Why do few food-allergic adolescents treat anaphylaxis with adrenaline?--Reviewing a pressing issue

Food Allergy

Food allergy is a growing health problem affecting both pediatric and adult patients. Food allergies are often immunoglobulin E (IgE) mediated but other food-induced non-IgE-mediated diseases exist. Diagnosis of food allergy relies on the combination of clinical and reaction history, skin and IgE testing as well as oral food challenges. Although oral immunotherapy has been able to achieve sustained unresponsiveness in some patients, no cure for food allergies has been found to date. Avoidance of the inciting food as well as availability of epinephrine autoinjectors remains the mainstay of treatment.

Food allergy: a proposed new tool for educating children and young people and supporting them to self-manage

Self-managing food allergy in children and young people presents challenges for families as they attempt to find a balance between their child's safety and freedom. Nurses have an important role in providing education that supports children, young people and their parents to self-manage food allergy safely but not at the expense of the child or young person's social development. At Nottingham Children's Hospital, the allergy service and youth service have developed an education and support tool composed of three domains, 'awareness', 'checking' and 'emergency kit', forming the acronym ACE. The authors suggest that the ACE tool could be used by healthcare professionals as a framework for educating children and young people with food allergy and their parents, as well as by children and young people and their parents at home to risk assess and risk manage everyday situations and new scenarios or events.

Preventing food allergy fatalities

Fatal anaphylaxis to food is thankfully rare, but every death is a potentially avoidable tragedy. Usually, there will be a coronial inquest to establish the 'how and why' for each death. Reviewing these food allergy-related deaths identifies a number of common themes and risk factors. While some are non-modifiable (such as age, gender and ethnicity), others are and include delayed epinephrine administration and communication difficulties in allergen avoidance. This review highlights the key messages in food allergy-related fatality prevention for healthcare professionals and patients alike, and where available, we explain the evidence behind such recommendations. We describe the data behind the good practice points to facilitate their adoption in routine practice without generating additional anxiety for what is a comparatively rare event. We also propose an information leaflet for patients and carers, developed with patients and endorsed by two major allergy charities, to facilitate dissemination of the recommendations in this review.

Food Allergy

Food allergy is a growing health problem affecting both pediatric and adult patients. Food allergies are often immunoglobulin E (IgE) mediated but other food-induced non-IgE-mediated diseases exist. Diagnosis of food allergy relies on the combination of clinical and reaction history, skin and IgE testing as well as oral food challenges. Although oral immunotherapy has been able to achieve sustained unresponsiveness in some patients, no cure for food allergies has been found to date. Avoidance of the inciting food as well as availability of epinephrine autoinjectors remains the mainstay of treatment.

Anaphylaxis in Children

ABSTRACT

Anaphylaxis is a potentially life-threatening event in children, commonly encountered in the prehospital and emergency department settings. Recently published clinical guidelines emphasize early recognition of anaphylaxis and administration of epinephrine as the mainstay of management. Literature regarding adjuvant therapies, biphasic reactions, observation times, and disposition of patients with anaphylaxis remains controversial. In this article, we will review the background and pathophysiology of anaphylaxis, as well as the diagnostic approach, management, and future directions of anaphylaxis in children.

Risk factors for severe reactions in food allergy: Rapid evidence review with meta-analysis

This rapid review summarizes the most up to date evidence about the risk factors for severe food-induced allergic reactions. We searched three bibliographic databases for studies published between January 2010 and August 2021. We included 88 studies and synthesized the evidence narratively, undertaking meta-analysis where appropriate. Significant uncertainties remain with respect to the prediction of severe reactions, both anaphylaxis and/or severe anaphylaxis refractory to treatment. Prior anaphylaxis, an asthma diagnosis, IgE sensitization or basophil activation tests are not good predictors. Some molecular allergology markers may be helpful. Hospital presentations for anaphylaxis are highest in young children, yet this age group appears at lower risk of severe outcomes. Risk of severe outcomes is greatest in adolescence and young adulthood, but the contribution of risk taking behaviour in contributing to severe outcomes is unclear. Evidence for an impact of cofactors on severity is lacking, although food-dependent exercise-induced anaphylaxis may be an exception. Some medications such as beta-blockers or ACE inhibitors may increase severity, but appear less important than age as a factor in life-threatening reactions. The relationship between dose of exposure and severity is unclear. Delays in symptom recognition and anaphylaxis treatment have been associated with more severe outcomes. An absence of prior anaphylaxis does not exclude its future risk.

Proposal of 0.5 mg of protein/100 g of processed food as threshold for voluntary declaration of food allergen traces in processed food-A first step in an initiative to better inform patients and avoid fatal allergic reactions: A GA²LEN position paper

BACKGROUND

Food anaphylaxis is commonly elicited by unintentional ingestion of foods containing the allergen above the tolerance threshold level of the individual. While labeling the 14 main allergens used as ingredients in food products is mandatory in the EU, there is no legal definition of declaring potential contaminants. Precautionary allergen labeling such as "may contain traces of" is often used. However, this is unsatisfactory for consumers as they get no information if the contamination is below their personal threshold. In discussions with the food industry and technologists, it was suggested to use a voluntary declaration indicating that all declared contaminants are below a threshold of 0.5 mg protein per 100 g of food. This concentration is known to be below the threshold of most patients, and it can be technically guaranteed in most food production. However, it was also important to assess that in case of accidental ingestion of contaminants below this threshold by highly allergic patients, no fatal anaphylactic reaction could occur. Therefore, we performed a systematic review to assess whether a fatal reaction to 5mg of protein or less has been reported, assuming that a maximum portion size of 1kg of a processed food exceeds any meal and thus gives a sufficient safety margin.

METHODS

MEDLINE and EMBASE were searched until 24 January 2021 for provocation studies and case reports in which one of the 14 major food allergens was reported to elicit fatal or life-threatening anaphylactic reactions and assessed if these occurred below the ingestion of 5mg of protein. A Delphi process was performed to obtain an expert consensus on the results.

RESULTS

In the 210 studies included, in our search, no reports of fatal anaphylactic reactions reported below 5 mg protein ingested were identified. However, in provocation studies and case reports, severe reactions below 5 mg were reported for the following allergens: eggs, fish, lupin, milk, nuts, peanuts, soy, and sesame seeds.

CONCLUSION

Based on the literature studied for this review, it can be stated that cross-contamination of the 14 major food allergens below 0.5 mg/100 g is likely not to endanger most food allergic patients when a standard portion of food is consumed. We propose to use the statement "this product contains the named allergens in the list of ingredients, it may contain traces of other contaminations (to be named, e.g. nut) at concentrations less than 0.5 mg per 100 g of this product" for a voluntary declaration on processed food packages. This level of avoidance of cross-contaminations can be achieved technically for most processed foods, and the statement would be a clear and helpful message to the consumers. However, it is clearly acknowledged that a voluntary declaration is only a first step to a legally binding solution. For this, further research on threshold levels is encouraged.

