Management of Anaphylaxis After Pre-Hospital Epinephrine Use in Children With Food-Induced Anaphylaxis

This study evaluated the need for additional emergency treatment following food-induced anaphylaxis in children who received appropriate prehospital epinephrine.Children younger than 18 years with known immunoglobulin E–mediated food allergies who presented to one of 7 Canadian pediatric emergency departments (EDs) (2011-2023) and received at least 1 prehospital epinephrine dose. Patients not meeting National Institute of Allergy and Infectious Diseases criteria for anaphylaxis were excluded.Outcomes of interest included use of at least 2 prehospital epinephrine doses, ED epinephrine administration, and hospital admission. Data collected included demographics, suspected food triggers, symptoms, severity, and comorbidities. Reactions were categorized by the most severe symptom as mild, moderate, or severe.A total of 1127 children were studied (median age: 7 years; 60.6% male). Mucocutaneous reactions were the most common (pruritus: 47.3%, urticaria: 55.4%, angioedema: 51.9%), followed by respiratory symptoms (throat tightness: 39.5%, breathing difficulties: 40.3%), gastrointestinal symptoms (36.8%), and cardiovascular symptoms (cyanosis: 1.9%, circulatory collapse: 0.4%, hypotension: 2.4%); 7.9% of patients had severe reactions. Every patient received at least 1 prehospital dose of epinephrine; 84.3% received 1 dose, 12.4% received 2, and 3.3% received 3 or more prehospital doses. In the ED, 18.5% received additional intramuscular epinephrine and 0.9% received it intravenously. Other treatments included antihistamines, beta-agonists, corticosteroids, and intravenous fluids. Overall, 6.2% required 3 or more epinephrine doses, and 2.7% were hospitalized. Factors associated with needing additional epinephrine in the ED included reaction due to tree nuts and more severe reactions.Only a minority of patients who received prehospital epinephrine required further treatment in the ED. This supports the use of shared decision-making when talking to families about ED evaluation after epinephrine use.These results highlight how caregiver education can lead to safer care out of the hospital—ideally encouraging earlier epinephrine use and reducing associated health care costs.