This Q&A is an interview with Dr. Dave Stukus, MD, an Associate Professor of Pediatrics in the Division of Allergy/Immunology at Nationwide Children’s Hospital. Dr. Dave Stukus was not compensated for this article.
Anaphylaxis is the most serious kind of food allergy reaction. It’s unpredictable and can quickly escalate and may result in death. A recent study by Robinson, Greenhawt and Stukus, Factors associated with epinephrine administration for anaphylaxis in children before arrival to the emergency department, reviewed the records of hundreds of patients to research the use of epinephrine in treating anaphylaxis. Of 408 patients admitted to the hospital with anaphylaxis, only 148 patients (36.6%) received epinephrine prior to arriving at the Emergency Department or Urgent Care Center. Patients who did not receive epinephrine before arrival were less likely to be discharged to home (therefore, more likely to be admitted for further evaluation and treatment). Reactions that occurred at home were less likely to be treated with epinephrine compared to those that occurred at school (31.5% compared to 61.2%); and epinephrine was less likely to be administered with 2 or 3-system organ system involvement that with only one system. Food was the most common trigger (83.8%), with peanuts and tree nuts being the most common specific foods involved. There were no fatalities.
To better understand the study, Sherry Coleman Collins (SCC), registered dietitian and food allergy expert, asked study co-author Dr. David Stukus (DS) to share his insight into the findings and implications for managing food allergies.
SCC: What exactly does epinephrine do for an individual suffering from an allergic reaction?
DS: Epinephrine (also known as adrenaline, which is present inside all of our bodies) is the 1st line and only effective treatment for anaphylaxis, which is a severe rapidly progressive allergic reaction that can involve any combination of symptoms affecting more than one body system. Normally, epinephrine helps us in our ‘fight or flight’ response and helps increase our heart rate, breathing capacity, and ability to run from danger. When used as treatment, epinephrine works very quickly to reverse all aspects of an allergic reaction, which makes people feel better within minutes. It also helps to prevent allergy cells from releasing chemicals (histamine) that are causing symptoms in the first place, which helps halt progression of the reaction. Epinephrine can treat hives, wheezing, nausea/vomiting, and low blood pressure, all of which can occur during anaphylaxis.
SCC: Why is delaying administration of epinephrine such an important topic?
DS: If anaphylaxis goes untreated, symptoms can continue to progress in severity and even cause death. Not treating anaphylaxis promptly allows more mediators to be released, which can allow the reaction to last longer and be more severe. Epinephrine works within minutes, but also has a very short duration of action. If epinephrine is not given early at the start of an anaphylactic reaction, it may only partially treat symptoms and then will rapidly be removed from circulation, allowing the reaction to continue. While deaths from anaphylaxis thankfully are rare, the number one factor associated with almost all cases is delayed or lack of administration of epinephrine.
SCC: What should parents of allergic children and adults with allergies know that might help overcome their hesitancy in administering epinephrine?
DS: Practice, practice, practice! Every caregiver and child who has been prescribed an epinephrine autoinjector should practice the technique with a training device. These can be tricky to use, even for health care professionals. Practice should occur at every physician visit and at home as well. The more familiar someone is with the device, it is less likely to be used incorrectly. In addition, parents and children should practice role playing different situations, including which symptoms should be treated with epinephrine, what to do if they’re at school/restaurant/friend’s house, as well as making sure someone calls 911 immediately. I also encourage lots of questions at the allergy appointment to better understand how and why epinephrine is so important. Lastly, many parents are hesitant to use epinephrine as it requires inserting a needle into their child’s thigh – a daunting task for any parent. It may help to see the actual size of the needle (less than the diameter of a dime) and understand that all symptoms of anaphylaxis can be reversed by this one treatment. Misconceptions about side effects are rampant as well – when used properly through a preloaded autoinjector, epinephrine is very safe and will not cause severe side effects such as heart problems or significant injury.
SCC: Are there “next steps” that you would suggest in researching this topic? Unanswered questions or unclear results?
DS: We have so many unanswered questions! Which patients are at highest risk for anaphylaxis and most likely to need epinephrine? Does everyone with a food allergy diagnosis need to have epinephrine with them at all times, or can we somehow determine true risk? Why do some people hesitate to use when necessary and how can we screen/assess those individuals early and provide more intensive education? How can we better train and educate health care professionals regarding proper use of epinephrine so they can educate their patients?
SCC: Anything else that you would like readers to learn from your study?
DS: We found that everyone is susceptible. The issue of not administering epinephrine for anaphylaxis does not discriminate – it affected children from various races, ages, gender, and experiencing reactions in a variety of locations (including inside their own home). It is important to use this information to provide ongoing education to raise awareness and help as many people as possible.
SCC: What should those outside the allergy community know about administering epinephrine during an anaphylaxis emergency?
DS: Those unfamiliar with allergies often have misconceptions and lack of understanding in regards to the potential severity of anaphylaxis, the need to use epinephrine instead of other treatments such as antihistamines or steroids, and fail to call 911 or seek emergency care after epinephrine is administered. We need to continue to increase awareness outside of the allergy community. Every state now has laws allowing schools to stock their own epinephrine and administer to any student experiencing anaphylaxis, even if they don’t have their own prescription. As we implement this stock epinephrine legislation, it is important to provide all school personnel with proper training so they can be helpful in a time of need.
Dr. Dave Stukus, MD, is an Associate Professor of Pediatrics in the Division of Allergy/Immunology at Nationwide Children’s Hospital. In addition to his interest in caring for families with asthma, food allergies and other allergic conditions, he also serves as the Director of the Hospital’s Complex Asthma Clinic. Dr. Stukus serves as an official spokesperson for the American College of Allergy, Asthma, and Immunology and was elected to the Board of Directors for the Asthma and Allergy Foundation of America in 2014. Dr. Stukus actively participates in social media on Twitter through @AllergyKidsDoc. Dr. Stukus obtained his medical degree at the University of Pittsburgh School of Medicine. He completed his residency at Nationwide Children’s Hospital and his fellowship at the Cleveland Clinic. He is Board Certified in Allergy/Immunology and Pediatrics.