Fatal Food Anaphylaxis: Distinguishing Fact From Fiction

Although there is a general perception that the prevalence of food allergy is increasing, data supporting this are limited. Food is the least common cause of fatal anaphylaxis, and fortunately, it is a very rare event; however, it is also unpredictable. There is widespread consensus that severe reactions cannot be predicted in a clinically meaningful way. Certain food triggers are more frequently associated with fatal anaphylaxis than others. In observational studies, peanut and tree nuts account for at least 30% to 50% of fatalities, with seafood and cow's milk also associated with fatal reactions. Fatal food-induced anaphylaxis is most likely to occur during adolescence and young adulthood, although the reasons for this are unclear. International guidelines agree that intramuscular (IM) epinephrine is the treatment of choice for managing food-triggered anaphylaxis and has a good safety profile when given by the IM route. However, fatalities still occur despite the timely administration of epinephrine. Food-allergic individuals must navigate a world that requires daily vigilance for allergens and preparedness for allergic reactions. Although the actual risk of fatal reactions is minimal, it is not zero, and severe reactions are unpredictable. Clinicians need to help patients better understand the very low but real risk of fatal reaction and enable them to lead as normal a life as possible through appropriate education, safety netting, and risk reduction.

Accidental ingestions to known allergens by food allergic children and adolescents

BACKGROUND

Accidental ingestions (AI) of food allergens in children compared with adolescents with food allergies are poorly characterized. It is suggested that AIs are higher in adolescents than children and that their reactions may be more severe, presumptively due, at least in part, to increased risk-taking behavior. We compared reported AIs in children versus adolescents.

METHODS

An online cross-sectional survey was distributed to parents of children with food allergies via Twitter, food allergy advocacy groups in the UK, South Africa, and Australia, and locally at Children's Hospital Colorado.

RESULTS

Of 558 respondents, 105 were parents of adolescents, and 453 had children <12 years. 73% (341) reported an AI since diagnosis, with 85% of adolescents having had an AI versus 70% of children (p = 0.0058). The annualized rate of AI was significantly lower in the adolescent population at 0.21 versus 0.53 in children (p = <0.0001). Although adolescents reported fewer severe reactions (2% vs. 16%, p = 0.0283), more adolescents required epinephrine administered by a medical professional for their most severe AI, (48% vs. 24%, p = 0.0378). Comparison of the two age groups is limited by the fact that many AIs in the adolescent group occurred prior to age 12. There was no significant difference between the groups as to where the food was consumed or the type of food. There was a significant difference in accidental ingestions in patients in all age groups with more than one reported food allergy; 78% of those with more than one food allergy reported a prior history of at least one accidental ingestion, compared with 59% in those with a single food allergy (p < 0.0001). Regional differences were also noted with respondents in the United States reporting 0.3 accidental ingestions a year, 0.4 in the UK, and 0.5 in other countries (p = 0.0455). The number of reactions was, on average, 27% lower (95% CI: 40, 11%) in the United States compared with the UK (p = 0.0019).

CONCLUSION

The number of severe reactions, and epinephrine need, differs in children compared with adolescents, although many of the reported reactions in both groups occurred before the age of 12. There were also regional differences with the United States reporting a lower number of AIs and less AIs per year than the other participating regions, as well as increased rates of AI in participants with more than one food allergy. Further characterization of the differences in AIs between children and adolescents, as well as between regions, is needed to assist with more patient-centered anticipatory guidance.

Self-administration of adrenaline for anaphylaxis during in-hospital food challenges improves health-related quality of life

OBJECTIVE

To assess the impact of anaphylaxis on health-related quality of life (HRQL) and self-efficacy in food-allergic patients undergoing in-hospital food challenge.

DESIGN

Secondary analysis of a randomised controlled trial.

SETTING

Specialist allergy centre.

PATIENTS

Peanut-allergic young people aged 8-16 years.

INTERVENTIONS

Double-blind, placebo-controlled food challenge to peanut, with HRQL and self-efficacy assessed using validated questionnaire, approximately 2 weeks prior to and 2 weeks after challenge. Where possible, anaphylaxis was treated with self-injected adrenaline (epinephrine).

MAIN OUTCOME MEASURES

Change in HRQL and self-efficacy.

RESULTS

56 participants had reactions at food challenge, of whom 16 (29%) had anaphylaxis. Overall, there was an improvement in HRQL (mean 2.6 points (95% CI 0.3 to 4.8); p=0.030) and self-efficacy (mean 4.1 points (95% CI 2.4 to 5.9); p<0.0001), independent of whether anaphylaxis occurred. Parents also reported improved HRQL (mean 10.3 points (95% CI 5.9 to 14.7); p<0.0001). We found evidence of discordance between the improvement in HRQL and self-efficacy as reported by young people and that perceived by parents in their child.

CONCLUSIONS

Anaphylaxis at food challenge, followed by self-administration of injected adrenaline, was associated with an increase in HRQL and self-efficacy in young people with peanut allergy. We found no evidence that the occurrence of anaphylaxis had a detrimental effect. Young people should be encouraged to self-administer adrenaline using their autoinjector device to treat anaphylaxis at in-hospital challenge.

TRIAL REGISTRATION NUMBER

NCT02149719.

Biologics in food allergy: up-to-date

Introduction: In recent years, the advent of immunotherapy has remarkably improved the management of IgE-mediated food allergy. However, some barriers still exist. Therefore, the effort of researchers aims to investigate new perspectives in the field of non-allergen specific therapy, also based on the current knowledge of the pathogenesis of this disease.Areas covered: This review aims to focus on the role of biologics as a treatment option in patients with IgE-mediated food allergy. These agents are characterized by their ability to inactivate the Th2 pro-inflammatory pathways. Biologics can be used both alone and in association with immunotherapy. Monoclonal antibodies targeting IgE, the IL-4/IL-13 axis, IL-5, and alarmins have been proposed and investigated for treating food allergy.Expert opinion: The clinical efficacy and safety of biologics have been demonstrated in several preclinical studies and randomized controlled trials. Future studies are still required to address current unmet needs, including the identification of the optimal dose to be used by ensuring the effectiveness of therapy.

Psychosocial Aspects of Food Allergy: Resiliency, Challenges and Opportunities

Food allergy is a public health concern and has been found to be increasing in prevalence; however, psychosocial factors differentiate challenges related to management throughout the lifespan. Resilience has been found to improve quality of life in other chronic diseases, but little has been published regarding increasing resilience in food allergy. The psychosocial impacts of food allergy vary by age group and developmental stage. This article reviews developmental milestones within the context of food allergy in infancy, school-age children, adolescents, and adults. Recommendations for promoting resilience in patients with food allergy are provided.

Assessing daily food allergy self-management among adolescents using a 24-hour recall interview

BACKGROUND

Severe food allergic reactions can be life-threatening or fatal and are experienced by up to 40% of children with food allergies, with adolescents at greatest risk. There are no comprehensive measures to assess food allergy management behaviors that could prevent allergic reactions.

