Translating Best Evidence into Best CareEDITOR’S NOTE: Journals reviewed for this issue: Archives of Disease in Childhood, Archives of Pediatrics and Adolescent Med-icine, British Medical Journal, Journal of the American Medical Association, The Journal of Pediatrics, The Lancet, New EnglandJournal of Medicine, Pediatric Infectious Diseases Journal, and Pediatrics.Heidi Marleau, MLS, Ebling Library for the Health Sci-ences, University of Wisconsin, contributed to the review and selection of this month’s abstracts.

—John G. Frohna, MD, MPH

Children at risk for food-related anaphylaxisshould carry two doses of epinephrineRudders SA, Banerji A, Corel B, Clark S, Camargo CA, Jr.Multicenter study of repeat epinephrine treatments forfood-related anaphylaxis. Pediatrics 2010;125:e711-8.

Question Among children who present to the emergency de-partment (ED) with food-related anaphylaxis, how many re-quire more than one dose of epinephrine?

Design Retrospective cohort.

Setting Pediatric emergency departments at both Massachu-setts General Hospital and Children’s Hospital Boston.

Participants 605 cases of children (median age 5.8 years, 62%male) presenting to the ED for food-related acute allergic re-actions between January 1, 2001, andDecember 31, 2006werereviewed. Through random sampling and appropriateweighting, this represents a study cohort of 1255 patients.

Intervention A structured chart review was performed tocollect information about causative foods, clinical presenta-tions, and emergency treatments.

Outcomes The percentage of participants who requiredmore than one dose of epinephrine.

Main Results A variety of foods provoked the allergic reac-tions, including peanuts (23%), tree nuts (18%), and milk(15%). Approximately half (52% [95% confidence interval,48 to 57]) of the children met diagnostic criteria for food-re-lated anaphylaxis. Among those with anaphylaxis, 31% re-ceived 1 dose and 3% received >1 dose of epinephrinebefore their arrival to the ED. In the ED, patients with ana-phylaxis received antihistamines (59%), corticosteroids(57%), and epinephrine (20%). Over the course of their re-action, 44% of patients with food-related anaphylaxis re-ceived epinephrine, and among this subset of patients, 12%(95% CI, 9 to 14) received >1 dose. Risk factors for repeatepinephrine use included older age and transfer from an out-side hospital. Most patients (88%) were discharged from thehospital. On ED discharge, 43% were prescribed self-inject-able epinephrine, and only 22% were referred to an allergist.

Conclusions Among children with food-related anaphylaxiswho received epinephrine in the ED, 12% received a seconddose. Results of this study support the recommendation thatchildren at risk for food-related anaphylaxis carry 2 doses ofepinephrine.

Commentary This retrospective study represents the largestreview of ED management and clinical features of food re-

lated anaphylaxis in children. Among children receiving epi-nephrine for food-related anaphylaxis in the ED, 12%received repeat epinephrine, similar to previous data demon-strating an incidence of additional dosing at 16-19%.1,2 Thisdata supports recommendations that children at risk for foodrelated anaphylaxis carry two doses of self-injectable epi-nephrine. Limitations include the urban ED patient popula-tion that excludes anaphylaxis treated in outpatient clinicsand could overestimate epinephrine requirements. Studiesin similar non-rural settings showed the second dose of epi-nephrine was given by a healthcare professional in 94% of re-actions.3 Given the authors’ recommendation that at-riskpatients carry multiple doses of epinephrine, particularlywhen emergency care access is limited, a study in a rural set-ting may further support the need for self-carried multidoseepinephrine.3 In addition, even though limited data exists,research exploring similar recommendations for patientswith other triggers of anaphylaxis is important. Further un-derstanding of risk factors and long-term outcomes of thesechildren will help predict who requires multiple doses of epi-nephrine. Until then, this study further supports recommen-dations for children at risk for food-related anaphylaxis tocarry two doses of self-injectable epinephrine.

Alex Thomas, MDMark H. Moss, MD

University of WisconsinSchool of Medicine and Public Health

Madison, Wisconsin

References

1. Jarvinen KM, Sicherer SH, Sampson HA, Nowak-Wegrzyn A. Use of mul-

tiple doses of epinephrine in food-induced anaphylaxis in children. J Al-

lergy Clin Immunol. 2008;122:133-8.

2. Kelso JM. A second dose of epinephrine for anaphylaxis: how often

needed and how to carry. J Allergy Clin Immunol. 2006;117:464-5.

3. Carr BG, Branas CC, Metlay JP, Sullivan AF, Camargo CA Jr. Access to

emergency care in the United States. Ann Emerg Med. 2009;54:261-9.

Resistant organisms more likely in children withurinary tract infection who have had recentantimicrobial treatmentPaschke AA, Zaoutis T, Conway PH, Xie D, Keren R. Previ-ous antimicrobial exposure is associated with drug-resistant

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