Lianne Soller, PhD,Ingrid Baerg, RN, BSN, Timothy Teoh, MD, Tiffany Wong, MD, FRCPC,Kyla J. Hildebrand, MD, FRCPC, MScCH (HPTE), Victoria E. Cook, MD ...
Supervised epinephrine autoinjector administration in a cohort of children with anaphylaxis during oral food challenges Lianne Soller, PhD, Ingrid Baerg, RN, BSN, Timothy Teoh, MD, Tiffany Wong, MD, FRCPC, Kyla J. Hildebrand, MD, FRCPC, MScCH (HPTE), Victoria E. Cook, MD, Catherine Biggs, MD, Nicole Lee, MSc, Lindsay Yaworski, RN, Tracy Gonzalez, RN, BSN, Edmond S. Chan, MD, FRCPC. Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, BC Children’s Hospital, Vancouver, British Columbia
Background Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur • Intramuscular epinephrine is the first-line treatment for food-induced ridiculus mus. Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla anaphylaxis. consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate eget, arcu. In • Patients are prescribed an epinephrine autoinjector (EAI), which may be self- or enim justo, rhoncus ut, imperdiet a, venenatis vitae, justo. Nullam dictum felis eu pede mollis caregiver administered. even when the device available, it is often pretium. Integer tincidunt. CrasHowever, dapibus. Vivamus elementum semperisnisi. Aenean vulputate not used. eleifend tellus. Aenean leo ligula, porttitor eu, consequat vitae, eleifend ac, enim. Aliquam lorem • ante, Reasons EAI underuse include failure to recognize anaphylaxis symptoms dapibus for in, viverra quis, feugiat a, tellus. Phasellus viverra nulla ut metus varius laoreet. Quisque rutrum. Aenean imperdiet. ultricies nisi vel augue. Curabitur ullamcorper ultricies and fear in administering theEtiam device nisi. Nam eget dui. rhoncus. Maecenas tellus eget condimentum sem • Anaphylaxis isEtiam a potential outcome oftempus, oral food challenges (OFCs) rhoncus, and quam semper libero, sit amet adipiscing sem neque sed ipsum. Nam quam nunc, blandit vel, therefore presents an ideal opportunity to train parents and children using the luctus pulvinar, hendrerit id, lorem. Maecenas nec odio et ante tincidunt tempus. Donec vitae EAI ut in libero a realvenenatis scenario of anaphylaxis. sapien faucibus. Nullam quis ante. Etiam sit amet orci eget eros faucibus • tincidunt. Our previous presented data onDonec the first 163 patients enrolled Duis leo.publication Sed fringilla mauris sit amet nibh. sodales sagittis magna. Sedin the study, and that supervised EAIvelit administration consequat, leo showed eget bibendum sodales, augue cursus nunc, during an OFC had a
positive impact on parent confidence in recognizing anaphylaxis and using the Nulla massaHowever, quis enim. at Donec pede that justo,study fringillawas vel, published, aliquet nec, vulputate eget, EAIconsequat (Teoh 2016). the time only 18 cases arcu. In enim justo, rhoncus ut, imperdiet a, venenatis vitae, justo. Nullam dictum felis eu pede required epinephrine. mollis pretium. Integer tincidunt. Cras dapibus. Vivamus elementum semper nisi. Aenean • vulputate This study sought confirm findingseu, in consequat a larger cohort of children. eleifend tellus.to Aenean leothose ligula, porttitor vitae, eleifend ac, enim.
Methods
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2. Lorem ipsum dolor sit amet, consectetuer adipiscing Results Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. • Of 329 families approached to participate in the study, 317 consented (96.4% Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur response ridiculus mus.rate). Donec(Table quam 1) felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla • 353 oral foodquis challenges were performed in these 317 children, with the consequat massa enim. Donec pede justo, fringilla.