OBJECTIVE

To describe food allergy self-management behaviors as reported by adolescents on a 24-hour recall measure and identify related factors.

METHODS

Adolescents aged 10 to 14 years with immunoglobulin E-mediated food allergy completed the Food Allergy Management 24-Hour Recall as an interview. Participants answered questions on each food they ate on the previous day and food allergy self-management behaviors.

RESULTS

Participants were a diverse sample (28% White) of 101 adolescents (mean age = 11.80 years; 53% male sex). Most meals and snacks (76%) were observed by adults. Epinephrine autoinjectors (EAIs) were reportedly available for almost all meals and snacks (93%). Almost all foods had been eaten before (95%) and were verified as allergen free (92%). Furthermore, 35% of the time, past experience with the food was the only method used to verify safety. Child age, number of food allergies, or time since allergic reaction was not related to self-management behavior. EAI availability and ingredient verification were most common at home and in school; adult observation was least likely in the home.

CONCLUSION

Adolescents reported that EAIs were frequently available, but they relied on past experience with food to determine safety. Appropriate assessment of food safety should be a primary intervention target. The Food Allergy Management 24-Hour Recall may be a useful tool to assess and track food allergy self-management.

Novel diagnostic techniques and therapeutic strategies for IgE-mediated food allergy

Background: Immunoglobulin E (IgE) mediated food allergy is a potentially life-threatening condition and represents a heavy burden for patients and their families. Identification of the most suitable way for management of each patient has currently become the primary goal for physicians. Methods: This study reviewed the current literature related to IgE-mediated food allergy. Results: The use of innovative diagnostic tools, such as allergen-specific IgG4 determination, basophil activation test, and component-resolved diagnostics, is currently available to facilitate a proper diagnosis of food allergy. After several decades of "passive clinical management" of the disease, which was based only on avoidance of the allergenic food and the use of epinephrine in the event of anaphylaxis, there has been a switch to active treatment. The most recent evidence-practice guidelines strongly recommend the use of immunotherapy as an effective therapeutic option, particularly in cases of allergy to cow's milk, egg, or peanut. The use of omalizumab, in association with immunotherapy or alone, has been tested in several studies, and results on its effectiveness seemed to be encouraging. Other biologics, such as dupilumab, reslizumab, mepolizumab, and other anticytokines therapies, are being investigated. Another interesting future treatment strategy could be the use of DNA vaccines. Conclusion: In recent years, the management of IgE-mediated food allergy has greatly improved. Knowledge of pathogenetic mechanisms, understanding of the disease course, and the introduction of novel biomarkers led to more accurate diagnoses along with the active treatment of patients.

Food anaphylaxis in the United Kingdom: analysis of national data, 1998-2018

OBJECTIVE

To describe time trends for hospital admissions due to food anaphylaxis in the United Kingdom over the past 20 years.

DESIGN

Analysis of national data, 1998-2018.

SETTING

Data relating to hospital admissions for anaphylaxis and deaths, and prescription data for adrenaline autoinjector devices.

PARTICIPANTS

UK population as a whole and devolved nations (England, Scotland, Wales, and Northern Ireland).

MAIN OUTCOME MEASURES

Time trends, age, and sex distributions for hospital admissions for anaphylaxis due to food and non-food triggers, and how these admission rates compare with the case fatality rate (number of fatalities as a proportion of hospital admissions).

RESULTS

Between 1998 and 2018, 101 891 people were admitted to hospital for anaphylaxis. Of these admissions, 30 700 (30.1%) were coded as due to a food trigger. Food anaphylaxis admissions increased from 1.23 to 4.04 per 100 000 population per year (from 1998 to 2018), an annual increase of 5.7% (95% confidence interval 5.5% to 5.9%, P<0.001). The largest increase in hospital admissions was observed in children younger than 15 years, with an increase from 2.1 to 9.2 admissions per 100 000 population per year (an annual increase of 6.6%, 95% confidence interval 6.3% to 7.0%). For comparison, the annual increase was 5.9% (5.6% to 6.2%) in people aged 15-59 years and 2.1% (1.8% to 3.1%) in those aged 60 years and older. 152 deaths were identified where the fatal event was probably caused by food induced anaphylaxis. The case fatality rate decreased from 0.7% to 0.19% for confirmed fatal food anaphylaxis (rate ratio 0.931, 95% confidence interval 0.904 to 0.959, P<0.001) and to 0.30% for suspected fatal food anaphylaxis (0.970, 0.945 to 0.996, P=0.024). At least 46% (86 of 187, which also includes 35 deaths in 1992-98) of deaths were triggered by peanut or tree nut. Cow's milk was responsible for 17 of 66 (26%) deaths in school aged children. Over the same time period, prescriptions for adrenaline autoinjectors increased by 336% (estimated rate ratio 1.113, 95% confidence interval 1.112 to 1.113; an increase of 11% per year).

CONCLUSIONS

Hospital admissions for food induced anaphylaxis have increased from 1998 to 2018, however the case fatality rate has decreased. In school aged children, cow's milk is now the most common single cause of fatal anaphylaxis.

The effectiveness of interventions to improve self-management for adolescents and young adults with allergic conditions: A systematic review

BACKGROUND

This systematic review aimed to review the literature on interventions for improving self-management and well-being in adolescents and young adults (11-25 years) with asthma and allergic conditions.

METHODS

A systematic literature search was undertaken across eight databases. References were checked by two reviewers for inclusion. Study data were extracted, and their quality was assessed in duplicate. A narrative synthesis was undertaken.

RESULTS

A total of 30 papers reporting data from 27 studies were included. Interventions types were psychological (k = 9); e-health (k = 8); educational (k = 4); peer-led (k = 5); breathing re-training (k = 1). All interventions were for asthma. Psychological interventions resulted in significant improvements in the intervention group compared with the control group for self-esteem, quality of life, self-efficacy, coping strategies, mood and asthma symptoms. E-Health interventions reported significant improvements for inhaler technique, adherence and quality of life. General educational interventions demonstrated significantly improved quality of life, management of asthma symptoms, controller medication use, increased use of a written management plan and reduction in symptoms. The peer-led interventions included the Triple A (Adolescent Asthma Action) programme and a peer-led camp based on the Power Breathing Programme. Improvements were found for self-efficacy, school absenteeism and quality of life.

CONCLUSION

Although significant improvements were seen for all intervention types, many were small feasibility or pilot studies, few studies reported effect sizes and no studies for allergic conditions other than asthma met the inclusion criteria. Research using large longitudinal interventional designs across the range of allergic conditions is required to strengthen the evidence base.

Understanding the challenges faced by adolescents and young adults with allergic conditions: A systematic review

BACKGROUND

Adolescence represents a vulnerable time for individuals with asthma and allergic conditions. They suffer an unexpected degree of morbidity. This systematic review aimed to understand the challenges faced by adolescents and young adults with these conditions.

