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Three Part Question

In [parents of children with history of anaphylaxis] is there [evidence for the effective use of adrenaline autoinjectors]during [anaphylactic emergencies]?

Clinical Scenario

A 10-year-old child is to be discharged from the paediatric emergency department after presenting in anaphylactic shock. In accordance with National Institute for Health and Clinical Excellence guidelines you prescribe an adrenaline autoinjector (AAI) and teach him and his mother the six-step technique for use using a training device. They both seem happy but you wonder if they will still remember the technique in the future or in an emergency situation?

Search Strategy

Medline 1946 to June Week 1 2013

EMBASE 1980 to 2013 Week 26

CINAHL Plus
((exp patient/) OR (exp parent/) OR (exp caregiver/) OR (parent$.mp) OR (carer.mp)) AND ((exp Patient Education as Topic/) OR (exp health education/) OR (exp teaching/) OR (educat$.mp) OR (teach$.mp) OR (instruct$.mp)) AND ((exp epinephrine/) OR (exp self, administration/) OR (exp injections, intramuscular/) OR (adrenalin$.mp) OR (autoinjector.mp) OR (auto-injector.mp) OR (epipen.mp) OR (auvi-q.mp) OR (JEXT.mp) OR (IM.mp) OR (intramuscular$.mp)) Limits–Human, English Language, Children 0–18 years.

CINAHL–MESH term (epinephrine) AND MESH term (patient education).

