Anaphylaxis knowledge gaps and future research priorities: A consensus report

BACKGROUND

Despite a better understanding of the epidemiology, pathogenesis, and management of patients with anaphylaxis, there remain knowledge gaps. Enumerating and prioritizing these gaps would allow limited scientific resources to be directed more effectively.

OBJECTIVE

We sought to systematically describe and appraise anaphylaxis knowledge gaps and future research priorities based on their potential impact and feasibility.

METHODS

We convened a 25-member multidisciplinary panel of anaphylaxis experts. Panelists formulated knowledge gaps/research priority statements in an anonymous electronic survey. Four anaphylaxis themed writing groups were formed to refine statements: (1) Population Science, (2) Basic and Translational Sciences, (3) Emergency Department Care/Acute Management, and (4) Long-Term Management Strategies and Prevention. Revised statements were incorporated into an anonymous electronic survey, and panelists were asked to rate the impact and feasibility of addressing statements on a continuous 0 to 100 scale.

RESULTS

The panel generated 98 statements across the 4 anaphylaxis themes: Population Science (29), Basic and Translational Sciences (27), Emergency Department Care/Acute Management (24), and Long-Term Management Strategies and Prevention (18). Median scores for impact and feasibility ranged from 50.0 to 95.0 and from 40.0 to 90.0, respectively. Key statements based on median rating for impact/feasibility included the need to refine anaphylaxis diagnostic criteria, identify reliable diagnostic, predictive, and prognostic anaphylaxis bioassays, develop clinical prediction models to standardize postanaphylaxis observation periods and hospitalization criteria, and determine immunotherapy best practices.

CONCLUSIONS

We identified and systematically appraised anaphylaxis knowledge gaps and future research priorities. This study reinforces the need to harmonize scientific pursuits to optimize the outcomes of patients with and at risk of anaphylaxis.

Emergency department revisits and rehospitalizations among infants and toddlers for acute allergic reactions

Background and Objective: Allergic reactions, including anaphylaxis, are rising among children. Little is known about health care utilization among infants and toddlers. Our objective was to characterize health care utilization and charges for acute allergic reactions (AAR). Methods: We conducted a retrospective cohort study of trends in emergency department (ED) visits and revisits, hospitalizations and rehospitalizations, and charges among infants and toddlers (ages < 3 years), with an index ED visit or hospitalization for AAR (including anaphylaxis). We used data from population-based multipayer data: State Emergency Department Databases and State Inpatient Databases from New York and Nebraska. Multivariable logistic regression was used to identify factors associated with ED revisits and rehospitalizations. Results: Between 2006 and 2015, infant and toddler ED visits for AAR increased from 27.8 per 10,000 population to 35.2 (P_trend < 0.001), whereas hospitalizations for AAR remained stable (P_trend = 0.11). In the one year after an index AAR visit, 5.1% of these patients had at least one AAR ED revisit and 5.9% had at least one AAR rehospitalization. Factors most strongly associated with AAR ED revisits included an index visit hospitalization and receipt of epinephrine. Total charges for AAR ED visits (2009-2015) and hospitalizations (2011-2015) were more than $29 million and $11 million, respectively. Total charges increased more than fourfold for both AAR ED revisits for AAR rehospitalizations during the study period. Conclusion: Infants and toddlers who presented with an AAR were at risk for ED revisits and rehospitalizations for AAR within the following year. The charges associated with these revisits were substantial and seemed to be increasing.

Severity grading system for acute allergic reactions: A multidisciplinary Delphi study

BACKGROUND

There is no widely adopted severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions, thus limiting the ability to optimize and standardize management practices and advance research.

OBJECTIVE

The aim of this study was to develop a severity grading system for acute allergic reactions for use in clinical care and research.

METHODS

From May to September 2020, we convened a 21-member multidisciplinary panel of allergy and emergency care experts; 9 members formed a writing group to critically appraise and assess the strengths and limitations of prior severity grading systems and develop the structure and content for an optimal severity grading system. The entire study panel then revised the grading system and sought consensus by utilizing Delphi methodology.