METHODS

A systematic literature search was undertaken across eight databases. References were checked by two reviewers for inclusion. Study data were extracted, and their quality was assessed in duplicate. A narrative meta-synthesis was undertaken.

RESULTS

A total of 108 papers describing 106 studies were retrieved, most focused on asthma. Five themes were identified across studies: (a) Health-related quality of life-impairment was associated with poor disease control, psychosocial issues, adolescent-onset allergic disease and female sex; (b) Psychological factors-asthma and food allergy were associated with anxiety and depression, atopic dermatitis was associated with suicidal ideation, and that parental emotional support may be protective; (c) Adherence-suboptimal adherence was associated with older age, barriers to medication usage, poor symptom perception and failure to take responsibility, and positive factors were routines, simpler treatment regimes, better knowledge and perceptions about medications; (d) Self-management-facilitated by education, knowledge and a positive attitude; and (e) Supportive relationships-families could modify barriers to adherence and foster positive views about self-management, adolescents suggested that their peers should be more involved in supporting them, and adolescents also wished to have support from nonjudgemental healthcare professionals.

CONCLUSIONS

We have some understanding of the challenges faced by adolescents with asthma, less so for other allergic conditions. This knowledge will be used to support guidelines for managing adolescents.

Management of Peanut Allergy

Peanut allergy is a growing public health concern in westernized countries. Peanut allergy is characterized as an often severe and lifelong allergy, which can have detrimental effects on quality of life and trigger anxiety. Although multiple therapeutic options are emerging, the focus of current management strategies is strict peanut avoidance and carriage of self-injectable epinephrine. The greatest risk of reacting to peanut comes from direct ingestion, whereas casual skin contact or airborne exposure is highly unlikely to provoke significant symptoms. Patients and families must be educated about how to best execute strict peanut avoidance through careful label reading as well as how to understand and address likely and unlikely risk with regard to peanut exposure in public, in particular when dining outside of the home and for children attending school or child care. This review discusses the risk of exposure in public such as at school or on an airplane and how such risk can be abated, situations and scenarios when dining out of the house that may pose more risks than others, the essentials of US and EU label reading laws with particular emphasis on precautionary labeling and the risk implied by such, quality of life and psychosocial issues that may affect the peanut allergic individual and family, and a discussion of how risk may differ and evolve based on the patient's age.

Effect of sleep deprivation and exercise on reaction threshold in adults with peanut allergy: A randomized controlled study

BACKGROUND

Peanut allergy causes severe and fatal reactions. Current food allergen labeling does not address these risks adequately against the burden of restricting food choice for allergic patients because of limited data on thresholds of reactivity and the influence of everyday factors.

OBJECTIVE

We estimated peanut threshold doses for a United Kingdom population with peanut allergy and examined the effect of sleep deprivation and exercise.

METHODS

In a crossover study, after blind challenge, participants with peanut allergy underwent 3 open peanut challenges in random order: with exercise after each dose, with sleep deprivation preceding challenge, and with no intervention. Primary outcome was the threshold dose triggering symptoms (in milligrams of protein). Primary analysis estimated the difference between the nonintervention challenge and each intervention in log threshold (as percentage change). Dose distributions were modeled, deriving eliciting doses in the population with peanut allergy.

RESULTS

Baseline challenges were performed in 126 participants, 100 were randomized, and 81 (mean age, 25 years) completed at least 1 further challenge. The mean threshold was 214 mg (SD, 330 mg) for nonintervention challenges, and this was reduced by 45% (95% CI, 21% to 61%; P = .001) and 45% (95% CI, 22% to 62%; P = .001) for exercise and sleep deprivation, respectively. Mean estimated eliciting doses for 1% of the population were 1.5 mg (95% CI, 0.8-2.5 mg) during nonintervention challenge (n = 81), 0.5 mg (95% CI, 0.2-0.8 mg) after sleep, and 0.3 mg (95% CI, 0.1-0.6 mg) after exercise.

CONCLUSION

Exercise and sleep deprivation each significantly reduce the threshold of reactivity in patients with peanut allergy, putting them at greater risk of a reaction. Adjusting reference doses using these data will improve allergen risk management and labeling to optimize protection of consumers with peanut allergy.

Carrying rates of epinephrine devices in children with food-induced anaphylaxis

Background

Carrying epinephrine can save lives in patients with anaphylaxis. The feature of epinephrine in prefilled syringe that commonly prescribed in Thailand may influence the willingness to carry. However, the rates of carrying prefilled syringe epinephrine are unknown in children with history of food-induced anaphylaxis.

Objective

To determine the rate of epinephrine carrying in children with history of food-induced anaphylaxis and factors influencing the decision to use the devices.

Methods

A cross-sectional study was conducted by performing the structured interview in the parent(s) who were the main caregiver of the children with history of food-induced anaphylaxis.

Results

The parents of 99 children (male, 50.5%) were interviewed. The median age of the child was 11 years old (range, 9 months to 18 years). Rate of carrying epinephrine was 84.7% (always 57.6%, some occasions 27.2%). The most common reason for not carrying was the thoughts that the children could avoid the food allergens. The first-aid facility at school was available in 48.3%. Rate of carrying epinephrine tended to be lesser in children attend the schools without first aid facility (p = 0.053). Forty-one patients had relapsing episodes, 34 (82.9%) had epinephrine carried, and 20 (58.8%) injected the epinephrine. The most common reason for not using epinephrine despite carrying was that they were afraid of getting injection (28.5%).

Conclusion

Most children with history of food-induced anaphylaxis carried epinephrine, but only half used it at the episodes. Interventions to promote epinephrine-carrying and injection training are needed in our setting.

An economic evaluation of immediate vs non-immediate activation of emergency medical services after epinephrine use for peanut-induced anaphylaxis

BACKGROUND

Layperson food allergy management plans commonly stipulate that if epinephrine is used to immediately call 911 and seek care in the nearest medical facility for observation.

OBJECTIVE

To evaluate the cost-effectiveness of this strategy, vs a watchful waiting approach before activating emergency medical services (EMS).

METHODS

We performed a cost-effectiveness analysis using Markov modeling simulated over a 20-year horizon comparing activating EMS immediately after epinephrine use for allergic reactions to peanut vs a "wait and see" approach in which EMS was only activated if symptoms of the reaction did not promptly resolve after treatment. The base-case model assumed a 10-fold increased fatality risk with delayed EMS activation.

RESULTS

The fatality risk associated with early EMS use was minimal, with a per-patient fatality rate over a 20-year horizon of 1.2 × 10^-6, vs 1.9 × 10^-6 for a wait and see approach. The incremental cost per life-year saved was $142,943,447 for early EMS vs wait and see, with the cost per death prevented reaching $1,349,335,651 as the simulation concluded. Cost of early EMS activation rose to $321,625,534 per life-year saved ($3,035,454,848 per death prevented) if a 5-fold increase in fatality risk was assumed, and was $12,997,173 per life-year saved ($122,689,936 per death prevented) if a 100-fold increase in fatality risk was assumed.