majority (88.6%) undergoing a single OFC. Nulla consequat quis enim. Donecchallenges pede justo, failed, fringilla of vel, aliquet vulputate eget, • One hundredmassa and fifteen (32.6%) which 53nec, (46.1%) arcu. In enimat justo, rhoncus ut, imperdiet a, venenatis vitae, justo. Nullam dictum felis eurate pede required least one dose of epinephrine. This represents an anaphylaxis mollis pretium. Integer tincidunt. Cras dapibus. Vivamus elementum semper nisi. Aenean of 15% in our OFC population. vulputate eleifend tellus. Aenean leo ligula, porttitor eu, consequat vitae, eleifend ac, enim. • We found a significantly positive impact in all four confidence domains measured. (Figure 1) • Those who reported greater knowledge of EAI technique and skill in EAI use were more likely to have older children (OR: 1.23, 95% Confidence Interval (CI): 1.02-1.47 and OR: 1.17, 95% CI, 1.00, 1.37). • Those who received epinephrine during their food challenge were more likely to be older children (OR: 1.12, 95% CI, 1.02, 1.22). The type of food challenged (peanut, tree nut, egg, or milk) did not predict epinephrine use. • Many children receiving epinephrine experienced skin symptoms, GI symptoms, and upper respiratory symptoms, with a smaller percentage experiencing lower respiratory symptoms and cardiovascular symptoms. Table 1: Patient and Parent Characteristics (n=317 children, 353 OFCs)
Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. • Parents and their children (less than 18 years old) undergoing OFCs at the Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur Britishmus. Columbia Allergy Clinic were asked to Nulla ridiculus Donec Children’s quam felis,Hospital ultricies (BCCH) nec, pellentesque eu, pretium quis, sem. administer thequis EAIenim. under the pede supervision of a nurse and/or allergist if consequat massa Donec justo, fringilla
Age in years, median (IQR)
5 (3, 9)
Male, % (95%CI)
62.5 (56.9, 67.8)
Parent Healthcare professional, % (95%CI)
23.9 (19.6, 28.7)
•
Parent post-secondary education, % (95%CI) 88.6 (84.7, 91.7)
• • • • •
References Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, Teoh T, Mill C, Wong T, Baerg I, Alexander A, Hildebrand KJ, et al. Impact of supervised vulputate eget, arcu. In enim justo, rhoncus ut, imperdiet a, venenatis vitae, justo. epinephrine autoinjector administration during food challenges on parent confidence. Ann Nullam dictum felis eu pede mollis pretium. Integer tincidunt. Cras dapibus. Vivamus Allergy, Asthma Immunol. 2016;116(5):467–9. elementum semper nisi. Aenean vulputate eleifend tellus. Aenean leo ligula, porttitor Shemesh E, D’Urso C, Knight C, Rubes M, Picerno KM, Posillico AM, et al. Food-Allergic eu, consequat vitae, eleifend ac, enim. Aliquam lorem ante, dapibus in, viverra quis, Adolescents at Risk for Anaphylaxis: A Randomized Controlled Study of Supervised Injection to feugiat a, tellus. Phasellus viverra nulla ut metus varius laoreet. Quisque rutrum. Improve Comfort with Epinephrine Self-Injection. J Allergy Clin Immunol Pract. 2017 Apr 3;5(2): 391–397.e4.
Perceive food allergy as severe, % (95%CI)
36.5 (31.4, 41.8)
Carry an Epipen, % (95%CI) 94.9 (91.9, 97.1) Nulla consequat massa quis enim. Donec pede Food challenged, % justo, fringilla vel, aliquet nec,32.3% peanut; vulputate eget,25.8% egg;19.5% tree nut; 11.6% cow’s a, milk arcu. In enim justo, rhoncus ut, imperdiet venenatis vitae, justo. Nullam dictum felis eu pede mollis pretium. Integer tincidunt. Cras Figure 1: dapibus. Pre-challenge and post-challenge mean confidence
scores
4.5 4
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Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor. Aenean massa.3 Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus.2.5 Donec quam felis, ultricies nec, pellentesque eu, pretium quis, sem. Nulla consequat massa quis enim. Donec pede justo, fringilla 2 Mean Confidence scores
•
anaphylaxis occurred during the OFC. A pre-challenge questionnaire asked questions about demographics and clinical characteristics, and baseline confidence in four domains: 1) confidence in ability to recognize a severe allergic reaction, 2) confidence in EAI administration, 3) perceived knowledge of EAI technique, and 4) perceived skill in EAI use. An identical post-challenge questionnaire was completed by the person who administered the EAI (parent or child). EAI was administered when the patient experienced symptoms in at least two different body systems (skin, GI, upper respiratory, lower respiratory, cardiovascular) Confidence levels were evaluated on a 5-point scale (1 indicating not very confident and 5 indicating very confident). Multivariate logistic regression was performed to determine patient and parent characteristics (from table 1) associated with an increase in confidence for each of the four domains (versus no change or decrease in confidence). Multivariate logistic regression was also performed to assess patient and parent characteristics associated with receiving epinephrine during the OFC. This study received IRB approval from the UBC Children’s and Women’s Research Ethics Board.
1.5
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1 Nulla consequat massa quis enim. Donec pede justo, fringilla vel, aliquet nec, vulputate eget, 0.5 rhoncus ut, imperdiet a, venenatis vitae, justo. Nullam dictum felis eu pede arcu. In enim justo, mollis pretium. Integer tincidunt. Cras dapibus. Vivamus elementum semper nisi. Aenean 0 Recognition Administration Knowledge vulputate eleifend tellus. Aenean leo ligula, porttitor eu, consequat vitae, eleifend ac,Skill enim. Aliquam lorem ante, dapibus in, viverra quis, feugiat ut metus Pre-challenge 3.58 3.25 a, tellus. Phasellus 3.61 viverra nulla2.73 varius laoreet. Quisque rutrum. Post-challenge 3.96 4.23 4.26 3.85 Confidence domains Lorem ipsum dolor sit amet, consectetuer adipiscingPost-challenge elit. Aenean commodo ligula eget dolor. Pre-challenge Aenean massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus.