Search Outcome

A total of 703 papers were discovered, 9 of which were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Topal et al, 2013, Turkey	64 patients with history of allergic reaction whom had been prescribed an AAI (50 caregivers and 14 children>12 years old)	Single centre cross sectional descriptive study	Able to perform 6 steps for a successful injection on training device	39.4% of participants were able to complete all 6 steps	Author assumes teaching was given to all patients along with technique reviews at follow up. No comparison made between the teaching from allergists and non-allergists.
			Factors associated with appropriate use	Ability was strongly associated with; belief it was necessary (p=0.04), attending follow ups )p=0.01) and history of severe reaction (p=0.01) Inverse relationship between ability to use device and time elapsed since last visit (p=0.002) or last teaching session (p=0.01
			Decision to use AAI in an allergic reaction	7 children had anaphylactic reactions since receiving AAI, of which 5 had them with them, although only 1 chose to use it.
Arkwright et al, 2006, UK	122 parents of consecutive children prescribed AAIs attending allergy clinic 56 AAIs prescribed by GP 35 prescribed by non allergy specialists 31 prescribed by allergists	Single centre, prospective and direct study – case notes of children review, once they attended a follow up appointment their AAI technique was reviewed	Parents ability to administer successful injection using 5 step technique on dummy device	47% of parents were able to use the device.
			Effect of prescriber and training techniques on correct use	Those who had received device from allergy clinic were significantly better than those who had received device from GP, p<0.01 Those who had received a demonstration of the device were significantly better than those who had received only written information, p=0.003
			Other factors associated with correct use	Parents associated with lay organisations were significantly better than those who were not, p=0.001.
			Decision to use AAI during severe reaction	No parents had used the device, despite 26 severe cases being reported.
Kim et al, 2005, USA	165 parents of children with food allergy and AAI from local food allergy support groups and private paediatric clinics	Single centre, cross sectional descriptive questionnaire study, with a visual analogue scale for ‘perceived comfort’ 0cm = very uncomfortable to 10cm = very comfortable	Knowledge of key steps for AAI use	Administration questions answered correctly by 90% of parents	Selection bias due to the locations chosen for enrolment, majority of responders were white mothers with degrees, no African American or Hispanic parents included No objective testing of ability
			Comfort using AAI on child	Mean distance of 6.6cm. 75 patients felt ‘very uncomfortable’ using AAI on child. 51% concerned about recognising the signs, 40% feared hurting their child, 36% though they would forget the technique in an emergency situation. Increased comfort levels were associated with prior use of AAI (p=0.009) and prior AAI training (p=0.005)
			Decision to use AAI during severe reaction	70 (42%) of children had experienced serious reaction, only 14 (8%) of parents administered adrenaline
Blyth et al, 2002, UK	Parents of 25 children enrolled via contact with schools that identified pupils with AAI’s.	Cross sectional survey including questionnaire and structured interview	Ability to successfully inject training device using 6 step technique	6 (24%) parents were able to complete all 6 steps.	Small sample Children only enrolled via school nurses. No information on non responders No analysis to determine who had trained the parents who were successful.
Gold and Sainsbury, 2000, Australia	68 Parents of children with a history of anaphylaxis and an AAI attending paediatric allergy service at tertiary centre in Adelaide	Single centre, cross sectional retrospective, structured telephone questionnaire survey	Knowledge of anaphylaxis symptoms – scored out of 11.	16% of parents able to name between 9 and 11 symptoms of anaphylaxis, those who have seen 2 or more serious reactions were more successful than those who had seen one or none (12%vs26%)	No objective testing of AAI ability No data on non responders
			Knowledge on how to use AAI (4 step technique)	16% of parents were able to recall all 4 steps of AAI technique 5% could not recall any steps
			Decision to use AAI in necessary situations	45 anaphylactic reactions had occurred, but only 14 parents used AAI (31%)
Sicherer et al, 2000, USA	101 consecutively referred food allergic patients (95 parents and 6 patients over the age of 12)	Single centre, cross sectional descriptive study	Having AAI device on them at all times	86% stated they had the device on them at all times however only 71% had it on them in clinic, of which 10% were expired.	Only includes food allergic children
			Ability to use AAI (following 6 or 9 step technique depending on device)	32% of participants were able to correctly use an AAI.
			Factors associated with correct use	Membership to a lay organisation, (p=0.007) and owning a device for >2.5 years (p=0.0003) were associated with improved ability Having been prescribed the device by an allergist conferred greater (but not significant p=0.006) ability.
Huang SW. 2007, USA	224 parents of children with a history of anaphylaxis. Parents were retrained after initial attempt and reassessed at next appointment.	Single centre cross sectional study	Ability to use AAI trainer using 9 step technique	First visit– 22% completed all 9 steps Second visit – 68% Third visit – 94%
Segal et al, 2012, Israel	141 children (or parents for those <12 years) returning for follow up after AAI training at diagnostic visit	Single centre cross sectional study	Ability to use AAI using 5-step/10 point technique.	5.6% of participants achieved 10 points, 19% of participants scored 0 points.	Only training provided by allergist was consider. No non-specialist group.
			Ability to use AAI increases after training	Mean score had improved from 4.71 to 6.73 (p<0.001) after AAI training Time from diagnostic visit to 1st follow up had no effect on total score.
Diwakar et al, 2010, UK	74 patients whom carried an AAI and attended tertiary centre allergy clinic over a 2 month period Split into three groups 1. AAI training provided by allergist (n=30) 2. AAI training provided by non allergists (n=24) 3. AAI provided with no training (n=20)	Single centre cross sectional questionnaire based survey for prospective clinical audit	Knowledge on AAI technique (maximum score of 7)	Significant difference in knowledge between specialist trained and untrained patients (5.97 vs 5.05, p=0.007) Knowledge difference between those non specialist trained and those with no training was not significant, p=0.075	Small sample size No explanation of method for knowledge and confidence scores No objective testing of ability
			Confidence in using AAI (maximum score 2)	Significant difference in knowledge between specialist trained and untrained patients (1.5 vs 0.75, p=0.001) Confidence difference between non specialist trained and those with no training was close to significant, p=0.06
Hellstrom, A et al 2010 Sweden	5 children who had recently been prescribed an AAI over a 5 month period Children were initially taught how to use the device, given time to practice and then self injected with a active device	Single centre cross sectional study	Ability to correctly use AAI device on themselves	All 15 children were able to administer adrenaline correctly	Small sample size Did not use a validated anxiety questionnaire
			Anxiety difference before and after AAI use using anxiety questionnaire	Seven children reported anxiety before the injection, falling to one after the injection.