CONCLUSION

Medical observation of a treated and promptly resolved peanut allergic reaction has minimal benefit and excessive costs. Immediately activating EMS after using epinephrine for a peanut allergic reaction in this context is not cost-effective.

Epinephrine auto-injector carriage and use practices among US children, adolescents, and adults

BACKGROUND

Previous studies have suggested that epinephrine auto-injector (EAI) carriage and emergency use practices could be suboptimal for patients prescribed these devices for anaphylaxis management.

OBJECTIVE

To characterize EAI prescription fill rates, carriage, and use practices and associated factors and perceived barriers to recommended anaphylaxis management behaviors in US children, adolescents, and adults.

METHODS

Survey data were collected for adults (n = 450) and parents of children (n = 255) and adolescents (n = 212) who had been prescribed an EAI. Of eligible participants, survey completion rates were higher than 90%. A multiple-group structural equation model was fit to test adjusted associations.

RESULTS

Most patients (89%) filled their EAI prescriptions; however, of those who did not, the most commonly cited barriers to filling prescriptions were no history of reactions (26%) and EAI cost (25%). Forty-four percent carried at least 1 EAI "all the time" and 24% carried multiple EAIs. Sixty-five percent of respondents reported a personal history of EAI use. Most adults (52%) reported that an EAI was not used, although it would have been beneficial during their most severe allergic reaction. The most frequently given reasons for not using an EAI among respondents owning one were that an EAI was not available (45%) followed by their allergy was undiagnosed at the time (35%). To improve clinical anaphylaxis management, 61% of patients desired more effective patient education and 47% desired more time dedicated to patient education during the physician visit.

CONCLUSION

These data suggest that current anaphylaxis management practices are suboptimal but could be facilitated through lowering EAI-related out-of-pocket costs and improving patient education efforts.

Current trends in food allergy-induced anaphylaxis management at school

OBJECTIVE

To review the evidence and current policies regarding the use of epinephrine at schools and child care centers DATA SOURCES AND STUDY SELECTIONS: A narrative review was performed based on the result of conference proceedings of a group of interprofessional stakeholders who attended the USAnaphylaxis Summit 2017 presented by Allergy & Asthma Network.

RESULTS

Anaphylaxis is a well-recognized medical emergency that requires prompt treatment with intramuscular epinephrine. Anaphylaxis can be associated with poor quality of life. There is renewed recent focus on anaphylaxis management in schools. This interest has been spurred by an increase in the number of children with food allergy who are attending school, data that support up to 25% of first-time anaphylactic events occurring on school grounds, and a well-publicized fatality that helped to initiate a movement for stock, undesignated, non-student-specific epinephrine. Stock epinephrine is now available in 49 states, with an increasing number of states instituting mandatory reporting for use of such devices. Nursing efforts are paramount to support and implement stock epinephrine programs. Many states do not have clarity on delegation of authority for who can administer stock epinephrine, and there is evidence of variability in storage of stock devices. Few states have outcomes data that support successful implementation of stock epinephrine programs.

CONCLUSION

Additional data are needed to demonstrate successful implementations of stock epinephrine programs and their outcomes. Such programs should include support for school nursing and clearer delineation of authority for medication administration as well as standards for where and how devices are stored.

Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management

This review provides general information to serve as a primer for those embarking on understanding food allergy and also details advances and updates in epidemiology, pathogenesis, diagnosis, and treatment that have occurred over the 4 years since our last comprehensive review. Although firm prevalence data are lacking, there is a strong impression that food allergy has increased, and rates as high as approximately 10% have been documented. Genetic, epigenetic, and environmental risk factors are being elucidated increasingly, creating potential for improved prevention and treatment strategies targeted to those at risk. Insights on pathophysiology reveal a complex interplay of the epithelial barrier, mucosal and systemic immune response, route of exposure, and microbiome among other influences resulting in allergy or tolerance. The diagnosis of food allergy is largely reliant on medical history, tests for sensitization, and oral food challenges, but emerging use of component-resolved diagnostics is improving diagnostic accuracy. Additional novel diagnostics, such as basophil activation tests, determination of epitope binding, DNA methylation signatures, and bioinformatics approaches, will further change the landscape. A number of prevention strategies are under investigation, but early introduction of peanut has been advised as a public health measure based on existing data. Management remains largely based on allergen avoidance, but a panoply of promising treatment strategies are in phase 2 and 3 studies, providing immense hope that better treatment will be imminently and widely available, whereas numerous additional promising treatments are in the preclinical and clinical pipeline.

An analysis of anaphylaxis cases at a single pediatric emergency department during a 1-year period

BACKGROUND

Case series of anaphylaxis can vary regarding causes, treatments, and follow-up of patients. Unfortunately, case series that are specific to the pediatric population are few.

OBJECTIVE

To describe confirmed cases of pediatric anaphylaxis in patients presenting to a pediatric hospital emergency department (ED).

METHODS

We identified all ED visits with the International Classification of Diseases, Ninth Revision (ICD-9) codes 995.XX (allergic reactions) and 989.5 (sting or venom reaction) for 1 calendar year (January 1, 2014, through December 31, 2014). Cases were reviewed by an allergist and an emergency medicine physician to identify true anaphylaxis cases using National Institute of Health/National Institute of Allergy and Infectious Diseases criteria. Any questionable or debatable cases were evaluated and adjudicated by a second allergist.

RESULTS

We identified 927 unique ED visits. Of these visits, 40 were determined to definitively meet anaphylaxis criteria. Median age of the patients was 6.5 years. A total of 70% of patients were male, and 80% were African American. Causes included foods (65%), venom or insect sting (12.5%), and medications (5%), and 17.5% were idiopathic. All patients had multiorgan involvement, with 98% having skin involvement, 78% having lower respiratory tract symptoms, and 40% having gastrointestinal symptoms. There were no deaths. Only 33% of patients received epinephrine at some point in their care. Only 12 patients were referred to an allergist, and only 4 of these were actually seen by an allergist.

CONCLUSION

At our center, foods are the most common trigger for pediatric anaphylaxis. Patients continue to be undertreated, and referral to an allergist from the ED is rare.

Green, Yellow, and Red risk perception in everyday life - a communication tool

BACKGROUND

Adolescents have the highest risk for food allergy-related fatalities. Our main aim was to investigate the level of risk in everyday social situations as perceived by adolescents/young adults with peanut allergy, their families, and their friends.

METHODS

The web-based 'Colours Of Risks' (COR) questionnaire was completed by 70 patients (aged 12-23 years), 103 mothers and fathers, 31 siblings (aged 12-26 years), and 42 friends (aged 12-24 years). COR deals with six main contexts (home, school/university, work, visiting/social activities, special occasions/parties, and vacations), each with 1-12 items. Response categories are green (I feel safe), yellow (I feel uncertain), or red (I feel everything is risky).