RESULTS

The writing group recommended that an optimal grading system encompass the severity of acute allergic reactions on a continuum from mild allergic reactions to anaphylactic shock. Additionally, the severity grading system must be able to discriminate between clinically important differences in reaction severity to be relevant in research while also being intuitive and straightforward to apply in clinical care. Consensus was reached for all elements of the proposed severity grading system.

CONCLUSION

We developed a consensus severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions. Successful international validation, refinement, dissemination, and application of the grading system will improve communication among providers and patients about the severity of allergic reactions and will help advance future research.

Trends in US hospitalizations for anaphylaxis among infants and toddlers: 2006 to 2015

BACKGROUND

Anaphylaxis is a potentially fatal acute allergic reaction. Its overall prevalence appears to be rising, but little is known about US hospitalization trends among infants and toddlers.

OBJECTIVE

To identify the trends and predictors of hospitalization for anaphylaxis among infants and toddlers.

METHODS

We used the nationally representative National Inpatient Sample (NIS), from 2006 to 2015, to perform an analysis of trends in US hospitalizations for anaphylaxis among infants and toddlers (age, <3 years) and other children (age, 3-18 years). For internal consistency, we identified patients with anaphylaxis by the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code and excluded those with the International Classification of Diseases, Tenth Revision, Clinical Modification (late 2015). We calculated trends in anaphylaxis hospitalizations over time by age group and then used multivariable logistic regression to describe anaphylaxis hospitalizations among infants and toddlers.

RESULTS

Among infants and toddlers, there was no significant change in anaphylaxis hospitalizations during the 10-year study period (P_trend = .14). Anaphylaxis hospitalization among infants and toddlers was more likely in males, with private insurance, in the highest income quartile, with chronic pulmonary disease, who presented on a weekend day, to an urban teaching hospital, located in the Northeast. In contrast, anaphylaxis hospitalizations among older children (age, 3-<18 years) rose significantly during the study (P_trend < .001).

CONCLUSION

Anaphylaxis hospitalizations among infants and toddlers in the United States were stable from 2006 to 2015, whereas hospitalizations among older children were rising. Future research should focus on the trends in disease prevalence and health care utilization in the understudied population of infants and toddlers.

Persistent, refractory, and biphasic anaphylaxis: A multidisciplinary Delphi study

BACKGROUND

The use of inconsistent definitions for anaphylaxis outcomes limits our understanding of the natural history and epidemiology of anaphylaxis, hindering clinical practice and research efforts.

OBJECTIVE

Our aim was to develop consensus definitions for clinically relevant anaphylaxis outcomes by utilizing a multidisciplinary group of clinical and research experts in anaphylaxis.

METHODS

Using Delphi methodology, we developed agenda topics and drafted questions to review during monthly conference calls. Through online surveys, a 19-member panel consisting of experts in allergy and/or immunology and emergency medicine rated their level of agreement with the appropriateness of statements on a scale of 1 to 9. A median value of 1.0 to 3.4 was considered inappropriate, a median value of 3.5 to 6.9 was considered uncertain, and a median value of 7.0 to 9.0 was considered appropriate. A disagreement index was then calculated, with values less than 1.0 categorized as "consensus reached." If consensus was not reached after the initial survey, subsequent surveys incorporating the aggregate de-identified responses from prior surveys were sent to panel members. This process was repeated until consensus was reached or 4 survey rounds had been completed, after which the question was categorized as "no consensus reached."

RESULTS

The panel developed outcome definitions for persistent, refractory, and biphasic anaphylaxis, as well as for persistent and biphasic nonanaphylactic reactions. There was also consensus among panel members regarding the need to develop an anaphylaxis severity grading system.

CONCLUSION

Dissemination and application of these definitions in clinical care and research will help standardize the terminology used to describe anaphylaxis outcomes and serve as the foundation for future research, including research aimed at development of an anaphylaxis severity grading system.

Topical Review: Pediatric Food Allergies Among Diverse Children

OBJECTIVE

To present a brief review of the literature regarding potential racial/ethnic disparities in pediatric food allergy (FA).

METHODS

Topical review considering data regarding FA prevalence, asthma comorbidity, epinephrine access/use, and psychosocial impact (e.g., burden, quality of life).

