When Should Children and Adolescents Assume Responsibility for Self-Treatment of Anaphylaxis?

This article has been reviewed by Thanai Pongdee, MD, FAAAAI

While first-line treatment of anaphylaxis is the timely use of epinephrine autoinjector (SIE), current guidelines do not specify the age at which the responsibility of administering SIE should be transferred from the adult caregiver to the child.  

Several studies have looked at this issue. Simons, et al (1) surveyed pediatric allergists and found that most expected their patients to describe symptoms of anaphylaxis and the need to use SIE, as well as being able to demonstrate its use, by age 9 to 11 years. Most pediatric allergists expected children to self-carry and use SIE by age 12 to 14 years.   

The factors described as most important in determining readiness were: 1) ability to demonstrate appropriate and correct use of SIE, 2) ability to recognize the symptoms of anaphylaxis, 3) comfort level with self-carrying and using SIE, 4) previous history of anaphylaxis, and 5) co-morbid conditions such as developmental delay, ADHD, autism spectrum disorder, and depression.  

The same investigators (2) also studied the question of when the responsibility of using SIE use should shift but from the perspective of caregivers. This survey was conducted with questionnaires distributed at a Food Allergy & Anaphylaxis Network conference. Caregivers expected children younger than 6 to 8 years to be able to recognize symptoms of anaphylaxis. They also believed that the age for assuming responsibility for SIE use should take place at age 6 to 11 years.

Caregivers cited the child’s maturity, history of anaphylaxis, ability to demonstrate use of the SIE and specific situations, such as lack of adequate support in the school setting as important readiness factors. The investigators suggest that caregivers selected a lower age of shifting responsibility of SIE use compared to allergists because of their personal experience with anaphylaxis, high expectation of their child’s ability to recognize and self-treat anaphylaxis, uncertainty about the availability of adequate treatment from the school and community settings, and uncertainties regarding local policies for anaphylaxis management.

Shifting the responsibility of SIE use from the caregiver to the child should be a gradual process that begins only after a family-physician discussion. It should be individualized to the child’s developmental and maturity level, the child’s demonstrated knowledge of the signs and symptoms of anaphylaxis and use of the SIE device, as well as the individual needs of the child, family and school setting.

Ideally, this process should begin at early school age (kindergarten/first grade) with simple education. By the later elementary grades, it can evolve to the child self-carrying SIE and eventually evolve to giving the child permission to actually self-administer SIE by middle school age. It is recommended that the process should be completed before the teen years, when multiple studies show higher risk of non-compliance (3), greater risk-taking behaviors (4), and therefore greater risk for severe and fatal anaphylaxis (5,6). Make sure that you discuss these issues when you and your child see your physician.

1. Simons E, et al. Timing the transfer of responsibilities for anaphylaxis recognition and use of an epinephrine auto-injector from adults to children and teenagers: pediatric allergists’ perspective. Ann Allergy Asthma Immunol. 2012:108:321-25.
2. Simons E, et al. Caregivers’ perspectives on timing the transfer of responsibilities for anaphylaxis recognition and treatment from adults to children and teenagers. J Allergy Clin Immunol. 2013:1:309-11.
3. Noimark L, et al.  The use of adrenaline autoinjectors by children and teenagers. Clin Exp Allergy 2011;42:284-92.
4. Sampson MA, Muñoz-Furlong A, Sicherer SH.  Risk-taking and coping strategies of adolescents and young adults with food allergy. J Allergy Clin Immunol. 2006 Jun;117(6):1440-5.
5. Atkins D1, Bock SA. Fatal anaphylaxis to foods: epidemiology, recognition, and prevention. Curr Allergy Asthma Rep. 2009 May;9(3):179-85.
6. Marrs T, Lack G.  Why do few food-allergic adolescents treat anaphylaxis with adrenaline?--Reviewing a pressing issue. Pediatr Allergy Immunol. 2013 May;24(3):222-9. doi: 10.1111/pai.12013.

Additional inforamtion about anaphylaxis.

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