RESULTS

There was a high level of agreement between participants in defining situations as safe, uncertain, or risky, but female patients and mothers rated fewer situations as safe compared to male patients and fathers. Being with close friends and family, and attending planned parties without alcohol were perceived as situations of low risk. While 94% of patients took an epinephrine auto-injector (EAI) into risky situations, only 65% took it into safe situations. In contrast to the close family, 31% of the friends did not know the patient had an EAI, and fewer knew how to administer the EAI.

CONCLUSION

Young adults with peanut allergy face challenges when moving from the safe home with ready assistance if needed, to independence with unpredictable surroundings and less certain help. Perceived 'safe' situations may in fact be the riskiest, as patients often do not take the EAI with them.

Health-related quality of life in food allergy : Impact, correlates, and predictors

In food allergy, since the likelihood of a fatal reaction is low but fear, uncertainty, and lifestyle restrictions high, health-related quality of life (HRQL) may be a more meaningful measure of outcome in research and practice. HRQL is influenced by physiological, psychological, and environmental variables and can be best understood by considering the interactions of factors that cut across multiple levels. In this article we review both quantitative and qualitative research findings to provide an in-depth picture of the impact of food allergy on the concerns and the everyday lives of children, teens, adults, and parents. Research on factors that are related to, and impact on, HRQL is also discussed. We conclude by exploring some methodological and design issues in relation to the measurement of HRQL in food allergy and offer some recommendations for research and practice.

Quality of life in childhood, adolescence and adult food allergy: Patient and parent perspectives

BACKGROUND

Studies of children with food allergy typically only include the mother and have not investigated the relationship between the amount of allergen needed to elicit a clinical reaction (threshold) and health-related quality of life (HRQL). Our aims were (i) to compare self-reported and parent-reported HRQL in different age groups, (ii) to evaluate the impact of severity of allergic reaction and threshold on HRQL, and (iii) to investigate factors associated with patient-reported and parent-reported HRQL.

METHODS

Age-appropriate Food Allergy Quality of Life Questionnaires (FAQLQ) were completed by 73 children, 49 adolescents and 29 adults with peanut, hazelnut or egg allergy. Parents (197 mothers, 120 fathers) assessed their child's HRQL using the FAQLQ-Parent form. Clinical data and threshold values were obtained from a hospital database. Significant factors for HRQL were investigated using univariate and multivariate regression.

RESULTS

Female patients reported greater impact of food allergy on HRQL than males did. Egg and hazelnut thresholds did not affect HRQL, but lower peanut threshold was associated with worse HRQL. Both parents scored their child's HRQL better than the child's own assessment, but whereas mother-reported HRQL was significantly affected by limitations in the child's social life, father-reported HRQL was affected by limitations in the family's social life. Severity of allergic reaction did not contribute significantly to HRQL.

CONCLUSION

The risk of accidental allergen ingestion and limitations in social life are associated with worse HRQL. Fathers provide a unique perspective and should have a greater opportunity to contribute to food allergy research.

Clinical Management of Psychosocial Concerns Related to Food Allergy

Current estimates indicate that 4% to 8% of children in the United States are diagnosed with food allergy, and more than 40% of US children with food allergy experience severe allergic reactions. Families trying to avoid foods that may trigger an allergic reaction and ensure adequate treatment of allergic reactions that do occur face numerous challenges. The rise in the number of children diagnosed with food allergies underscores the importance of food allergy-related interventions to address elevated psychosocial concerns, such as parenting stress, anxiety, and worries about bullying. This review provides an overview of common psychosocial concerns among children with food allergy and their families across the developmental spectrum, and offers guidance to medical providers regarding the identification and treatment of food allergy-related psychosocial challenges.

Can we identify patients at risk of life-threatening allergic reactions to food?

Anaphylaxis has been defined as a 'severe, life-threatening generalized or systemic hypersensitivity reaction'. However, data indicate that the vast majority of food-triggered anaphylactic reactions are not life-threatening. Nonetheless, severe life-threatening reactions do occur and are unpredictable. We discuss the concepts surrounding perceptions of severe, life-threatening allergic reactions to food by different stakeholders, with particular reference to the inclusion of clinical severity as a factor in allergy and allergen risk management. We review the evidence regarding factors that might be used to identify those at most risk of severe allergic reactions to food, and the consequences of misinformation in this regard. For example, a significant proportion of food-allergic children also have asthma, yet almost none will experience a fatal food-allergic reaction; asthma is not, in itself, a strong predictor for fatal anaphylaxis. The relationship between dose of allergen exposure and symptom severity is unclear. While dose appears to be a risk factor in at least a subgroup of patients, studies report that individuals with prior anaphylaxis do not have a lower eliciting dose than those reporting previous mild reactions. It is therefore important to consider severity and sensitivity as separate factors, as a highly sensitive individual will not necessarily experience severe symptoms during an allergic reaction. We identify the knowledge gaps that need to be addressed to improve our ability to better identify those most at risk of severe food-induced allergic reactions.

Assessing the efficacy of oral immunotherapy for the desensitisation of peanut allergy in children (STOP II): a phase 2 randomised controlled trial: a critical appraisal

AIM

Anagnostou et al. investigated the efficacy of oral immunotherapy (OIT) in treating peanut allergy.

SETTING AND DESIGN

An unmasked randomized controlled crossover trial of 7-16 year olds with double-blind placebo-controlled food challenge (DBPCFC)-proven peanut allergy. The first phase compared an active group undergoing 26 weeks of OIT with daily ingestion of peanut protein vs. a control group avoiding peanuts. Both groups underwent DBPCFC to peanut at 26 weeks. In the second phase the control group was then offered OIT for 26 weeks.

STUDY EXPOSURE

Participants undergoing OIT attended hospital every 2 weeks to initiate and increase their daily peanut protein dose through nine stages (2, 5, 12·5, 25, 50, 100, 200, 400 and 800 mg - about five peanuts), subsequently maintaining consumption at the highest tolerated dose. Primary outcome The primary outcome compared the proportions of active- and control-group participants able to ingest a cumulative dose of 1400 mg of peanut protein (about 10 peanuts) during their DBPCFC at the end of the first phase without reacting. Secondary outcomes Further outcomes included the proportion of participants who tolerated the top maintenance dosage of 800 mg protein up to 26 weeks; the proportion of the control group who were desensitized or tolerated daily ingestion of 800 mg protein in the second phase; threshold changes in no observed adverse effect level after OIT (NOAEL: defined as the highest dose of peanut protein tolerated in milligrams of protein during challenge or immunotherapy); change in quality of life; number and type of adverse events; and immunological parameters (basophil reactivity, peanut-specific IgE, total IgE and skin-prick test).

