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.