Inadequacy of current pediatric epinephrine autoinjector needle length for use in infants and toddlers

Kim, Harold; Dinakar, Chitra; McInnis, Paul; Rudin, Dan; Benain, Xavier; Daley, W. Allen; Platz, Elke

doi:10.1016/j.anai.2017.03.017

Cited by 33 publications

(18 citation statements)

References 26 publications

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“…There are also some concerns about the needle length of the AAIs. Recent studies using ultrasound have shown that certain AAIs may be associated with a risk of adrenaline bone injection . The optimal needle length of AAI to ensure optimal adrenaline diffusion requires further studies.…”

Section: Discussionmentioning

confidence: 99%

Food‐induced anaphylaxis in infancy compared to preschool age: A retrospective analysis

Pouessel

Jean-Bart

Deschildre

et al. 2019

Clin Experimental Allergy

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Objective: Little is known regarding food anaphylaxis in infancy. We aimed to describe specificities of food anaphylaxis in infants (≤12 months) as compared to preschool children (1-6 years). Methods:We conducted a retrospective study of all food anaphylaxis cases recorded by the Allergy Vigilance Network from 2002 to 2018, in preschool children focusing on infants.Results: Of 1951 food anaphylaxis reactions, 61 (3%) occurred in infants and 386 (20%) in preschool children. Two infants had two anaphylaxis reactions; thus, we analyzed data among 59 infants (male: 51%; mean age: 6 months [SD: 2.9]); 31% had a history of atopic dermatitis, 11% of previous food allergy. The main food allergens were cow's milk (59%), hen's egg (20%), wheat (7%) and peanut (3%) in infants as compared with peanut (27%) and cashew (23%) in preschool children. Anaphylaxis occurred in 28/61 (46%) cases at the first cow's milk intake after breastfeeding discontinuation. Clinical manifestations were mainly mucocutaneous (79%), gastrointestinal (49%), respiratory (48%) and cardiovascular (21%); 25% of infants received adrenaline. Hives, hypotension and neurologic symptoms were more likely to be reported in infants than in preschool children (P = .02; P = .004; P = .002, respectively).Antihistamines and corticosteroids were more often prescribed in preschool children than in infants (P = .005; P = .025, respectively). Conclusion:Our study found that in infants presenting with their first food allergy, in a setting with a high rate of infant formula use, the most predominant trigger was cow's milk. As compared to older preschool children, hives, hypotonia and hypotension were more likely to be reported in infants. We believe that this represents a distinct food anaphylaxis phenotype that can further support developing the clinical anaphylaxis criteria in infants. | 75POUESSEL Et aL.

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Section: Discussionmentioning

confidence: 99%

Food‐induced anaphylaxis in infancy compared to preschool age: A retrospective analysis

Pouessel

Jean-Bart

Deschildre

et al. 2019

Clin Experimental Allergy

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“…The declared variation in pressure that is accepted by companies for release of new batches, applied to EAIs has been presented elsewhere [9]. There are instruments that can apply a specified pressure to the ultrasound probe and such instruments should be used in all future trials and in the instruction to prescribing health care personnel [10,11]. Furthermore, we propose the variation in needle length and the influence of thick clothes should be defined.…”

Section: Discussionmentioning

confidence: 99%

Epinephrine auto-injector needle length

Dreborg

Tsai

Kim

2020

Allergy Asthma Clin Immunol

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Background: Epinephrine auto-injectors are expected to deliver the drug intramuscularly. Objective: To study whether injection through clothing influences the frequency of subcutaneous and intraosseous/ periosteal deposition of epinephrine. Methods: Skin to muscle and skin to bone distances were measured for 303 children and adolescents and 99 adults. Distance was determined by ultrasound, with high or low pressure on the ultrasound probe. The risk/percentage of subcutaneous and intraosseous/periosteal injections was calculated using the lower and upper limits for the authority-approved length of EAI needles as provided by two high pressure EAI manufacturers and one low pressure EAI manufacturer. The addition winter clothing on the delivery of epinephrine was illustrated by comparing drug delivery fissue depth with no clothes. Furthermore, the riof non-intramuscular delivery for the shortest and longest approved needle length was calculated. Results: When using EpipenJr ® in children < 15 kg the risk of intraosseous/periostal injection was reduced from 1% and 59% for the shortest and longest approved needle length to 0 and 15% with winter clothes. The Auvi-Q ® 0.1 mg had no risk of intraosseous/periosteal injection. However, the subcutaneous deposition risk increased from 94% and 28% to 100% and 99% with winter clothes. The risk of subcutaneous injection using EpipenJr ® in the youngest children increased from 13% and 0% to 81% and 1% with winter clothes, and with Epipen ® in adults from 45% and 17% to 60% and 38%. Emerade ® , had a risk of subcutaneous injection in adults increasing from 14% and 10% to 28% and 21% adding winter clothes. Conclusion: The risk of intraosseous/periosteal injections decreases and the risk of subcutaneous injection increases when injecting through winter clothes for all EAIs.

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“…Conversely, some children may need shorter needles and may in fact be at risk of having the needle penetrate bone. 42 The US Food and Drug Administration recently approved a shorter needle for an epinephrine autoinjector (Auvi-Q) to be used in children weighing 7.5 kg to 15 kg.…”

Section: Obese Patients May Need a Longer Needlementioning

confidence: 99%

Who needs to carry an epinephrine autoinjector?

Song

Lieberman

2019

CCJM

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A naphylaxis is potentially fatal but can be prevented if the trigger is identifi ed and avoided, and death can be avoided if episodes are treated promptly. A consensus defi nition of anaphylaxis has been diffi cult to achieve, with slight variations among international guidelines. The World Allergy Organization classifi es anaphylaxis as immunologic, nonimmunologic, or idiopathic. 1 The National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network highlight clinical symptoms and criteria. 2 The International Consensus on Food Allergy describes reactions as being immunoglobulin E (IgE)-mediated, cell-mediated, or a combination of the 2 mechanisms. 3 Despite the subtle differences in these definitions, all 3 international organizations have a common recommendation for anaphylaxis: once it is diagnosed, epinephrine is the treatment of choice. ■ EPINEPHRINE IS THE TREATMENT OF CHOICE FOR ANAPHYLAXIS Anaphylaxis commonly results from exposure to foods, medications, and Hymenoptera venom. 4 Avoiding triggers is key in preventing anaphylaxis but is not always possible. Although epinephrine is the cornerstone of the emergency treatment of anaphylaxis, many patients instead receive antihistamines and corticosteroids as initial therapy. Some take these medications on their own, and some receive them in emergency departments and outpatient clinics. 5 Diphenhydramine, a histamine 1 receptor antagonist, is often used as a fi rst-line medication. But diphenhydramine has a slow onset of action, taking 80 minutes after an oral dose REVIEW Dr. Song has disclosed membership on advisory committees or review panels for Allergopharma, and teaching and speaking for Novartis and Teva. Dr. Lieberman has disclosed consulting for Kaléo.

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Inadequacy of current pediatric epinephrine autoinjector needle length for use in infants and toddlers

Abstract: Our data suggest that the optimal EAI needle length for infants and toddlers weighing 7.5 to 15 kg should be shorter than the needle length in currently available pediatric EAIs to avoid accidental intraosseous injections.

Cited by 33 publications

References 26 publications

Food‐induced anaphylaxis in infancy compared to preschool age: A retrospective analysis

Food‐induced anaphylaxis in infancy compared to preschool age: A retrospective analysis

Epinephrine auto-injector needle length

Who needs to carry an epinephrine autoinjector?

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