Gaps in Anaphylaxis Care, Epinephrine Use Highlight Resource Need


An afternoon session at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting focused on key updates in pediatric anaphylaxis from the past year as seen in published data.

“Anaphylaxis remains an important allergic disorder, and the prevalence has been rising,” noted Julie Wang, MD, professor of pediatrics at the Icahn School of Medicine at Mount Sinai, as she began her presentation on key updates in pediatric anaphylaxis from the past year at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

According to data from the National Inpatient Sample on 2006 to 2015 cases of anaphylaxis as identified by International Classification of Disorder, Ninth Edition codes, the prevalence has risen across most age groups—3 to younger than 6 years, 6 to younger than 12 years, and 12 to younger than 18 years (all P < .001)—with the highest increases seen in preschool- and elementary-aged children. Cases for children younger than 3 years remained steady (P = .14).

Despite these increases, however, community use of epinephrine, “which is the treatment of choice for anaphylaxis,” remains at suboptimal levels, with findings from 20 studies showing that following any-cause anaphylaxis, epinephrine was utilized in as little as 1.4% of instances that subsequently required response from emergency medical services (EMS) personnel and hospitalization. Another analysis of 5 US studies points to a higher rate of 26.4%, but this means “that only a quarter of anaphylaxis cases showing up to the emergency department [ED] were treated with epinephrine before EMS attention,” Wang stated.

In fact, late administration of epinephrine has been linked to greater risk of a biphasic reaction, which is a recurrence of anaphylaxis following treatment for the condition. Delays of 30 minutes and not having the first dose administered until arrival at in the ED, she highlighted, can increase the risk of a biphasic reaction by more than 3-fold.

One of the chief barriers to epinephrine use is its lack of availability, with prescription rates remaining under the majority of patients requiring them, with data showing these rates ran from 23.6% to 45.74%—meaning less than half of patients at risk for anaphylaxis receive their autoinjectors. No prescribing differences were seen between allergists and general physicians.

Underuse can be seen in hospitals as well, with a study from Canada showing that despite 90.8% of anaphylaxis cases being correctly diagnosed in the ED, just 76.3% received epinephrine, with only 37.3% being treated with the agent in the ED.

Additional barriers to epinephrine use even when warranted, according to data from a study conducted at Icahn among patients with food allergy and their families, include that 48% did not think symptoms were severe enough, 36% used other medication, 29% of caregivers were scared/nervous, 16% were close to the hospital, and 11% did not want to administer the treatment even though they were not nervous or scared.

“This is despite responses that they felt confidence in knowing how to use the autoinjector and received education on its use,” Wang stated, “and highlights the need to develop training strategies that prepare caregivers to act during stressful situations, which is unlike what we typically do, which is train them in a calm setting in the office.”

In addition, at present, because there is no current system in wide use to rate the severity of acute allergic reactions, including anaphylaxis, Wang continued, it’s difficult to standardize how to provide optimal treatment. Although a 21-member panel convened in 2020, comprising allergy and emergency care experts, developed a rating system for acute allergic reactions (from mild allergic reaction to anaphylactic shock) that includes symptom details and examples for each body system and covers “the entire age spectrum,” it still needs to be validated.

“The hope is that an accepted and used severity scoring system will facilitate communication among health care providers and help clinicians teach patients about the continuum of symptoms that can occur during an allergic reaction,” she stated. “It can also support research in anaphylaxis by ensuring common terminology is used across studies.”

Potential benefits of having an allergy-specific grading system can be seen in a study from Mayo Clinic’s ED that evaluated how ED triage with the Emergency Severity Index impacts anaphylaxis care, with patient severity graded on a scale of 1 (requires life-saving care) to 5 (no care needed to stabilize the patient). Patients classified as level 1 or 2 (high acuity) received epinephrine more than half of the time (53%) and in less than half of the time compared with level 3 or 4 patients (lower acuity): 13 vs 28 minutes.

“Underuse of epinephrine is a chronic issue in both the community and medical settings,” Wang concluded. “Efforts are need to address barriers on the part of patients, caregivers, and clinicians that aim to improve communication and would be useful to support future anaphylaxis research.”


Wang J. Anaphylaxis: 7 for 11, update on pediatric allergy and immunology. Presented at: ACAAI 2021 Annual Scientific Meeting; November 4-8, 2021; New Orleans, LA.

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