Author, date and country | Patient group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
---|---|---|---|---|---|
Rudders, SA et al 2010 USA | 315 eligible paediatric admissions for allergy and anaphylaxis based on ICD9 codes collected over a 5-year period. | Large scale, multicentre medical chart review | M adrenaline is received in anaphylactic reactions before arrival in PED. | 31% of patients received one dose of IM adrenaline before PED arrival 3% of patients received two or more doses of IM adrenaline before PED arrival | No mention of the AAI dose used – possible if a lower dose was used (0.15mg) then heavier children (those >10years) may have been under dosed. |
IM adrenaline is received in anaphylactic reactions. | 44% of anaphylactic reactions received adrenaline, 12% received more than one dose. | ||||
Older children are more likely to received more than one dose of adrenaline | Patients greater than 10 years old (p=0.01) and those treated at an outside hospital before transfer to the tertiary centre (p=0.002) were more likely to receive one dose Patients who owned an AAI were not statistically more likely to receive more than one dose. | ||||
Jarvinen, KM et al 2009 USA | 436 positive paediatric oral food challenges performed in a tertiary allergy centre identified using online database search. | Retrospective electronic case note review | IM adrenaline is used for serious reactions | 50 children were treated with adrenaline 3 (0.06%) children received 2 doses of adrenaline | Small sample size No analysis of the one dose and two dose groups |
Older children were more likely to receive adrenaline than younger children | Adrenaline group were significantly older than those not treated p<0.001. | ||||
Jarvinen, KM et al. 2008 USA | 413 questionnaires given to parents of consecutive children (up to the age of 18) presenting for an initial or follow up appointment to hospital based allergy clinic over a 6-month period. | Self reported questionnaire cross sectional study. | A small number of children require two doses of IM adrenaline | 211 parents reported a history of anaphylaxis, only 20% parents used an AAI. In total 95 reactions had been treated with adrenaline, 81% received a single dose, 19% received multiple dose. | Self report questionnaire – recall bias |
Past medical history of asthma is associated with increased doses of adrenaline | Children in the multiple dose group had asthma than those in the one dose group, p=0.005. | ||||
Children with more severe symptoms are more likely to receive multiple doses | Symptoms of throat closure were associated with multiple doses of adrenaline | ||||
Requirement for multiple doses is not associated with a delay in the first dose of adrenaline. | Children in the multiple dose groups received their first dose of adrenaline sooner than the single dose group. | ||||
After multiple doses of adrenaline, hospital admission is required. | Children who had received multiple doses were observed in the hospital longer than those who received only one dose, p=0.003 | ||||
Manivannan, V. 2009 USA | All patients presenting to two ED and all other health care providers in Minnesota. | Population based retrospective cohort study | IM adrenaline is used for serious reactions. | 208 cases of anaphylaxis were identified 104 anaphylactic cases received adrenaline – of which 27 (13%) received more than one dose. The 2nd dose of adrenaline was provided by a healthcare professional in 100% of cases | Retrospective study – may have missed cases. |
Those receiving two doses were significantly younger than the one dose group | The two dose group were significantly younger than the one dose group, p=0.06. | ||||
Those receiving two doses require hospital admission | Number of hospital admissions was significantly greater in the two dose group (48.1% vs 15.6% of one dose group), p=0.001. | ||||
More respiratory and cardiovascular symptoms were seen in two dose group | Those in the two dose group were more likely to have wheezing symptoms (p=0.003), cyanosis (p=0.001) or hypotension (p=0.03) | ||||
Huang, F et al 2012 USA | 213 paediatric patients who had presented to the PED of tertiary centre anaphylaxis using ICD9. | Retrospective, single centre electronic case note review | IM adrenaline is given for serious reactions | 13 (6%) children received more than one dose of adrenaline | |
Hospitalisation more likely for the two-dose group. | 9 of 13 in the multiple dose groups were hospitalised compared with 18 of 156 in the single dose group, p<0.001. Children with two doses are more likely to be admitted to intensive case, p<0.0001 However if the two doses were given before arrival in PED patients were less likely to be admitted than those who had both or one of the doses administered by PED staff, p<0.05. | ||||
Rudder, SA et al. USA 2010 | All patients presenting to 3 major ED’s with stinging insect hypersensitivity – from ICD9 codes over a 6-year period. | Large multicentre retrospective medical record study. | More than one dose of IM adrenaline is used in some allergic reactions. | 152 patients met the ICD9 criteria, 26% of which had symptoms of anaphylaxis. 16% of patients received 2 doses of adrenaline – all before arrival at ED. | No analysis of the outcomes for the one dose and two dose groups. |
Arkwright PD. 2009 UK | All children presenting to a specialist paediatric allergy outpatient clinic who had an AAI prescribed. | Single centre, retrospective case note study | Ownership of AAI devices | 298 children were included, 282 had more than one device | Only food allergic children. Not clear if the devices were held in the same location or for different locations (e.g. home and school) |
Use of multiple doses | % of children had received multiple doses of adrenaline . 18 parents had used the device, however no parents had used 2 devices for the same reaction. | ||||
Kelso, JM. 2006 USA | All Children attending allergy clinic for allergy injections over a 5 year period (n=9592) | Single centre, retrospective case notes study. | More than one dose of IM adrenaline is used in some allergic reactions | 64 (0.67%) children required adrenaline, 54 received one dose, 8 (13%) received two doses and 2 (3%) children received 3 doses for their symptoms. | SC injections used from 2000-2002 and then a mixture of SC and IM from 2003-2004 – known not to be the more effective result for adrenaline. |
No difference between the one and greater than one dose groups | No significant difference between one and greater than one dose groups. |