Epinephrine appeared underused in the management of children with seafood-induced anaphylaxis before they reached the hospital, according to a study published in Annals of Allergy, Asthma & Immunology.

Daniel Sehayek, an MD candidate at Université Laval in Québec, and colleagues reviewed the cases of 146 children aged 18 years and younger who presented with seafood-induced cases of suspected anaphylaxis at six emergency departments recruited through the Cross-Canada Anaphylaxis Registry between 2011 and 2020.

Overall, 75 of the children (51.4%; boys, n = 40; median age, 4 years; interquartile range [IQR], 2.4-8.86) experienced fish-induced anaphylaxis, primarily due to salmon in 16 cases (21.3%), and 71 (48.6%; boys, n = 39; median age, 8.2 years; IQR, 3.65-13.6) had shellfish-induced anaphylaxis, primarily due to shrimp in 50 cases (70.4%).

Most cases of fish-induced and shellfish-induced anaphylaxis were classified as moderate (61.3%; 74.6%), with mild (32%; 21.1%) and severe (6.7%; 4.23%) cases also tallied.

Symptoms in these cases were mucocutaneous (fish, 94.7%; shellfish, 97.2%), respiratory (54.7%; 62%) gastrointestinal (45.3%; 49.3%) and cardiovascular (1.33%; 2.8%).

Twenty-seven of the children reacting to fish (36%) had a known fish allergy, and 16 children reacting to shellfish (22.5%) had a known shellfish allergy.

Patients with comorbid asthma were more likely to experience respiratory symptoms with fish-induced reactions (adjusted OR = 1.18; 95% CI, 1.02-1.36).

Once reactions began, 34.7% of those with fish-induced anaphylaxis received prehospital epinephrine, 40% received in-hospital epinephrine and 30.7% received no epinephrine.

Of the patients with shellfish-induced anaphylaxis, 16.9% received prehospital epinephrine, 57.7% received in-hospital epinephrine and 26.8% received no epinephrine.

Thirteen patients with a known fish allergy (48.1%) and five children with a known shellfish allergy (31.3%) used an epinephrine autoinjector before arriving at the hospital.

One patient with a fish-induced reaction (1.3%) and one patient with a shellfish-induced reaction (1.4%) were admitted to a hospital ward, and one patient with a shellfish-induced reaction (1.4%) was admitted to the ICU.

Patients with a shellfish allergy history were less likely to experience reactions at home (aOR = 0.79; 95% CI, 0.65-0.97), whereas patients with a fish allergy history were more likely to have comorbid asthma (aOR = 1.64; 95% CI, 1.15-2.36).

The researchers also found an association between use of epinephrine and known asthma among patients with a known fish allergy (aOR = 1.39; 95% CI, 1.05-1.84) and patients with a known shellfish allergy (aOR = 1.25; 95% CI, 1.02-1.54).

According to the researchers, the underuse of epinephrine autoinjectors in prehospital settings highlights the need among patients, parents and prehospital personnel for educational programs to increase their use in all anaphylaxis cases.

PERSPECTIVE

 

Andrea Pappalardo, MD, FAAAAI

Unfortunately, I do not find these results surprising, but they are significant. This study has shown that there is an underuse of prehospital and hospital epinephrine for moderate to severe systemic reactions to fish and shellfish in a large Canadian database. This is consistent with U.S. data.

With the recently updated anaphylaxis practice parameters, it is imperative that epinephrine be the go-to drug to treat anaphylaxis in all children and adults regardless of the setting. It is also scary to see that in fish-allergic patients, 12% required two or more injections, outlining the severity of reactions and that some patients experienced potentially near-fatal events.

We as a medical system need to be more comfortable prescribing, utilizing, training and educating regarding epinephrine use in our communities and within our practice. Epinephrine autoinjectors should be available in every first aid/emergency kit, and providers, family members, patients and community members should be able to use them instinctively in schools and other community settings.

To improve care, doctors need to educate as many people as possible — especially patients and their families — that epinephrine is the only lifesaving go-to drug in anaphylaxis. Antihistamines and steroids are no longer recommended, and anaphylaxis should be treated with epinephrine autoinjectors as first-line treatment and as rapidly as possible.

Within the community, the next steps in research should aim to understand the facilitators and barriers of epinephrine use within community settings and how we can campaign for the use of epinephrine more instinctively in a variety of community settings.

Within the medical system, we need to actively educate regarding the new anaphylaxis practice parameters and the risks associated with the delay of epinephrine use in a variety of inpatient, emergency and outpatient settings.

Andrea Pappalardo, MD, FAAAAI

Assistant professor of medicine and pediatrics, University of Illinois at Chicago

Medical director, Coordinated Healthcare for Complex Kids

Medical director, Mobile Care Chicago Asthma Van