key: cord-0691360-nxtj5f5z
authors: Glassberg, Brittany; Nowak-Wegrzyn, Anna; Wang, Julie
title: Factors Contributing to Underuse of Epinephrine Autoinjectors in Pediatric Patients with Food Allergy
date: 2020-09-18
journal: Ann Allergy Asthma Immunol
DOI: 10.1016/j.anai.2020.09.012
sha: 76ac888ac834d77c2819c49aa4ee4e9208519dfd
doc_id: 691360
cord_uid: nxtj5f5z

BACKGROUND: Epinephrine autoinjectors (EA) are the standard of care for severe food allergic reactions, although they are frequently underused or misused. OBJECTIVE: The goal of this work is to understand the factors associated with underuse of EA by caregivers of pediatric patients with food allergy. METHODS: A survey was administered to 200 caregivers of pediatric patients with food allergies to assess most severe lifetime allergic reaction, EA education, use and factors associated with incorrect use or underutilization. RESULTS: One hundred sixty-four surveys were completed; 118 (72%) of lifetime most severe reactions warranted EA use, but the EA was used in only 45 (38.1%). Reasons caregivers indicated for not administering the EA included: reactions did not seem severe enough, it was the patient’s first allergic reaction, use of other medication, and fear of using EA. CONCLUSION: Multiple factors contribute to underuse of EA for the treatment of severe allergic reactions. Results from this study highlight the need for continuous EA education in caregivers of and pediatric patients with food allergies, using a mutlipronged approach targeting clear symptom recognition and alleviation of fear of EA use.

: Survey Distribution Tables: Table I: Demographics  Table II : Epinephrine Autoinjector Education Anaphylaxis is a life threatening condition that is estimated to occur in 1.6% of 2 the United States population 1 . Food is the most common trigger for anaphylaxis in 3 children, and up to 8% of children in the United States suffer from food allergy. [1] [2] [3] [4] [5] There 4 are approximately 125,000 food-induced allergic reaction emergency room visits per 5

year in the United States, 14,000 of which are due to anaphylaxis. 6 Anaphylactic 6 reactions are frequently undertreated. 6,-8 7 Despite education about food avoidance, reactions due to accidental ingestion of 8 food allergens still occur. 5, 6 The treatment of choice for anaphylaxis is intramuscular 9 epinephrine, and guidelines support the prescription of auto-injectable epinephrine (EA) 10 to patients with food allergy to ensure prompt access to life-saving medication if 11 anaphylaxis occurs outside the medical setting. 1 Correct use of EA is surprisingly low, 12 ranging from 16-32%, measured through both observational studies and via patient 13 report. [9] [10] [11] [12] [13] [14] While patients or their caregivers are advised to carry an EA with them at all 14 times, studies show that only about half of patients regularly carry an unexpired EA. 15 A 15 recent meta-analysis of EA use found that the most common reasons for pitfalls in the 16 use of EA are lack of autoinjector availability, inadequate education of parents about 17 how to administer the epinephrine, concern for systemic effects, failure to administer 18 correctly, and accidental administration. 16 This study aimed to identify parental factors 19 that contribute to the underuse of EA during anaphylactic reactions in pediatric patients. 20

Study participants -Participants were recruited from the Jaffe Food Allergy survey was self-administered and collected at the end of the visit. Information collected 32 included demographics, allergy and anaphylaxis history and past experience with EA 33 use, education, and confidence. Participants were asked to rate their confidence in EA 34 use based on past experience and training, with a score of 1 being "Very Confident" and 35 considered statistically significant findings.