Comment(s)

Seven of the papers used objective testing of patients’ (those above the age of 12 years) or parents’ AAI technique, with mean scores ranging from 39.4% (50) to only 5.6% (56). The authors adopted a variety of scoring systems; Segal et al used a 10-point method, different to all other studies and may explain why the results were lower than other similar studies. Two studies used questionnaire methods to assess patients’ ability—using either open-ended questions in which patients described the technique or true/false questions. Kim et al chose the latter and saw significantly higher rates of ability in patients than all other studies—90% of patients correctly answered the six true/false questions relating to AAI technique. It is not surprising that participants were better in this method of analysis compared to a difficult objective test, in which mistakes such as holding the device the wrong way round or forgetting to press for the ‘click’ can be easily done. It is recommended that specialists provide AAI training; three of the studies considered how specialist training affects ability. Arkwright and Farragher and Diwakar et al found a significant difference between those who had been trained by allergists and those who had no training. (p<0.01 and p=0.007, respectively). Diwakar et al also noted there was no difference in knowledge or confidence for those who had been trained by non-specialists and those who had received no training, suggesting it is only training by allergists that is truly effective. There was a number of external factors that were strongly associated with improved AAI technique, Arkwright and Farragher and Sicherer et al both determined that membership of a lay organisation was significant, suggesting motivated families who sought advice and education beyond that provided by their doctors were more likely to use AAI correctly. Only two of the studies considered the benefit of additional training; both showed encouraging results. Low levels of AAI use is a multifactorial problem of which poor education is one only part; four studies asked patients or parents who had appropriate ability how often they had used their AAI, and despite a number of serious reactions warranting adrenaline they were rarely used. Kim et al and Hellstrom et al relate this to a ‘fear of the unknown’. These fears need to be addressed to ensure parents’/patients’ comfort levels are improved, Hellstrom et al even suggest using active AAI devices in controlled settings to reduce anxiety and improve AAI use.

Editor Comment

AAI, adrenaline autoinjector; GP, general practitioner.

Clinical Bottom Line

Ideally allergists should provide AAI technique training; both children and parents should be trained, using a training device. This education should be seen as a process, which needs to be reviewed and repeated at each appointment or contact with health services.

References

1. Topal E, Bakirtas A, Yilmaz O et al. A real-life study on acquired skills from using an adrenaline autoinjector. Int Arch Allergy Immunol 2013;160(3):301-6.
2. Arkwright PD, Farragher AJ. Factors determining the ability of parents to effectively administer intramuscular adrenaline to food allergic children. Pediatr Allergy Immunol 2006;17(3):227-9.
3. Kim JS, Sinacore JM, Pongracic JA. Parental use of EpiPen for children with food allergies. J Allergy Clin Immunol 2005;116(1):164-8
4. Blyth TP, Sundrum R. Adrenaline autoinjectors and schoolchildren: a community based study. Archives of Disease in Childhood 2002;86(1):26-7.
5. Gold MS, Sainsbury R. First aid anaphylaxis management in children who were prescribed an epinephrine autoinjector device (EpiPen). J Allergy Clin Immunol 2000;106(1 Pt 1):171-6.
6. Sicherer SH, Forman JA, Noone SA. Use Assessment of Self-Administered Epinephrine Among Food-Allergic Children and Pediatricians. Pediatrics 2000;105(2):359-62.
7. Huang SW. Evaluating The Results of Teaching Epinephrine Auto-Injector Use in An Allergy Clinic. Pediatric Asthma, Allergy & Immunology 2007;20(1):19-22.
8. Segal N, Garty BZ, Hoffer V et al. Effect of instruction on the ability to use a self-administered epinephrine injector. Isr Med Assoc J 2012;14(1):14-7.
9. Diwakar L, Heslegrave J, Richter AG et al. Self-injectable adrenaline devices: is training necessary? J Investig Allergol Clin Immunol 2010;20(5):452-3.
10. Hellstrom A, Eriksson K, Efraimsson EO et al. Assessment of self-administered epinephrine during a training session. Acta Paediatr 2011;100(7):e34-5.