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    AAP's first-ever action plan for epinephrine and anaphylaxis

    The American Academy of Pediatrics (AAP) has published critical guidance for patients at risk for an allergic emergency. Here’s what you need to know.


    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.

    In conclusion

    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.

    Next: Oral immunotherapy shows promise for treating peanut allergies

    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.


    1. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report—second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Ann Emerg Med. 2006;47(4):373-380.

    2. Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis—a practice parameter update 2015. Ann Allergy Asthma Immunol. 2015;115(5):341-384.

    3. Gupta RS, Springston EE, Warrier MR, et al. The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics. 2011;12891:e9-e17.

    4. Sicherer SH, Simons FER; Section on Allergy and Immunology. Epinephrine for first-aid management of anaphylaxis. Pediatrics. 2017;139(3):e20164006.

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    6. Rudders SA, Banerji A, Clark S, Camargo CA Jr. Age-related differences in the clinical presentation of food-induced anaphylaxis. J Pediatr. 2011;158(2):326-328.

    7. Smith PK, Hourihane JO, Lieberman P. Risk multipliers for severe food anaphylaxis. World Allergy Organ J. 2015;8(1):30.

    8. White MV, Hogue SL, Bennett ME, et al. EpiPen4Schools pilot survey: occurrence of anaphylaxis, triggers, and epinephrine administration in a US school setting. Allergy Asthma Proc. 2015;36(4):306-312.

    9. Strothman K, Scherzer D, Mustillo P, et al. Inpatient management and discharge planning for children admitted for food-induced anaphylaxis. J Allergy Clin Immunol. 2015;135:AB204.

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    14. Huang F, Chawla K, Järvinen KM, Nowak-Wegrzum A. Anaphylaxis in a New York City pediatric emergency department: triggers, treatments, and outcomes. J Allergy Clin Immunol. 2012;129(1):162. e3-168.e3.

    15. Greenberger PA, Rotskoff BD, Lifschultz B. Fatal anaphylaxis: postmortem findings and associated comorbid diseases. Ann Allergy Asthma Immunol. 2007;98(3):252-257.

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    17. Grossman SL, Baumann BM, Garcia Peña BM, et al. Anaphylaxis knowledge and practice preferences of pediatric emergency medicine physicians: a national survey. J Pediatr. 2013;163(3):841-846.

    18. Umasunthar T, Procktor A, Hodes M, et al. Patients’ ability to treat anaphylaxis using adrenaline autoinjectors: a randomized controlled trial. Allergy. 2015;70(7):855-863.

    19. Brown JC, Tuuri RE. Lacerations and embedded needles due to EpiPen use in children. J Allergy Clin Immunol Pract. 2016;4(3)549-551.

    20. Krugman SD, Chiaramonte DR, Matsui EC. Diagnosis and management of food-induced anaphylaxis: a national survey of pediatricians. Pediatrics. 2006;118(3):e554-e560.

    21. Hernandez-Trujillo V, Simons FE. Prospective evaluation of an anaphylaxis education mini-handout: the AAAAI Anaphylaxis Wallet Card. J Allergy Clin Immunol Pract. 2013;1(2):181-185.

    22. De Schryver S, Clarke AE, La Vieille S, et al. C-Care: impact of labeling in food induced anaphylaxis in children treated at the Montreal Children’s Hospital. J Allergy Clin Immunol. 2015;135(2):AB201.

    23. Sicherer SH, Mahr T; American Academy of Pediatrics Section on Allergy and Immunology. Management of food allergy in the school setting. Pediatrics. 2010;126(6):1232-1239.

    Todd A Mahr, MD
    Dr Mahr is director, Pediatric Allergy, Asthma, and Immunology, Gundersen Health System, La Crosse, Wisconsin, and adjunct clinical ...
    Vivian P Hernandez-Trujillo, MD
    Dr Hernandez-Trujillo is associate clinical professor of Pediatrics, Herbert Wertheim School of Medicine, Florida International ...


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