was that caregivers reported a need to gain additional information on how to proceed after a positive OFC.

“Despite the fact that the families who participated in this study all witnessed a systemic allergic reaction in their infant or toddler, the majority considered the overall experience to be positive, and all found administering the autoinjector in the setting of the OFC to be very positive,” Pistiner said.

He further noted that prior studies have demonstrated hesitation or concern while participating in OFCs and in administrating epinephrine autoinjectors to young children.

“The experiences of the parents in this study may prove to be very reassuring to other parents,” Pistiner said, adding that sharing the findings with families of young children may provide reassurance and address major concerns and barriers.

“Those who conduct oral food challenges may consider having a trained family member administer an epinephrine autoinjector under the supervision of their team in the event of a systemic reaction requiring epinephrine,” Pistiner said. “A positive challenge can be a ‘glass is half full’ moment and be used to convey important teaching points and gain first-hand experience in a controlled setting.”

When asked about the way in which this study can inform future policy and research, Pistiner explained that sharing that administration of an EAI can be a positive experience may be reassuring to families and improve confidence in administration. It can also address any fears or misperceptions that may get in the way of prompt and effective treatment with an EAI.

“Additionally, quality improvement initiatives and future research are needed to explore how to support parents upon discharge from a positive OFC, including follow-up, family education and outpatient management,” he said.