RESULTS

Methodological variation precludes firm conclusions regarding disparities in prevalence; however, some data suggest Black children may be at particular risk. The comorbidity of FA and asthma among urban populations may increase risk of negative outcomes. There are clear racial/ethnic and socioeconomic disparities in epinephrine access and use. Psychosocial measures are frequently validated on samples that are not racially or ethnically diverse. Studies investigating FA's psychosocial impact are often composed of mostly White, non-Hispanic participants (>85% of study sample).

CONCLUSIONS

Further research is needed to clarify prevalence patterns by race/ethnicity, to investigate the sources of disparity in epinephrine use, and to evaluate the differential impact of FA on diverse children.

Early treatment of food-induced anaphylaxis with epinephrine is associated with a lower risk of hospitalization

BACKGROUND

Food-induced anaphylaxis (FIA) is potentially life threatening. Prompt administration of epinephrine is universally recommended by current treatment guidelines.

OBJECTIVE

To identify factors associated with early epinephrine treatment for FIA and to specifically examine the association between early epinephrine treatment and hospitalization.

METHODS

A chart review study conducted at Hasbro Children's Hospital/Rhode Island Hospital. By using the International Classification of Diseases, Ninth Revision codes, we identified all patients who presented to the emergency department with FIA between January 1, 2004, and December 31, 2009. Early epinephrine treatment was defined as receipt of epinephrine before arrival to the emergency department. The independent association between early epinephrine treatment and hospitalization was assessed using logistic regression.

RESULTS

Among the 384 emergency department visits for FIA identified during the study period, 234 patients received epinephrine (61%). Among this subset, most (164 [70%]) received early epinephrine treatment, whereas a smaller number of patients (70 [30%]) first received epinephrine in the emergency department (late treatment). Patients who received early epinephrine treatment were older (7.4 vs 4.3 years; P = .008), were more likely to have a known food allergy (66% vs 34%; P < .001), and were more likely to own an epinephrine autoinjector (80% vs 23%; P < .001). Patients treated early were less likely to be hospitalized (17% vs 43%; P < .001). After adjusting for age, sex, and race, the patients who received early epinephrine treatment remained at significantly decreased risk of hospitalization compared with those who received late epinephrine treatment (odds ratio 0.25 [95% CI, 0.12-0.49]).

CONCLUSIONS

In this population, early treatment of FIA with epinephrine was associated with significantly lower risk of hospitalization. Accordingly, this study supports the benefit of prompt administration of epinephrine for the treatment of FIA.

Risk factors for severe anaphylaxis in patients receiving anaphylaxis treatment in US emergency departments and hospitals

BACKGROUND

Although reported risk factors for severe anaphylaxis include older age, presence of comorbid medical conditions, and concomitant medications, previous studies have used varying definitions for anaphylaxis and heterogeneous methodology.

OBJECTIVE

To describe risk factors for severe anaphylaxis among US patients treated in emergency departments (EDs) or hospitals for anaphylaxis.

METHODS

Individuals with an ED visit/hospitalization for anaphylaxis were identified from 2 MarketScan Research Databases using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. Eligibility for the current study required continuous medical and prescription coverage for at least 1 year before and after the index date. Severe anaphylaxis was defined as a reaction requiring hospital admission.

RESULTS

Among 11,972 individuals, 2,622 (22%) had severe anaphylaxis. Unadjusted analysis showed that severe anaphylaxis was associated with older age and higher comorbidity burden. These patients were also less likely to have filled an epinephrine autoinjector (EAI) prescription or visited an allergist/immunologist, but more likely to have had an ED visit/hospitalization (any cause). On multivariable analysis, filling an EAI prescription (odds ratio [OR], 0.64; 95% CI, 0.53-0.78) or visiting an allergist/immunologist (OR, 0.78; 95% CI, 0.63-0.95) before the index event was associated with a lower risk of severe anaphylaxis, while any previous ED visit (OR, 1.18; 95% CI, 1.07-1.30) or hospitalization (OR, 1.55; 95% CI, 1.36-1.75) was associated with a higher risk of severe anaphylaxis.

CONCLUSIONS

In this large cohort with an ED visit or hospitalization for anaphylaxis, 22% had severe anaphylaxis. Pre-index preventive anaphylaxis care (ie, EAI prescription fill and allergist/immunologist visit) was associated with a significantly lower risk, supporting the benefits of preventive anaphylaxis care in real-world practice.

