Table 1 Epinephrine self-injection for anaphylaxis in children
Author, date, countryPatient groupStudy typeOutcomesKey resultsStudy weaknesses
Pumphrey et al, 1999, UK164 cases of fatality with anaphylaxis recorded as the cause of death between 1992 and 1998 (148 had records available for further analysis)Analysis of registry dataMedian time to respiratory or cardiac arrest.30 min for foods (range 6–360), 15 min for venom (range 4–120) and 5 min for iatrogenic reactions (range 1–80)Registry data, not specifically designed to answer this question.Only fatal cases included. Cases where epinephrine self-treatment prevented death therefore not included. Adults and children included
Details of patients who had been given repinephrine self-treatment kits5 did not use the kit (not with patient in 2 cases, out of date in 1 case, may have collapsed too quickly in 1 case, found dead holding unused kit in 1 case (could not assemble it?)
Gold et al, 2000, Australia68 children with a history of anaphylaxis who were prescribed EpiPens by the paediatric allergy service.Data collected by telephone interview with parentsRetrospective telephone surveyParental recall of method of administration with EpipenOnly 16 (24%) of parents were able to recall all 4 steps required for the correct use of Epipens; 5% could not recall any steps.Suboptimal study design to answer this question. A prospective observational cohort would be more informative (randomised controlled trial would be ideal but probably unethical).Possible selection bias—the parents of only 80% of the patients identified were interviewed. 19% could not be contacted—their outcome is unknown.No standard criteria for initial prescription of Epipen.Time since index reaction not standardised.In-hospital epinephrine use apparently assessed by parental interview.Severity of episodes not objectively measured
Epipen use in anaphylaxisEpipen given in 13 (29%) of 45 anaphylactic reactions. Of those not given Epipen, 15 (45%) were later given epinephrine in hospital. Of those given Epipen, 2 of 13 (15%) later received epinephrine in hospital (p<0.05)
Hospital admissionEpipen not given: 15 of 32 (47%) admitted; Epipen given: 2 of 13 (15%) admitted (p<0.05)
Colver et al, 2005, UK229 cases of children (aged under 16 years) admitted to hospital with food allergic reactions between 1998 and 2000Prospective surveyDeath3 children died. One received epinephrine via auto-injector at homePatients only included after reported hospital admission. Emergency department attendances without admission not included
Near fatal anaphylaxisOccurred in 6 children. In 3 children excess epinephrine administration (in hospital) was implicated in clinical deterioration.
Potential reduction in severity by use of epinephrine auto-injectors6 severe cases and 7 non-severe cases received epinephrine via auto-injector before arriving at hospital. Auto-injectors could therefore have reduced the severity of a maximum of 13/229 reactions
Potential benefits if epinephrine auto-injectors had been more widely availableOf the 58 severe cases, a maximum of 6 could have benefited had auto-injectors been available to them (the remainder either did not have epinephrine at any point, already had an auto-injector but did not use it, had epinephrine administered by primary care or ambulance staff within 10 min, had not had a previous allergic reaction to food or were over 12 years old and their only previous reaction had been to allergens as babies)