Impact of Reaction Setting on the Management, Severity, and Outcome of Pediatric Food-Induced Anaphylaxis: A Cross-Sectional Study

The authors sought to investigate the impact of reaction location on the management, severity, and outcome of pediatric food-induced anaphylaxis (FIA) in Canada.

Pediatric patients presenting to a Canadian emergency department (ED) with symptoms fulfilling the criteria for anaphylaxis and their caregivers were invited by their treating ED physician to participate in the Cross-Canada Anaphylaxis Registry. Participants included 3604 children from 11 EDs, representing 5 provinces. The median age was 5 years, and 60.2% of patients were male.

In this cross-sectional study, data were obtained from a standardized questionnaire including demographics, comorbidities, the trigger for anaphylaxis, presenting symptoms, location of reaction, prehospital and in-hospital management, and the outcome. Cases were also retrospectively recruited by record review using a standardized data extraction form and a previously validated algorithm. Most cases (61.3%) were retrospectively recruited. Anaphylaxis was defined according to the National Institute of Allergy and Infectious Diseases and Food Allergy and Anaphylaxis Network definition as a reaction involving at least 2 systems and/or hypotension.

Among cases of FAI where a known location could be determined from the questionnaire or medical record (85%), most occurred at home (68.1%). Less frequently reported settings were school or daycare (12.8%), other locations (11.4%), restaurants (7.4%), and in the workplace (0.3%). In restaurants, the most common FAI trigger was an unknown trigger (34.4%), whereas peanut was the most common trigger at home (19.5%) and at school or daycare (18.6%). An epinephrine autoinjector (EAI) was administered during prehospital care in 66.7% of reactions that occurred at school or daycare, 50% at work, 44.5% in restaurants, 40.2% in other locations, and 36.7% of reactions at home. In the ED, epinephrine administration was most frequent in reactions that occurred at work, in restaurants, and in other settings (50% to 60%) and least common when FIA occurred at school or daycare (33.6%). The setting where FIA occurred was not associated with reaction severity or hospitalization. Patients with known food allergies were more likely to have reactions at school or daycare and less likely to have reactions at home.

Prehospital EAI use was higher at school or daycare than in other settings. Interventions including education and policies regarding training and maintenance of EAIs may improve anaphylaxis recognition and treatment.

The authors note that the provinces of Ontario and Alberta have introduced legislation to increase anaphylaxis training and awareness in schools, but there is variation in implementation of training. There is known heterogeneity of requirements in the United States regarding undesignated EAIs in schools. The current study supports the need for further research on FAI training and awareness. Furthermore, the current study suggests the need for additional educational interventions and programming for parents and caregivers to promote and enable EAI use in nonschool or daycare settings.