RESULTS

Primary outcome Twenty-four of 39 (62%) of the active group were able to tolerate the 1400 mg of peanut protein during their DBPCFC after 26 weeks of OIT, compared with none of the 46 control participants (P < 0·001). Secondary outcomes Twenty-five of 46 (54%) of the control group had a negative 1400-mg peanut protein challenge at the end of phase 2. Combining the two groups, 49 of 85 children (58%) were desensitized. Thirty-three of 39 (85%) active participants in phase one and 42 of 46 (91%) control participants in phase two tolerated 800 mg of OIT daily - a combined result of 75 of 85 (88%) trial participants. The median absolute change in NOAEL between baseline and 26 weeks was 1345 mg (P = 0·002), or a 25·5-fold increase (P < 0·001) for the active group. Both the active and control groups demonstrated a significant improvement (decrease) in Food Allergy Quality of Life scores after OIT in the under-13-year-old participants: -1·61 and -1·41, respectively (both P < 0·001). Mild side-effects predominated, with 54 (57%) reporting abdominal pain and 31 (33%) reporting vomiting. However, 21 (22%) also reported wheezing and one (1%) laryngeal oedema. One participant received adrenaline by self-administration on two occasions for wheezing.

CONCLUSIONS

Anagnostou et al. concluded that OIT successfully induced desensitization in challenge-proven peanut-allergic children and resulted in a clinically and socially meaningful increase in tolerated peanut protein. Quality of life improved after intervention and there was a good safety profile.

Anaphylaxis in adolescents: a potential tripartite management framework

PURPOSE OF REVIEW

The incidence of anaphylaxis is increasing across all ages, but the risk of morbidity and fatality is disproportionately high in adolescents. This may, at least in part, be a consequence of a constellation of potentially modifiable psychosocial factors that tend to manifest during adolescence. This study highlights the shortcomings in and the barriers to effective management of anaphylaxis in adolescents, and proposes an integrated tripartite framework that may help promote successful management.

RECENT FINDINGS

Existing mainstay anaphylaxis self-management approaches - comprising careful avoidance of triggers, recognition of early features indicative of anaphylaxis and prompt self-administration of intra-muscular adrenaline (epinephrine) - often fail in adolescents. Key barriers to successful management centre on the impact of the psychosocial environment during adolescents' developmental transition. As a result, risk-taking, poor judgement of actions during reactions and non-compliance to management instructions are common.

SUMMARY

To be successful, anaphylaxis management strategies require more multidimensional approaches among adolescents. We propose a tripartite management framework that emphasizes integration of the following components: better understanding of adolescence; incorporation of the constituents of adolescents' social networks; and adolescent-tailored healthcare perspectives. This theoretical framework now requires translation into an intervention, feasibility and pilot testing, and formal evaluation through randomized controlled trials.

Improving the safety of oral immunotherapy for food allergy

Food allergy is a major public health problem in children, impacting upon the affected individual, their families and others charged with their care, for example educational establishments, and the food industry. In contrast to most other paediatric diseases, there is no established cure: current management is based upon dietary avoidance and the provision of rescue medication in the event of accidental reactions, which are common. This strategy has significant limitations and impacts adversely on health-related quality of life. In the last decade, research into disease-modifying treatments for food allergy has emerged, predominantly for peanut, egg and cow's milk. Most studies have used the oral route (oral immunotherapy, OIT), in which increasing amounts of allergen are given over weeks-months. OIT has proven effective to induce immune modulation and 'desensitization' - that is, an increase in the amount of food allergen that can be consumed, so long as regular (typically daily) doses are continued. However, its ability to induce permanent tolerance once ongoing exposure has stopped seems limited. Additionally, the short- and long-term safety of OIT is often poorly reported, raising concerns about its implementation in routine practice. Most patients experience allergic reactions and, although generally mild, severe reactions have occurred. Long-term adherence is unclear, which rises concerns given the low rates of long-term tolerance induction. Current research focuses on improving current limitations, especially safety. Strategies include alternative routes (sublingual, epicutaneous), modified hypoallergenic products and adjuvants (anti-IgE, pre-/probiotics). Biomarkers of safe/successful OIT are also under investigation.

The compliance and burden of treatment with the epinephrine auto-injector in food-allergic adolescents

BACKGROUND

Food-allergic patients at high risk of potential fatal anaphylaxis should carry an epinephrine auto-injector (EAI) at all times. This treatment may be perceived as burdensome and this may affect compliance and health-related quality of life (HRQL). The aims of the study were (1) to determine the burden of treatment (BoT) of an EAI, (2) to examine the relationship between this burden and compliance, and (3) to analyze which factors contribute to the BoT of the EAI as perceived by food-allergic adolescents and their parents.

METHODS

Dutch food-allergic adolescents prescribed an EAI, and their parents completed a questionnaire package (n = 55). Relationships between BoT and HRQL, illness severity and perception, and anxiety measures were investigated.

RESULTS

Food-allergic adolescents and their parents were (extremely) positive about the EAI (54.5%; 72.7%, respectively) (=low BoT). The BoT measure showed a significantly greater burden in food-allergic adolescents prescribed an EAI who reported not carrying the EAI at all times than adolescents who reported they did. The BoT scores of both adolescents and their parents were not associated with HRQL, illness severity and perception, or trait anxiety.

CONCLUSIONS

The majority of food-allergic adolescents and their parents were positive about the EAI (=low BoT). However, the BoT was significantly associated with self-reported compliance with carrying the EAI. The BoT was higher in food-allergic adolescents prescribed an EAI who reported not carrying the EAI at all times. The BoT measure seems to be a useful tool to study compliance with carrying an EAI. The BoT of an EAI is not associated with HRQL. The BoT measures a distinct concept related to compliance behavior.

Food Allergy in childhood: phenotypes, prevention and treatment

The prevalence of food allergy in childhood increased in the last decades, especially in Westernized countries where this phenomenon has been indicated as a second wave of the allergic epidemic. In parallel, scientific interest also increased with the effort to explain the reasons of this sudden rise and to identify potential protective and risk factors. A great attention has been focused on early exposures to allergenic foods, as well as on other nutritional factors or supplements that may influence the immune system in a positive direction. Both interventions on maternal diet before birth or during breastfeeding and then directly on infant nutrition have been investigated. Furthermore, the natural history of food allergy also seems to be changing over time; IgE-mediated cow's milk allergy and egg allergy seem to be more frequently a persistent rather than a transient disease in childhood, as described in the last years. Food avoidance and the emergency drugs in case of an adverse event, such as epinephrine self-injector, are currently the first-line treatment in patients with food allergies, with a resulting impairment in the quality of life and social behaviour. During the last decade, oral immunotherapy emerged as an optional treatment with remarkable results, offering a novel perspective in the treatment for and management of food allergy.

Epinephrine auto-injector prescriptions to food-allergic patients in primary care in The Netherlands

Background

The knowledge of general practitioner(s) (GPs) regarding food allergy and anaphylaxis and practices in the prescription of epinephrine auto-injector(s) (EAIs) among GPs has previously only been studied using questionnaires and hypothetical cases. Therefore, there are currently no data as to whether or not GPs prescribe EAIs to high risk food-allergic patients presenting to primary care practices. The aim of this study was therefore to describe and evaluate practice in EAI prescription by GPs to food-allergic patients in The Netherlands.

