Underutilization of Epinephrine for Anaphylaxis in Children

Cute upset little girl is holding the big ripe strawberry

By Martina M. McGrath, MD
August 15, 2017

Food allergies are increasingly common and are reported to affect up to 7% of children.1 The most severe form of allergy is anaphylaxis, which is a rapid onset, potentially life-threatening, allergic reaction. Treatment is by urgent administration of intramuscular epinephrine, and early administration is associated with decreased severity of reaction and reductions in mortality.2 Despite the widespread availability of epinephrine, and extensive efforts in education of families and caregivers about recognition of anaphylaxis, delays in recognizing severe reactions and administering the appropriate treatment are still common.2,3

Robinson et al have reported a large observational study of children and young people presenting to a single tertiary referral center in Colorado with anaphylaxis, where they examined the factors associated with epinephrine administration prior to presentation to the emergency department (ED).4 Four hundred and eight cases of anaphylaxis identified between 2009 and 2013 were included in this analysis. The inciting allergens included food, latex, and medications. Prior to presentation to the ED, 81% of patients had received some medication for their reaction. However, only 36% had received epinephrine, the remaining patients had been treated with antihistamines. Furthermore, the odds of receiving epinephrine were significantly lower in those that had a reaction at home (OR 0.57, 95% CI 0.36-0.9), compared to at school (OR 2.64, 95% CI 1.42-4.89). Disturbingly, despite the fact that almost two-thirds had a prior history of anaphylaxis, only 48% of these patients had been prescribed epinephrine. Of those prescribed it, only 70% had it available at the time of reaction.

Speaking to the benefits of early treatment, patients treated with epinephrine prior to ED presentation were much less likely to require further doses of epinephrine on arrival, and were much more likely to be discharged home than admitted to the hospital (OR 0.56, 95% CI 0.35-0.99).

The study has several limitations; it relied on coding data to identify cases of anaphylaxis and, therefore, is subject to under-recognition. Treatment or lack of treatment was abstracted from the electronic medical record and was not independently verified with patients or families and could be subject to significant errors in reporting. Finally, this was a single-center study and may not be representative of a broader patient population.

However, despite these limitations, the findings are a cause of concern. A large proportion of patients with known anaphylaxis did not have epinephrine prescribed or available to them. This suggests either a lack of access to care or failure to provide appropriate treatment. Furthermore, 47% of reactions occurred in children under the age of five and a large proportion occurred at home, suggesting that parents and primary caregivers may have difficulty recognizing anaphylaxis or are reluctant to administer the drug at home.

Intramuscular epinephrine is a safe, effective, and potentially lifesaving therapy for children with anaphylaxis. This study suggests that further education and training is necessary to ensure patients have access to the treatment they need, and that families can use it confidently and appropriately in an emergency setting.

Learn more about recognizing and treating anaphylaxis in this online CME course from Harvard Medical School: Identifying and Treating Anaphylaxis

More allergy CME courses:

Foundational Principles of Allergy and Immunology
Recognizing and Treating True Food Allergies
Urticaria and Angioedema: Mechanisms, Triggers, and Treatment
Treating Respiratory and Drug Allergies


  1. Wood RA, Camargo CA Jr, Lieberman P, et al. Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States. J Allergy Clin Immunol. 2014; 133:461-467.
  2. Stukus DR, Green T, Montandon SV, Wada KJ. Deficits in allergy knowledge among physicians at academic medical centers. Ann Allergy Asthma Immunol. 2015; 115:51-55.
  3. Fineman SM, Bowman SH, Campbell RL, et al. Addressing barriers to emergency anaphylaxis care: from emergency medical services to emergency department to outpatient follow-up. Ann Allergy Asthma Immunol 2015; 115:301-305.
  4. Robinson M, Greenhawt M, Stukus DR. Factors associated with epinephrine administration for anaphylaxis in children before arrival to the emergency department. Ann Allergy Asthma Immunol xxx 2017, 1-6. Epub ahead of print. Article accessed online 08/01/17.

Headshot of Dr. McGrathDr. Martina McGrath is an Instructor in Medicine at Harvard Medical School, and a member of the Renal Division, Department of Medicine, at Brigham and Women’s Hospital, both in Boston. Dr. McGrath is the Medical Editor for the Trends in Medicine blog.

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