Why do so few adolescents inject adrenaline for anaphylaxis? Tom Marrs Clinical Lecturer in Paediatric Allergy
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1 Why do so few adolescents inject adrenaline for anaphylaxis? Tom Marrs Clinical Lecturer in Paediatric Allergy
2 Jarmil 14 yo boy Known peanut and tree nut allergies Adrenaline prescribed Father peanut allergy Flight from Slovakia to UK Ate pudding supplied on flight...
3 Recommendations for YOU!!!! Discuss: Worst allergic reaction Symptom-based management Early adrenaline Support: Scenario with dummy device Membership of lay organisations Dialogue: Professional to supportee dialogue
4 Fatal food-induced anaphylaxis Deferred administration of adrenaline Uncontrolled asthma Simons & Simons Curr Op ACI 2010, Pumphrey CEA 2000, Bock et Munoz-Furlong & Sampson JACI 2001
5 Poor Usage of Adrenaline 16 34% of patients treat anaphylaxis with adrenaline Simons et al. JACI 2009, Kim et al. JACI 2005, Uguz et al. CEA 2005, Noimark et al. CEA 2012
6 PRACTICAL PREPAREDNESS Administration 75% are unable to administer Even 75% doctors cannot administer! Advice for maintaining medication availability Carrying adrenaline Varies according to activity: 94% carry when travelling 43% during sports May not be honest with themselves Gold & Sainsbury JACI 2000, Grouhi et al. JACI 1999, Sampson M et al. JACI 2006, Sicherer, Forman & Noone Pediatrics 2000
7 PRACTICAL ISSUES DURING ANAPHYLAXIS Learning from Survivors internet survey questionnaire about anaphylaxis experience 1885 participants asked about worst allergic reaction 78 82% reported multi-system allergic responses 1385 (73.5%) did not use adrenaline 500 (26.5%) did use adrenaline Simons, Clark & Camargo JACI 2009
8 1385 (73.5%) did not use because: 38% antihistamine used 28% not prescribed adrenaline 8% asthma puffer used 8% adrenaline not available 8% unsure when to give adrenaline 8% previous reaction did not need adrenaline 6% afraid 500 used, but 275 problems with: 32% deciding whether to use 16% deciding whether to go to A&E 11% holding in place for 10 seconds 9% auto-injector disposal 8% site for administration 8% whether to repeat dose Simons, Clark & Camargo JACI 2009
9 Recognition of anaphylaxis is poor Majority cannot remember anaphylaxis May not have received adrenaline Survey of 969 UK families with adrenaline 245 experienced anaphylaxis: Only 41 (16.7%) used their adrenaline 15% of wheezing administered adrenaline Akeson Worth Sheikh CEA 2007, Noimark et al. CEA 2012
10 Emergency plan what to say Discuss symptoms, not anaphylaxis Low threshold for early use Use adrenaline PLUS other for red box Call ambulance: Don t go to your GP or Don t get in car for A&E Don t sit in toilet cubicle
11 Public health and role modelling...
12 TRADE-OFFS Allergen avoidance trade-off If adrenaline to hand / near A&E Adrenaline is not infallible Testing At least half have knowingly eaten allergen Gauge symptoms as to whether continue Avoidance takes precedence Macadam et al. Clin Trans Allergy 2012, Sampson M et al. JACI 2006, Monks et al. CEA 2012, Pumphrey & Gowland JACI 2007
13 Practical issues Discussing previous reactions: May not remember May have not used adrenaline Symptom-based indication for adrenaline Do not give other medicine instead Then ambulance Akeson, Worth & Sheikj CEA 2007, Simons, Clark & Camargo JACI 2009, Noimark et al. CEA 2012, Simmons JACI 2004
14 Perceived comfort for future adrenaline administration Very comfortable UNRELATED TO KNOWLEDGE UNRELATED TO PRIOR ANAPHYLAXIS Uncomfortable RELATED TO: ADRENALINE TRAINING PRIOR USE OF ADRENALINE EMPOWERMENT When problems arise, I handle them I am confident in protecting my child I am confident and act quickly. Kim, Sinacore & Pongracic JACI 2005
15 Appraisal of risk Adolescents do not assume they are invincible US survey reporting 5 % of adolescents felt they were likely to die in the next year Complex relationship between risk knowledge, chosen behaviours and belief systems Fischoff et al J Adol Health 2010, Cook & Bellis Pub Health 2001
16 Rational, but less informed Complex decisions behind daily behaviours Balancing place, people present and allergen likelihood Situational knowledge needs improvement Places restaurants, bakeries, curry houses Label interpretation Accessing healthcare appropriately Give information and monitor, rather than instruct Discuss mock scenarios likely to be encountered Macadam Clin Trans All 2012, Akeson Worth and Sheikh CEA 2007
17
18 Support for food allergy management Supported Isolated HEALTH PROFESSIONALS TO ADVISE SUPPORTED BY: MONITORING AND REFLECTION PEER SUPPORT LAY ORGANISATIONS WORKSHOPS & FORUMS RISKS: FEELING DIFFERENT BULLYING DEFENSIVE STRATEGIES
19 AC: How should we share information? Worth et al. Clin Trans Allergy 2013
20 Discussing risky behaviour Parental monitoring rather than direction Who takes responsibility for food allergy? Asking key scenario based questions: Who else knows about your allergies? What did you think when you entered restaurant? Why did you retreat to toilet? Lay organisation support Workshops
21 Recommendations for YOU!!!! Discuss: Worst allergic reaction Symptom-based management Early adrenaline Support: Scenario with dummy device Membership of lay organisations Dialogue: Professional to supportee dialogue
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