Q:

9/22/2014
Our practice teaches the families of food allergic children and local school nurses the importance of early epinephrine administration for systemic reactions to accidental food exposures. This year we are seeing a trend of families requesting that their child self-carries an epinephrine auto-injector at very young ages (5-7 years old). I am all for accessible epinephrine but do worry about a child loosing his or her autoinjector and not having it when needed (especially in private schools without non-designated epinephrine and standing orders to use it). This clearly needs to be addressed on a case by case basis, but do you have any suggestions or guidelines for the age at which most children can safely self-carry an epinephrine auto-injector?

A:

Thank you for your inquiry.

There is no consensus opinion or formal doctrine of which I am aware as to when a child becomes old enough to self-administer epinephrine. However, we do have a very helpful statement in the lay literature by Dr. Scott Sicherer dealing with this issue. I have copied below a link to Dr. Sicherer's advice in this regard. In addition, there is a helpful article by Dr. Sicherer and Dr. Estelle Simons, who performed a survey of pediatric allergists to discern at what age most allergists were willing to transfer responsibility for the injection of epinephrine from the caregiver to the child.

In essence, I think it becomes quite clear that most allergists would not feel comfortable vesting the responsibility of carrying an autoinjector and deciding when to use it on a child as young as 5 to 7 years of age. In fact, the majority, as you can see from the abstract copied below, would not do so until an approximate age of 12 years (this of course would be dependent very much on the child's level of development and judgment). Personally, I have never transferred this responsibility to a child any younger than 13 years of age, but when one reaches this approximate age, at least some consideration might be given to this transfer of responsibility. However, as noted, I would be very reluctant to trust a 5 to 7 year-old to carry, technical skills, or judgment required to administer an autoinjector for the treatment of a possible anaphylactic event.

Thank you again for your inquiry and we hope this response is helpful to you.

When Can a Child Self-Inject? - Dr Scott Sicherer

Ann Allergy Asthma Immunol 2012 May; 108(5):321-5. doi: 10.1016/j.anai.2012.03.004.
Timing the transfer of responsibilities for anaphylaxis recognition and use of an epinephrine auto-injector from adults to children and teenagers: pediatric allergists' perspective.
Simons E, Sicherer SH,
Abstract
Background: The optimal time for transferring responsibilities for anaphylaxis recognition and epinephrine auto-injector use from adults to children and teenagers has not yet been defined.
Objective: To determine whether pediatric allergists have age-specific goals for beginning to transfer responsibilities for anaphylaxis recognition and epinephrine auto-injector use from parents and caregivers to children and teenagers at risk of anaphylaxis in the community.
Methods: Members of the American Academy of Pediatrics Section on Allergy and Immunology (AAP-SOAI) were surveyed about when they typically begin to transfer these responsibilities from adults to children and teenagers.
Results: Eighty-eight allergists responded to the survey, 97.7% of whom provided service to children and teenagers with food allergies. Few allergists expected to begin transferring responsibilities for anaphylaxis recognition and epinephrine auto-injector use to children younger than 9 to 11 years. By the time their patients reached age 12 to 14 years, however, most allergists expected them to be able to describe some anaphylaxis symptoms (95.4%), demonstrate how to use an epinephrine auto-injector trainer (93.1%), begin carrying self-injectable epinephrine (88.2%), recognize the need for epinephrine (88.1%), learn to self-inject epinephrine (84.5%), and be able to self-inject epinephrine (78.6%) (cumulative data). The allergists rated the following as "very important" readiness factors for beginning to transfer responsibilities: medical history, developmental level, and ability to demonstrate auto-injector technique.
Conclusion: Most pediatric allergists expected that by age 12 to 14 years, their patients should begin to share responsibilities with adults for anaphylaxis recognition and epinephrine auto-injector use; however, they individualized the timing based on assessment of patient readiness factors.

Sincerely,
Phil Lieberman, M.D.

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