Favorable trends in the frequency of U.S. emergency department visits for food allergy, 2001-2009

Several studies suggest an increase in both the prevalence of food allergy and in the frequency of emergency department (ED) visits for food-related allergic reactions, including anaphylaxis. This study evaluates time trends in the frequency of ED visits for food allergy, with a focus on possible differences by age. Data from two multicenter ED-based studies were used to identify the proportion of patients assigned to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes with actual food-related acute allergic reaction and the proportion of these patients with food-induced anaphylaxis. We multiplied these proportions against counts from nationally representative data (2001-2009) to estimate the number of U.S. ED visits for each ICD-9-CM code with likely food allergy. Over the 9-year study period, there were ∼1,892,000 ED visits for food allergy. The number of ED visits for food allergy did not significantly change among children aged <18 years (77,000 visits in 2001 versus 92,000 visits in 2009; p = 0.85), but among adults aged ≥18 years, there was a decline (147,000 visits versus 97,000 visits; p = 0.046). Looking across all ED visits (any cause), the proportion of ED visits for food allergy was stable for children (0.29% versus 0.28%; p = 0.22) but decreased for adults (0.18% versus 0.09%; p = 0.01). The number of U.S. ED visits for food-related acute allergic reactions is significantly higher than prior reports. These results also suggest that the frequency of ED visits for food allergy was stable or decreased from 2001 to 2009, despite reports suggesting an ongoing rise in the prevalence of food allergy.

National survey of pediatric services available in US emergency departments

Background

Children account for nearly 20% of all US emergency department (ED) visits, yet previous national surveys found that many EDs lack specialized pediatric care. In response, a 2001 joint policy statement recommended resources needed by EDs for effective pediatric emergency care delivery. We sought to update and enhance previous estimates of pediatric services available in US EDs.

Methods

We administered a telephone survey to a 5% random sample (n = 279) of all US EDs from the 2007 National Emergency Department Inventory-USA. The survey collected data on local capabilities (including typical management of three clinical scenarios) and prevalence of a coordinator for pediatric emergency care. We used descriptive statistics to summarize data. Multivariable logistic regression was used to examine the association between survey respondent and ED characteristics as well as the presence of a coordinator for pediatric emergency medicine.

Results

Data were collected from 238 hospitals (85% response rate). A minority of hospitals had pediatric departments (36%) or intensive care units (12%). The median annual number of ED visits by children was 3,870 (interquartile range 1,500–8,800). Ten percent of hospitals had a separate pediatric ED; only 17% had a designated pediatric emergency care coordinator. Significant positive predictors of a coordinator were an ED pediatric visit volume of ≥1 patient per hour and urban location. Most EDs treated only mild-to-moderate cases of childhood bronchiolitis and asthma exacerbation (77% and 65%, respectively). Less than half (48%) of the hospitals reported the ability to surgically manage a child with acute appendicitis.

Conclusion

We found little change in pediatric emergency services compared to earlier estimates. Our study results suggest a continued need for improvements to ensure access to emergency care for children.

Age-related differences in the clinical presentation of food-induced anaphylaxis

Food-induced anaphylaxis may be more difficult to recognize in younger children. We describe age-related patterns in the clinical presentation of children with anaphylaxis, which may facilitate the early recognition and treatment of this potentially life-threatening condition.

Predictors of hospital admission for food-related allergic reactions that present to the emergency department

BACKGROUND

guidelines do not provide specific hospitalization criteria for patients presenting to the emergency department (ED) with food-related allergic reactions.

OBJECTIVE

to determine predictors of hospital admission for ED patients with food-related allergic reactions.

METHODS

we performed a medical record review at 3 academic centers of patients presenting to the ED for food-related allergic reactions (International Classification of Diseases, Ninth Revision, Clinical Modification codes 693.1, 995.0, 995.1, 995.3, 995.7, 995.60-995.69, 558.3, 692.5, and 708.X) between January 1, 2001, and December 31, 2006. We focused on patient demographics, medical history, food triggers, clinical presentation, pre-ED and ED management with a specific focus on epinephrine treatment, and disposition. Predictors of hospital admission were determined using multivariable logistic regression.

