Management of anaphylaxis after pre-hospital epinephrine use in children with food-induced anaphylaxis.

BACKGROUND

Previous guidelines recommend prompt epinephrine administration, followed by observation in the emergency department (ED). The need for transfer in all cases of anaphylaxis has recently been challenged.

OBJECTIVE

To evaluate the need for additional ED treatment among children with anaphylaxis who received prehospital epinephrine.

METHODS

Between 2011 and 2023, data were collected on symptoms, triggers, comorbidities, and prehospital and in-hospital management from children (<18 years) with food-induced anaphylaxis who received at least 1 dose of prehospital epinephrine presenting at 7 pediatric EDs. Multivariable logistic regression assessed factors associated with the use of 2 or more prehospital epinephrine autoinjectors (EAIs), epinephrine use in the ED, and hospital admission.

RESULTS

Of the 1127 children (mean 8.1 ± 5.3 years; 60.6% male sex) with food-induced anaphylaxis who used at least 1 EAI prehospital, the most common trigger was peanuts (25.3%). There were 209 (18.5%) children who received additional epinephrine in the ED, most of whom (88.0%) received 1 dose. A total of 30 (2.7%) patients were admitted to hospital. Among all patients, severe reactions (cardiovascular instability/cyanosis/loss of consciousness) (adjusted odds ratio [aOR] 1.22; 95% CI 1.12-1.33) and reactions to tree nuts (aOR 1.09; 95% CI 1.03-1.16) were associated with increased odds of in-hospital epinephrine use. Prehospital inhaled β-agonists (aOR 1.08; 95% CI 1.01-1.16) use and severe reactions (aOR 1.13; 95% CI 1.05-1.22) were associated with the use of 2 or more EAI prehospital.

CONCLUSION

A minority of anaphylaxis cases that used prehospital EAIs required additional treatment, supporting that shared decision making about transfer to ED works for most patients.