One study conducted with 3 different EAs evaluated the ability of mothers of children aged 0 to 18 years, diagnosed with food allergy, to properly use their EA.18 In this study, users of pen-style EAs experienced errors including failing to remove all safety caps or using the wrong end of the device, which caused accidental digital injections. Importantly, changes to the prescribing information for pen-style EAs were made in 2015 per the US Food and Drug Administration (FDA) because of reported lacerations and embedded needles in children’s legs with the use of EpiPen devices.19 In the same study above, Auvi-Q users had the highest success rate during simulated allergic emergencies (26/28, 93% Auvi-Q vs 39/80, 49% pen-style devices; P<0.001).18
Barriers to successful treatment of anaphylaxis
Healthcare provider education
Across the continuum of healthcare providers, there will be more who never treated a patient with anaphylaxis than those who have. Improving knowledge about anaphylaxis and its treatment is an important, ongoing goal. In one study, 56% of US-based pediatricians (random national sample; n=1130) had knowledge deficits that may affect their ability to accurately diagnose anaphylaxis correctly and treat it with epinephrine.20
To improve healthcare provider knowledge, a wallet card from the American Academy of Allergy, Asthma, and Immunology (AAAAI) with critical information about anaphylaxis and its treatment was prospectively designed and tested as a tool for education on anaphylaxis with a group of pediatric resident physicians.21 The study demonstrated that pediatric resident physicians in the group receiving education about the wallet card were more likely than the control group to recognize anaphylaxis symptoms, name asthma as the most common comorbid disease in children with fatal or near-fatal anaphylaxis, and recall the names of available EAs and their fixed premeasured dosages of epinephrine. The wallet card can be downloaded from the AAAAI in English and Spanish: bit.ly/AAAAI-anaphylaxis-card.
Patient education and EA training
Not understanding when to use an EA is one of the most common barriers experienced during real-world reactions. Guidance on when to inject for children or adolescents experiencing an allergic reaction is shown in Table 2.
Education on allergen avoidance can help patients prevent most inadvertent exposures to known allergic triggers. Although not always possible, improved food labeling has enabled a greater likelihood of avoiding food triggers. Indeed, nearly half of inadvertent food-induced anaphylaxis cases can be linked to prepackaged labeled products.22 Likewise, prevention of cross-contamination of food should be highlighted as this is another frequent cause of accidental exposure.
Epinephrine auto-injector training can prepare patients to self-manage anaphylactic episodes. In general, patients and family members should be trained or refreshed on their EA’s instructions with each refill. However, despite a relatively straightforward process, errors are common in administration for a variety of reasons. To successfully address this issue, it is recommended that individuals practice the injection technique using “trainers” and review the manufacturer’s educational materials. Patients/families can also watch videos or review pictures of the instructions for their EA. Importantly, once patients are prescribed an EA and trained on their device, substitutions should be discouraged. Consistent use of the same device will help patients and their caregivers administer epinephrine as swiftly and safely as possible in case of an emergency.
Recent trends suggest that food allergy and anaphylaxis continue to grow in children, which necessitates reinforcement of best practices in pediatric anaphylaxis care. Maintaining an acceptable level of knowledge on anaphylaxis recognition and treatment, so that everyone involved in the care of children and adolescents with anaphylaxis can act when necessary, is critical to preventing fatalities.
Furthermore, EAs should be with the patient at all times, whether they are self-carried or carried by parents or caregivers. Review your school’s policies stating whether a child is allowed to carry his/her own EA and at what age. It is also important that caregivers (eg, grandparents, babysitters, camp staff, parents of friends) are knowledgeable on the use of the patient’s specific EA.
The AAP has provided guidance for pediatric healthcare providers on the appropriate use of epinephrine and the importance of developing a written emergency action plan for patients with anaphylaxis. This is the first time the AAP has published and made available an allergy and anaphylaxis emergency plan. The authors recommend that these guidances be adopted into current practice. Lastly, recognizing and addressing unmet medical needs and barriers to successful treatment of anaphylaxis in pediatric patients is necessary to improve patient outcomes.
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