Published online July 2, 2007
PEDIATRICS Vol. 120 No. 1 July 2007, pp. 238-239 (doi:10.1542/peds.2007-0731)

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LETTER TO THE EDITOR

Self-injectable Epinephrine for First-Aid Management of Anaphylaxis

Marcus Shaker, MD
Section of Allergy and Clinical Immunology
Dartmouth-Hitchcock Medical Center
Lebanon, NH 03756
Center for the Evaluative Clinical Sciences
Dartmouth Medical School
Hanover, NH 03755-1404

Donald Woodmansee, MD
M. Kay Wolfson, MD
Section of Allergy and Clinical Immunology
Dartmouth-Hitchcock Medical Center
Lebanon, NH 03756

David Goodman, MD MS
Section of Allergy and Clinical Immunology
Dartmouth-Hitchcock Medical Center
Lebanon, NH 03756
Center for the Evaluative Clinical Sciences
Dartmouth Medical School
Hanover, NH 03755-1404

To the Editor.—

Sicherer et al¹ reported in Pediatrics that anaphylaxis preparedness should include self-injectable epinephrine prescribed for any child "who has experienced generalized acute urticaria after an insect sting, because the risk of a more severe reaction from a future sting is approximately 10%." The authors cited a stinging-insect hypersensitivity practice parameter update²; however, the attributed risk of a progressive reaction is incorrect. The cited parameter states that "patients 16 years of age and younger who have experienced only cutaneous systemic reactions after an insect sting ... only have about a 10% chance of having a systemic reaction if re-stung, and if a subsequent systemic reaction does occur in these children, it is very unlikely to be worse than the initial isolated cutaneous reaction."² The parameter assessment was based on a 1990 study by Valentine et al³ in which 242 venom-allergic children 2 to 16 years of age with isolated cutaneous symptoms were randomly assigned to insect-venom immunotherapy or observation. In the treated group, 84 stings in 36 patients resulted in 1 systemic reaction (1.2% of stings). In contrast, 196 stings in 86 untreated children resulted in 18 systemic reactions (9.2% of stings). Of these 18 reactions, 16 were judged to be milder than the index reaction, 2 were similar, and none were more severe.

The severity of the initial insect-sting reaction is of particular prognostic value in children. In patients 16 years of age and younger who have experienced cutaneous systemic venom reactions without other allergic manifestations, the risk of a severe reaction if restung is quite low (<1%).^3,4 Indeed, the risk of a subsequent severe reaction is low enough that venom immunotherapy is generally unnecessary for these patients.² The current guideline recommendation² that these patients carry self-injectable epinephrine indefinitely but generally not begin venom immunotherapy is itself a bit confusing and inconsistent. If, indeed, these children were at a significant risk for severe anaphylaxis, then venom immunotherapy should be considered to reduce this risk. It is because these children are generally not at an increased risk of severe anaphylaxis that venom immunotherapy is usually withheld.

Patients with venom hypersensitivity and their family members may suffer a significant burden of anxiety that impacts quality of life.⁵ Although venom immunotherapy improves quality of life, the recommendation that anaphylaxis preparedness include an indefinite prescription for self-injectable epinephrine in venom-allergic children with strictly cutaneous symptoms may impair quality of life.⁶ For patients with a low risk of progressive anaphylaxis (such as children with strictly cutaneous reactions to stinging insects), a process of shared decision-making⁷ may be appropriate, because significant trade-offs are likely to exist between preparedness, inconvenience, and anxiety.⁶ It seems that, on the basis of the available evidence, the decision to prescribe prophylactic self-injectable epinephrine for children with generalized acute urticaria after an insect sting should be an individualized decision, not a universal recommendation.

REFERENCES

1. Sicherer SH, Simons FE; American Academy of Pediatrics, Section on Allergy and Immunology. Self-injectable epinephrine for first-aid management of anaphylaxis. Pediatrics. 2007;119 :638 –646[Abstract/Free Full Text]
2. Moffitt JE, Golden DB, Reisman RE, et al. Stinging insect hypersensitivity: a practice parameter update. J Allergy Clin Immunol. 2004;114 :869 –886[CrossRef][Web of Science][Medline]
3. Valentine M, Schuberth K, Kagey-Sobotka A. The value of immunotherapy with venom in children with allergy to insect stings. N Engl J Med. 1990;323 :1601 –1603[Abstract]
4. Golden DB, Kagey-Sobotka A, Norman PS, Hamilton RG, Lichtenstein LM. Outcomes of allergy to insect stings in children, with and without venom immunotherapy. N Engl J Med. 2004;351 :668 –674[Abstract/Free Full Text]
5. Confino-Cohen R, Melamed S, Goldberg A. Debilitating beliefs, emotional distress and quality of life in patients given immunotherapy for insect sting allergy. Clin Exp Allergy. 1999;29 :1626 –1631[CrossRef][Web of Science][Medline]
6. Oude Elberink JN, De Monchy JG, Van Der Heide S, Guyatt GH, Dubois AE. Venom immunotherapy improves health-related quality of life in patients allergic to yellow jacket venom. J Allergy Clin Immunol. 2002;110 :174 –182[CrossRef][Web of Science][Medline]
7. WebMD. Should I have allergy shots for allergies to stinging insects? Available at: www.webmd.com/allergies/Should-I-have-allergy-shots-for-allergies-to-insect-stings. Accessed March 2, 2007

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Shaker, M. Articles by Goodman, D. Search for Related Content PubMed Articles by Shaker, M. Articles by Goodman, D. Related Collections Allergy & Dermatology Social Bookmarking                         What's this?