Kids May Need Two EpiPens

A major study just out in the journal Pediatrics (Rudders, Susan Pediatrics, April 2010; vol 125: pp: e711-e718) has been making headlines in newspapers all over the country. Dr. Rudders' teams looked at 1255 children who were admitted to emergency rooms at two large Boston hospitals between 2001 and 2006. All the children were under 18, but the average age was closer to six. Just over half (52%) of the children had a true anaphylactic reaction. Of these 44% received epinephrine and 12% of these needed two shots. Some of these shots were given at home, some at the hospital.

That's an awful lot of anaphylactic children who received no epinephrine at all. A Reuters article summed up the study's findings of the failings.

What's troubling, the researchers say, is that half of the children with food-induced anaphylactic reactions did not get epinephrine either before getting to the hospital or while at the hospital. At the hospital, the children received antihistamines, steroids, intravenous fluids and inhaled medicines more often than epinephrine, "despite the lack of evidence" for their usefulness as a first-line treatment, the authors note.

Additionally, fewer than half of the children with food-related allergic reactions left the hospital with a prescription for self-injectable epinephrine and only 22 percent were advised to see an allergist.

Clearly, food-related anaphylaxis "continues to be under-recognized and inadequately treated," Rudders and colleagues warn. Estimates suggest that approximately 150 to 200 people die each year from food-related anaphylactic reactions, and delayed or lack of administration of epinephrine is often to blame.

UPI had a further important quote.

"Until we're able to clearly define the risk factors for the most severe reactions, the safest thing may be to have all children at risk for food-related anaphylaxis carry two doses of epinephrine," first author Dr. Susan Rudder says in a statement.

To offset costs, Rudders suggests, school nurses carry un-assigned extra doses of injectable epinephrine for the children who need them.

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Sometimes More Epinephrine Needed

Most parents of children who have truly serious, anaphylactic, food allergy reactions know to either have an epinephrine injector on them or to teach their children to always carry one when they're old enough to go off on their own.

The news service Reuters is reporting that an upcoming journal article warns that in almost 20% of cases, a single shot isn't enough. Two or even three injections are necessary.

As reported in an upcoming issue of the Journal of Allergy and Clinical Immunology, Dr. Kirsi M. Järvinen, from Mount Sinai School of Medicine in New York, and colleagues evaluated epinephrine use in children with food allergies by surveying the families of 413 patients.

Overall, 78 children, who were an average of 4.5 years old, were given epinephrine to treat a total of 95 reactions, the report indicates. Over 75 percent of these reactions involved peanut, tree nut, or cow's milk allergies.

Twelve (13 percent) of the reactions required two doses of epinephrine and an additional 6 (6 percent) required three doses, the researchers found.

Children who also had asthma were more likely to need multiple doses of epinephrine, whereas the amount of food eaten and delay of epinephrine treatment seemed to have no effect.

Journal of Allergy and Clinical Immunology, Volume 122, Issue 1, Pages 133-138 (July 2008), "Use of multiple doses of epinephrine in food-induced anaphylaxis in children," Kirsi M. Järvinen, MD, PhD, Scott H. Sicherer, MD, Hugh A. Sampson, MD, Anna Nowak-Wegrzyn, MD
abstract.