Two hundred surveys were distributed to caregivers during the study timeframe. 49

Fifteen caregivers declined participation; 14 agreed to participate but did not return the 50 survey to the study investigators. Of the remaining 171 surveys, 7 did not meet 51 inclusion criteria (3 patients had never received prescription for EA and 4 patients did 52

not have a definitive diagnosis of food allergy). 164 completed surveys were included 53 for analysis ( Figure 1 ). 54 69.5% of the pediatric patients were male. The mean patient age was 7.5 years 55 (+/-5.2 years), and the average caregiver age was 40.6 years (+/-10.2 years). 56

Caregivers were 76.8% patient mothers, 22.6% fathers and 0.06% other. Further 57 demographic information about the surveyed population can be found in Table I . The 58 most common food allergens were tree nuts (n=139; 84.8%), peanuts (n=108; 65.9%), 59 egg (n=58; 35.4%), sesame (n=48; 29.3%), and milk (n=47; 28.7%). Most patients had 60 an associated atopic condition, including eczema (n=117; 71.3%), pollen allergy (n=89; 61 54.3%), and asthma (n=60; 36.6%). 62

All but one of the caregivers reported previously receiving education on how to 63 use the prescribed EA (Table II) . The most common mode of teaching was via verbal 64 instruction (n=149; 90.9%), most frequently done by allergy specialist physicians 65 (n=156, 95.1%). General pediatricians were the second most common teacher of how 66 to use the EA (n=63; 38.4%). In addition to verbal instructions, caregivers were 67 educated using printed materials (n=137; 83.5%) and live demonstrations (n=134; 68 J o u r n a l P r e -p r o o f 81.7%). When asked how confident they were in their ability to use the EA in the case of 69 a severe allergic reaction, 71 (43.3%) caregivers stated "very confident," whereas 69 70 (42.1%) stated "fairly confident," 21 (12.2%) stated "somewhat confident," 3 (1.8%) 71 stated "not too confident," and one participant failed to respond. No caregivers stated 72 that they were not at all confident in administering EA. There was no statistically 73 significant correlation between the time since receiving EA education and the self-74

reported caregiver level of confidence in administering EA. 75

The survey inquired about the most severe allergic reaction the child had ever 76 experienced. All participants reported at least one past food-related allergic reaction for 77 their child. The most commonly reported symptom (Table III) The caregivers who did not use EA when it was warranted were further 92 questioned about the reason behind this choice (Table III) . Average confidence in EA 93 use was 1.7 +/-0.7 in the cohort at large and 1.95 +/-0.9 in this particular subset. This 94 scales to between "Very Confident" and "Fairly Confident" on the distributed survey. 95

The most common reason for lack of EA use in this cohort was that the symptoms did 96 not seem severe enough (n=35; 47.9%). A significant correlation between lack of use of 97 EA when warranted and belief that symptoms did not seem severe enough was noted, 98 with a Pearson correlation of 0.18 (95% CI: 0.04-0.33, p=0.016), as seen in Table IV . 99

The majority of caregivers used oral antihistamine (diphenydramine) instead, n=56; 100 76.7%. A significant correlation between lack of use of EA when warranted and use of 101 oral antihistamine was noted, with a Pearson correlation of 0.27 (95% CI: 0.12-0.40, 102 p=0.0005). Twenty nine percent (n=21) reported they did not use EA because the 103 caregiver was scared and/or nervous about the reaction; a significant correlation 104 between lack of use of EA when warranted and fear of reaction was noted, with a 105

Pearson correlation of 0.26 (95% CI: 0.11-0.40, p = 0.00077). Three caregivers reported 106 specific fear of the needle as the cause for not using the EA. Another reason that 107 contributed to lack of use of EA in this population was that the patient was evaluated by 108 a nearby doctor (Pearson correlation p = 0.00025). No caregivers reported not knowing 109 how to use the EA as a reason for not using it. No one cited financial constraints as a 110 reason for not having the EA available. Sixteen (21.9%) caregivers reported not using 111 the EA not because they were scared or nervous, but because they did not want to 112 administer it. 113 J o u r n a l P r e -p r o o f There was no statistically significant relationship between patient or caregiver 114 age or caregiver confidence and lack of EA use when the reaction was severe. This was 115 true for both reactions defined as severe due to airway symptoms, and those defined as 

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