RESULTS

through random sampling and appropriate weighting, the 1,112 cases reviewed represented a study cohort of 2,583 patients. Most patients (80%) were discharged from the ED. The age and sex of patients admitted to the hospital and those discharged were similar. Multivariable analysis identified 3 factors associated with a higher likelihood of hospital admission: meeting the criteria for food-related anaphylaxis (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.23-4.33), pre-ED epinephrine treatment (OR, 6.65; 95% CI, 3.04-14.57), and epinephrine treatment within 1 hour of ED triage (OR, 3.78; 95% CI, 1.68-8.50). Patients with food-related allergic reactions triggered by shellfish were less likely to be admitted to the hospital (OR, 0.23; 95% CI, 0.08-0.68).

CONCLUSIONS

most patients presenting to the ED with food-related allergic reactions are discharged. Several patient factors were independently associated with hospital admission in ED patients with food-related allergic reactions.

Multiple epinephrine doses for stinging insect hypersensitivity reactions treated in the emergency department

BACKGROUND

Data are sparse on epinephrine treatment for stinging insect hypersensitivity (SIH) reactions.

OBJECTIVE

To establish the frequency of receiving more than 1 dose of epinephrine in patients presenting to the emergency department (ED) with SIH reactions.

METHODS

We performed a medical record review of all 153 patients with SIH reactions presenting to 3 EDs in Boston, Massachusetts, between January 1, 2001, and December 31, 2006. Patients were identified by International Classification of Diseases, Ninth Revision (ICD-9) codes (989.5, 995.0, and 995.3). We focused on clinical presentations and treatments, including epinephrine treatments given before and during the ED visit.

RESULTS

The cohort was 54% male, with a median age of 33 years. Bees were the most frequently reported triggering insect (74%). A total of 59% of patients experienced large local reactions, whereas 36% had systemic reactions (10% cutaneous systemic and 26% anaphylaxis). The remaining 5% presented with normal local reactions to insect stings. Among patients with systemic reactions, 82% were stung within 3 hours of arrival at the ED. Most (60%) received treatments before arrival at the ED, including 26% who received epinephrine. While in the ED, these patients received antihistamines (76%), systemic corticosteroids (55%), and epinephrine (9%). Overall, 35% of patients with systemic reactions received epinephrine, and among this subset, 16% received more than 1 dose. Most patients with systemic reactions (67%) were discharged to home. At ED discharge, 68% received a prescription for self-injectable epinephrine, but only 11% had documentation of referral to an allergist.

CONCLUSIONS

Among patients with systemic SIH reactions who received epinephrine, 16% received a second dose. Physicians should consider prescribing 2 doses of self-injectable epinephrine for patients at risk for systemic SIH reactions.

Repeat epinephrine treatments for food-related allergic reactions that present to the emergency department

To date, there are sparse data on epinephrine treatment for food-related anaphylaxis in adults. We sought to establish the frequency of more than one epinephrine treatment for adult patients who present with food-related anaphylaxis to the emergency department (ED). We performed a chart review, at two academic centers, of all adults presenting to the ED for food allergy (ICD9CM codes 693.1, 995.0, 995.1, 995.3, 995.7, 995.60-995.69, 558.3, 692.5, and 708.X) between January 1, 2001 and December 31, 2006. We focused on causative foods; treatments, including the number of epinephrine treatments given before and during the ED visit; and disposition. Through random sampling and appropriate weighting, the 486 reviewed cases represented a study cohort of 1286 patients. The median age was 36 years and the cohort was 62% women. Shellfish (23%), peanuts (12%), tree nuts (14%), and fish (14%) provoked the allergic reaction most commonly. Most patients (62%; 95% confidence interval [CI], 57-68%) met criteria for food-related anaphylaxis. In the ED, anaphylaxis patients received epinephrine (18%), antihistamines (91%), corticosteroids (81%), and inhaled albuterol (19%). Overall, 17% (95% CI, 9-25%) of patients with food-related anaphylaxis given epinephrine received >1 dose over the course of their reaction. Among anaphylaxis patients admitted to the hospital, only 10% included anaphylaxis in the discharge diagnosis. At ED discharge (82% of patients), 18% were referred to an allergist and 39% were prescribed self-injectable epinephrine. Among ED patients with food-related anaphylaxis treated with epinephrine, 17% were given >1 dose. This study supports the recommendation that patients at risk for food-related anaphylaxis should carry 2 doses of epinephrine.

