PEDIATRICS Vol. 120 No. 1 July 2007, pp. 239-240 (doi:10.1542/peds.2007-1033)
LETTER TO THE EDITOR |
Self-injectable Epinephrine for First-Aid Management of Anaphylaxis: In Reply
Scott H. Sicherer, MDF. Estelle R. Simons, MD
For the American Academy of Pediatrics Section on Allergy and Immunology
We thank Drs Gaines and Shaker et al for their thoughtful comments. We fully agree that it is not always easy to assess the clinical risk of future anaphylaxis, which influences the decision to prescribe self-injectable epinephrine.1
We overstated the risk of subsequent anaphylaxis in children with generalized acute urticaria (mild cutaneous systemic reactions) after an insect sting as 
10%. It is, in fact, precisely 6.74% as stated in the study by Golden et al,2 which we cited at the end of our clinical report. It is important to note that this study by Golden et al included the earlier data published by Valentine et al,3 which are described in the letters by Drs Gaines and Shaker et al.
In the study by Golden et al, follow-up data were obtained on 89 children with initial mild cutaneous systemic reactions who had not received venom immunotherapy.2 When subsequently stung, 87% of the children had no systemic reaction, 6.74% had another mild cutaneous systemic reaction, 6.74% had a moderate systemic allergic reaction, and none had a severe allergic reaction. A moderate systemic reaction was defined as "signs and symptoms of a cutaneous reaction as well as discomfort in the throat or chest, mild symptoms of airway obstruction, light-headedness, and dizziness or mild hypotension,"2 a description that is consonant with the current definition of anaphylaxis.4
In this context, it is important to note that physicians cannot assume that children and their caregivers necessarily recognize and report all anaphylaxis symptoms, because even trained health care professionals underrecognize this disorder.1
Therefore, we continue to recommend that pediatricians prescribe self-injectable epinephrine for children who have mild cutaneous systemic reactions consisting of generalized acute urticaria after an insect sting, as recommended in a recent practice parameter.5 Some, like Shaker et al, may consider the prescription optional given the risks. At the very least, prescription of self-injectable epinephrine should be discussed with the caregivers who are responsible for the child, and consultation with an allergist should be considered.
REFERENCES
1. Sicherer SH, Simons FE. Quandaries in prescribing an emergency action plan and self-injectable epinephrine for first-aid management of anaphylaxis in the community. J Allergy Clin Immunol. 2005;115 :575 –583[CrossRef][Web of Science][Medline]
2. 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
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. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol. 2006;117 :391 –397[CrossRef][Medline]
5. 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]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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