The Pre-challenge and Post-challenge 95%CIs for the four confidence domains in Figure 1 did not overlap, demonstrating a significant difference in confidence across all four confidence domains. These results indicate that our intervention was effective in increasing confidence in the four domains measured in this study.
Characteristics of patients who failed tellus their OFC 5. NamTable eget2:dui. Etiam rhoncus. Maecenas tempus, eget (n=115) condimentum Characteristic Requiring Epinephrine (n=53) Not requiring Epinephrine rhoncus, sem quam semper libero, sit amet adipiscing sem neque sed (n=62) ipsum. Nam quam nunc, blandit vel, luctus pulvinar, hendrerit id, lorem. Maecenas nec Age (median) 6 years (IQR: 3.5, 12) 4.5 years (IQR: 2, 7.25) odio et ante tincidunt Gender 71.7% male 59.7% male Food challenged 45.3% peanut; 19% tree nut; 37.1% peanut; 22.6% egg; 14.5% Nam eget dui. Etiam rhoncus. Maecenas tempus, tellus eget condimentum rhoncus, sem quam 17% egg; 13.2% milk milk; 14.5% tree nut semper libero, sit amet adipiscing sem neque sed ipsum. Nam quam nunc, blandit vel, luctus Skin Symptoms (95%nec CI,odio 79.3,et96.9) 74.2% (95% CI, 61.5,vitae 84.5) pulvinar, hendrerit id, lorem. 90.6% Maecenas ante tincidunt tempus. Donec sapien ut libero venenatis faucibus. Nullam Etiam sit amet30.6% orci eget faucibus tincidunt. GI symptoms 75.5% quis (95%ante. CI, 61.7, 86.2) (95%eros CI, 19.6, 43.7) Duis leo. Sed fringilla mauris66.0% sit amet nibh. sodales sagittis magna. leo Upper Respiratory (95% CI, Donec 51.7, 78.5) 11.3% (95% CI,Sed 4.66,consequat, 21.9) eget bibendum sodales, augue velit cursus nunc symptoms Lower Respiratory symptoms
28.3% (95% CI, 16.8, 42.3)
0%
Cardiovascular symptoms
7.55% (95% CI, 2.09, 18.2)
0%
Other symptoms Number of epinephrine doses
11.3% (95% CI, 4.37, 23.0) 83% one dose; 11.3% two doses; 5.7% three doses
11.3% (95% CI, 4.66, 21.9) -
Conclusions • Our study found that administering epinephrine under medical supervision during oral food challenge has a positive impact on all four confidence domains that we measured – recognition, administration, knowledge, and skill. • This is the first study where parents or patients are coached to actually use an EAI during anaphylaxis, therefore most closely mimicking real life. One other study had adolescents self-inject an empty syringe into the thigh when they were not experiencing anaphylaxis, and it found that compared with an ‘education only’ control group, there was an increase in comfort with injection after the intervention (Shemesh 2017). • We describe the highest reported rate of anaphylaxis with OFC’s in the literature. • Our study is limited in that we did not have a control group; however, we did have the data from the pre-OFC questions for those who did not receive epinephrine, and the scores did not reveal any differences compared with those who received epinephrine (p=0.8962). • As the results of this study have been so promising, our allergy clinic has implemented self-injection of epinephrine using autoinjectors as part of routine practice for oral food challenges. • A limitation of applying this intervention is the potential cost of epinephrine autoinjectors. • Our future work includes a 2-year follow up study to assess whether EAIs have been used in the community since the OFC and parent/patient confidence around their experience injecting EAI in the community. We are also looking at Conclusion quality of life as, and comparing outcomes between a hospital based allergy Nam eget dui. Etiam rhoncus. Maecenas tempus, tellus eget condimentum rhoncus, sem quam clinic (BC Children’s) and a community clinic in Victoria, BC. semper libero, sit amet adipiscing sem neque sed ipsum. Nam quam nunc, blandit vel, luctus pulvinar, hendrerit id, lorem. Maecenas nec odio et ante tincidunt tempus. Donec vitae sapien ut libero venenatis faucibus. Nullam quis ante. Etiam sit amet orci eget eros faucibus tincidunt. Duis leo. Sed fringilla mauris sit amet nibh. Donec sodales sagittis magna. Sed consequat, leo eget bibendum sodales, augue velit cursus nunc.
Acknowledgements
We thank Lisa Wilson, Gael Kivlichan, Tess Erazo, Joy Jacobs, and Valencia Yamamoto in the allergy clinic for their assistance. We thank the BCCH Foundation for research support.
Acknowledgements
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