Anaphylaxis in schools and other child-care settings☆,☆☆,★,★★

The Wilderness Medical Society convened a panel to review the literature and develop evidence-based clinical practice guidelines on the treatment of anaphylaxis, with an emphasis on a field-based perspective. The review also included literature regarding the definition, epidemiology, clinical manifestations, and prevention of anaphylaxis. The increasing prevalence of food allergies in the United States raises concern for a corresponding rise in the incidence of anaphylaxis. Intramuscular epinephrine is the primary treatment for anaphylaxis and should be administered before adjunctive treatments such as antihistamines, corticosteroids, and inhaled β agonists. For outdoor schools and organizations, selecting a method to administer epinephrine in the field is based on considerations of cost, safety, and first responder training, as well as federal guidelines and state-specific laws.

Allergy immunotherapy can result in systemic allergic reactions and even life-threatening anaphylaxis requiring epinephrine administration.

The objective of this study was to describe epinephrine use in the clinical trial development programs of 3 rapidly dissolving sublingual immunotherapy tablets (SLIT-tablets; Merck & Co., Inc., Kenilworth, NJ/ALK, Hørsholm, Denmark/Torii Pharmaceutical Co., Ltd., Tokyo, Japan).

Data on epinephrine use were collected from 13 timothy grass SLIT-tablet trials (MK-7243; ≤2800 bioequivalent allergen units/75,000 SQ-T dose, n = 2497; placebo, n = 2139), 5 short ragweed SLIT-tablet trials (MK-3641; ≤12 Amb a 1-U, n = 1725; placebo, n = 770), and 11 house dust mite (HDM) SLIT-tablet trials (MK-8237; ≤12 SQ-HDM; n = 3930; placebo, n = 2246).

In grass SLIT-tablet trials, epinephrine was used 13 times (grass SLIT-tablet, n = 10; placebo, n = 3). Eight administrations were for grass SLIT-tablet-related adverse events (AEs): 4 for systemic allergic reactions and 4 for local mouth and/or throat swelling. In ragweed SLIT-tablet trials, epinephrine was used 9 times in 8 subjects (ragweed SLIT-tablet, n = 7; placebo, n = 1 [2 administrations for protracted anaphylaxis]). Four administrations were for ragweed SLIT-tablet-related AEs: 1 for systemic allergic reaction and 3 for local mouth and/or pharynx/throat swelling. In HDM SLIT-tablet trials, epinephrine was administered 13 times (HDM SLIT-tablet, n = 8; placebo, n = 5). Four administrations were for HDM SLIT-tablet-related AEs: 1 for systemic allergic reaction and 3 for local events. Of the 16 epinephrine administrations for events related to SLIT-tablet treatment, 11 occurred within the first week of treatment (7 administrations on day 1) and 5 were subject self-administered.

Epinephrine administrations in response to SLIT-tablet-related reactions in clinical trials are uncommon, typically occur within the first week of treatment, and are rarely self-administered. All SLIT-tablet-related events treated with epinephrine were nonserious.

Anaphylaxis is the most severe of all allergic reactions and can even prove fatal. There is limited evidence of a difference in prescribing patterns for self-injectable epinephrine (SIE) between general paediatricians and paediatricians with greater knowledge of allergology.

Assess knowledge about prescribing SIE of a sample of primary care/hospital paediatricians and paediatricians with specialised knowledge of allergology through a questionnaire asking them about clinical cases of anaphylaxis in their daily paediatric practice.

Participants were primary care and hospital paediatricians practicing in different regions of the province of Barcelona and paediatricians with specialised knowledge in the field of allergology from Spain.

A total of 183 paediatricians responded. Of that 59.6% were paediatricians with specialised knowledge of allergology. General paediatricians in most cases correctly prescribed SIE device (more than 70% answered correctly in five of the eight clinical cases). In the case of drug anaphylaxis, which is an avoidable allergen for which SIE is not indicated, 67.5% of general paediatricians would prescribe it. In the case of exercise-induced anaphylaxis there were also differences in the prescription of epinephrine by general paediatricians, with only 40% prescribing it.

In this study the percentage of SIE prescriptions would be higher than expected by general paediatricians, with no differences in the cases proposed between them and the paediatricians with better knowledge of allergology.

Despite these results, it is important to insist on conducting education programmes and disseminating them to facilitate physicians’ recognition and treatment of anaphylactic reactions.

School personnel are required to guarantee a secure school environment for children suffering from severe food allergies. We organized a workshop for school personnel to learn the appropriate management of anaphylaxis that included practical training with an adrenaline auto-injector (AAI). The objective of this study was to evaluate the workshop in terms of the improvement of self-efficacy (SE) of participants to deal with anaphylaxis.

All 93 school nurses, 73 schoolteachers and 110 childcare workers participating in the study completed a questionnaire before and after the workshop. The SE of the participants was evaluated using an original 15-item questionnaire.

Before the workshop, the SE of school nurses was the highest among the profession groups, and being involved with children prescribed an AAI was a common factor associated with a high SE. After the workshop, the SE increased in all groups, but most apparently in school nurses and those involved with children prescribed an AAI. The presence of an emergency plan was positively associated with the SE of schoolteachers only after the workshop, even though no such association existed beforehand.

Practical instruction of school nurses and school personnel involved with children prescribed an AAI resulted in dramatic improvement of the SE. These people are expected to play a central role in the development of an anaphylaxis management plan in their schools.