North-south differences in US emergency department visits for acute allergic reactions

BACKGROUND

In a previous study, latitude was positively associated with EpiPen prescription rates.

OBJECTIVE

To determine whether a similar geographic difference exists for emergency department (ED) visits for acute allergic reactions (including anaphylaxis).

METHODS

We combined National Hospital Ambulatory Medical Care Survey data for ED visits to noninstitutional hospitals from 1993 to 2005. Acute allergic reactions were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes 995.0, 995.60-995.69, 995.1, 995.2, 995.3, 989.5, and 693.1, and visit rates were compared across standardized geographic divisions.

RESULTS

Between 1993 and 2005, there were 17.3 million ED visits for acute allergic reactions, representing 1.3% (95% confidence interval [CI], 1.2%-1.3%) of all ED visits. Per 1000 population, the Northeast had 5.5 visits (95% CI, 4.7-6.2 visits) and the South had 4.9 visits (95% CI, 4.3-5.6 visits). In a multivariable model, the Northeast had a higher odds ratio (OR) than the South (1.13; 95% CI, 1.01-1.27; P = .04). The association was stronger when restricting the analysis to visits for food-related allergic reactions (OR, 1.33; 95% CI, 1.14-1.56; P < .001).

CONCLUSIONS

The ED visit rates for acute allergic reactions are higher in northeastern vs southern regions. These observational data are consistent with the hypothesis that vitamin D may play an etiologic role in anaphylaxis, especially food-induced anaphylaxis.

Season of birth and food allergy in children

BACKGROUND

The prevalence of food allergy is rising, and etiologic factors remain uncertain. Evidence implicates a role for vitamin D in the development of atopic diseases. Based on seasonal patterns of UV-B exposure (and consequent vitamin D status), we hypothesized that patients with food allergy are more often born in fall or winter.

OBJECTIVE

To investigate whether season of birth is associated with food allergy.

METHODS

We performed a multicenter medical record review of all patients presenting to 3 Boston emergency departments (EDs) for food-related acute allergic reactions between January 1, 2001, and December 31, 2006. Months of birth in patients with food allergy were compared with that of patients visiting the ED for reasons other than food allergy.

RESULTS

We studied 1002 patients with food allergy. Of younger children with food allergy (age < 5 years), but not older children or adults, 41% were born in spring or summer compared with 59% in fall or winter (P = .002). This approximately 40:60 ratio differed from birth season in children treated in the ED for non-food allergy reasons (P = .002). Children younger than 5 years born in fall or winter had a 53% higher odds of food allergy compared with controls. This finding was independent of the suspected triggering food and allergic comorbidities.

CONCLUSIONS

Food allergy is more common in Boston children born in the fall and winter seasons. We propose that these findings are mediated by seasonal differences in UV-B exposure. These results add support to the hypothesis that seasonal fluctuations in sunlight and perhaps vitamin D may be involved in the pathogenesis of food allergy.

Multicenter study of repeat epinephrine treatments for food-related anaphylaxis

OBJECTIVE

We sought to establish the frequency of receiving >1 dose of epinephrine in children who present to the emergency department (ED) with food-related anaphylaxis.

PATIENTS AND METHODS

We performed a medical chart review at Boston hospitals of all children presenting to the ED for food-related acute allergic reactions between January 1, 2001, and December 31, 2006. We focused on causative foods, clinical presentations, and emergency treatments.

RESULTS

Through random sampling and appropriate weighting, the 605 reviewed cases represented a study cohort of 1255 patients. These patients had a median age of 5.8 years (95% confidence interval [CI]: 5.3-6.3), and the cohort was 62% male. A variety of foods provoked the allergic reactions, including peanuts (23%), tree nuts (18%), and milk (15%). Approximately half (52% [95% CI: 48-57]) 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%), 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: 9-14) 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, 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.