Methods

Patients aged 12–23 years who consulted their GP for allergic symptoms were identified in a primary care database. Patients were classified as probably or unlikely to be food-allergic. A risk factor assessment was done to identify probably food-allergic patients at high risk for anaphylaxis to assess the need for an EAI.

Results

One hundred forty-eight out of 1015 patients consulted their GP for allergic symptoms due to food. Eighty patients were excluded from analysis because of incomplete records. Thirty-four patients were classified as probably food-allergic. Twenty-seven of them were considered high risk patients and candidates for an EAI. Importantly, only 10 of them had actually been prescribed an EAI by their GP.

Conclusions

This study shows that high risk food-allergic patients that visit their GPs are often not prescribed an EAI. Thus, previously identified low rates of EAI ownership may be partly due to GPs not prescribing this medication to patients for whom it would be appropriate to do so. These data suggest that there is a need for improvement of the quality of care for high risk food-allergic patients in primary care.

A behavioral economics intervention to encourage epinephrine-carrying among food-allergic adults: a randomized controlled trial

BACKGROUND

Adolescents and young adults with food allergies are at increased risk of adverse events, including death from anaphylaxis. Epinephrine is the cornerstone of emergency response, yet few individuals with serious food allergies consistently carry their emergency medication. Behavioral economics offers promising, previously untapped opportunities for behavior change in this arena.

OBJECTIVE

To test the effectiveness of modest financial incentives in promoting the carrying of epinephrine and to evaluate the acceptability of text messaging for delivering reminders and key health messages to young adults with food allergies.

METHODS

A mixed-methods randomized controlled trial in young adults with food allergies investigated the carrying of epinephrine auto-injectors using financial incentives plus text message reminders vs text message reminders alone. Epinephrine carriage was assessed 10 times during the 49-day intervention using rapid-reply cell phone photographs plus daily code words.

RESULTS

The intervention (financial incentive) group had their epinephrine auto-injectors at 54% of check-ins vs 27% of check-ins in the control (text-only) group (P = .023). Participants in the 2 groups consistently reported favorable impressions of text messaging as a desirable, unobtrusive way to receive information and support for food allergy management.

CONCLUSION

Although the intervention and control groups reported favorable impressions of text message-based reminder systems, the intervention group performed significantly better than the control group on a photograph-based measurement of epinephrine carriage. There remained ample room for improvement in the 2 groups given the goal of consistent, uninterrupted epinephrine carriage by people with potentially life-threatening food allergies.

TRIAL REGISTRATION

https://clinicaltrials.gov; NCT02354729.

Management and treatment of anaphylaxis in children: still too low the rate of prescription and administration of intramuscular epinephrine

Despite it being well known that anaphylaxis is a severe life-threatening reaction requiring prompt management and treatment, this entity is still under-recognized and not correctly managed, above all in children. The aim of this study was to analyze the most frequent features of anaphylaxis in a pediatric population (n=65 patients) and to identify factors predicting more severe reactions. Among the 70 recorded episodes, food was the main culprit of anaphylaxis, and patients with a positive history for allergic asthma had more severe episodes (P=0.008). A self-injectable adrenaline was used only in 2 of the 70 episodes and none of the 50 episodes managed in the Emergency Department was treated with intramuscular adrenaline. Only 10/65 patients (15&#x0025;) had a prescription for an auto-injector prior to the first episode of anaphylaxis. The retrospective analysis of the risk factors potentially requiring an epinephrine auto-injector prescription before the first anaphylactic episode, showed that of the 55 patients without prescription, at least 10 (18&#x0025;) should have been provided with a device, according to the most recent guidelines. In conclusion, notwithstanding intramuscular adrenaline being the first-line treatment of anaphylaxis, many episodes are still undertreated and the risk of anaphylaxis is still under-estimated. More efforts should be made to promote the correct management of anaphylaxis among both healthcare-providers and patients.

Diagnosis and treatment of pediatric food allergy: an update

The prevalence of pediatric food allergy and anaphylaxis has increased in the last decades, especially in westernized countries where this emerging phenomenon was marked as a "second wave" of the allergic epidemic. Over recent years great advances have been achieved in the field of in vitro allergy testing and component-resolved diagnosis has increasingly entered clinical practice. Testing for allergen components can contribute to a more precise diagnosis by discriminating primary from cross-reactive sensitizations and assessing the risk of severe allergic reactions.The basic concept of the management of food allergy in children is also changing. Avoidance of the offending food is still the mainstay for disease management, especially in primary health care settings, but it severely affects the patients' quality of life without reducing the risk of accidental allergic reactions. There is a growing body of evidence to show that specific oral tolerance induction can represent a promising treatment option for food allergic patients. In parallel, education of food allergic patients and their caregivers as well as physicians about anaphylaxis and its treatment is becoming recognized a fundamental need. International guidelines have recently integrated these new evidences and their broad application all over Europe represents the new challenge for food allergy specialists.

Quality of life in the setting of anaphylaxis and food allergy

The diagnosis of a food allergy generally has a considerable impact on patients. Not does it result in dietary restrictions, it is often also associated with a constant threat scenario, given the risk of sudden allergic reactions, including life-threatening anaphylaxis. It is essential for patients to receive training on how to deal with emergency situations and make the correct decision regarding the use of emergency medication. Severe allergic reactions occur only rarely if patients are well informed. However, the fear of allergic reactions results in a significant impairment in quality of life (QoL).

In recent years, numerous studies have been carried out on QoL in food-allergy and anaphylaxis patients. These studies provide insight into patient behaviour in everyday life. More importantly, by means of targeted and specific counselling, they also make it possible to reduce adverse effects on QoL and improve avoidance behaviour and compliance in terms of the requisite emergency measures.

The present article summarizes the available data and formulates recommendations aimed at improving the care of food-allergy patients in terms of QoL and compliance.

Anaphylaxis treatment: current barriers to adrenaline auto-injector use

Anaphylaxis is a life-threatening condition that is increasing in prevalence in the developed world. There is universal expert agreement that rapid intramuscular injection of adrenaline is life-saving and constitutes the first-line treatment of anaphylaxis. The unpredictable nature of anaphylaxis and its rapid progression makes necessary the availability of a portable emergency treatment suitable for self-administration. Thus, anaphylaxis treatment guidelines recommend that at-risk patients are provided with adrenaline auto-injectors (AAIs). Despite these clear recommendations, current emergency treatment of anaphylaxis continues to be inadequate in many cases. The aim of this review is to highlight the barriers that exist to the use and availability of AAIs and that prevent proper management of anaphylaxis. In addition, we review the characteristics of all AAIs that are presently available in Europe and the USA and discuss the need for regulatory requirements to establish the performance characteristics of these devices.