Families of children with food allergies know to inject epinephrine if they have a severe reaction, but the playbook for next steps may shift for some patients as coronavirus fears make them skittish about seeking emergency medical care.
Instead of automatically calling 911 after administering epinephrine, a modified plan suggests some families may be able to manage symptoms at home after injecting epinephrine, unless symptoms persist or worsen — but only after doctors and patients discuss the risks and benefits, said Dr. Thomas Casale, chief medical advisor for operations at the nonprofit Food Allergy Research & Education (FARE).
About 5.6 million U.S. children have food allergies, and 20% of them had an emergency-room visit in the last year due to a life-threatening reaction to food, according to FARE. Adults comprise more than 26 million of the 32 million Americans with food allergies. Severe and even fatal allergic reactions to food can happen at any age, but teenagers and young adults are at highest risk of death. Every year, food-related allergic reactions require 200,000 people to seek emergency medical care.
If patients are worried about potential exposure to Covid-19, Casale advises they talk with their allergists or physicians through telehealth visits, if possible, to review or revise their emergency plan during the coronavirus crisis.
Depending on local and personal factors, a modified plan may involve managing a severe reaction with autoinjectors such as EpiPens and careful follow-up at home instead of calling 911 after injecting the first dose of epinephrine, he said.
“We came to these conclusions to a large extent because a lot of patients were asking us what to do….because there’s great apprehension about going to the E.R.”
“It’s got to be a shared decision between patient and doctor and what’s appropriate for them,” he said.
Not a universal recommendation
Doctors can evaluate appropriateness based on the patient’s medical history, patient and caregiver knowledge and comfort, local Covid-19 burden and access to emergency services, he noted. A patient in hard-hit New York City or an emerging hotspot, for example, may be more reluctant to seek emergency care than one in a small town that’s relatively untouched by Covid-19.
The modified algorhithm is not a universal recommendation, said Dr. Julie Wang, professor of pediatrics at the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai in N.Y. “It’s not a blanket plan for all allergy patients.”
It provides guidance to doctors based on local risk assessment, she said. “There has to be an assurance that families will be capable and will be adherent and there will be at least two epinephrine autoinjectors available.”
It also comes with a kind of black box warning for patients who have had a severe reaction in the past that required intubation, ventilation or treatment with more than two doses of epinephrine. Patients who meet these criteria should activate emergency services immediately after injecting epinephrine, as usual.
What’s more, the most important medical advice for anaphylaxis treatment remains the same, Wang said.
“Epinephrine is and always was the first choice to treat anaphylaxis,” she said. “The number one recommendation is that epinephrine needs to be used early, and that has not changed and will not be changed.”
The modifications come at a time when Americans dramatically altered their use of emergency room care, according to data released early on June 3 from the Centers for Disease Control and Prevention (CDC).
Visits to emergency departments dropped 42% in April 2020 compared with April 2019 as the pandemic took hold, the CDC found. Decreases were most striking among children 14 and younger, women and people in the Northeast over those four weeks.
How it works
The pandemic-revised management protocol, published April 18 as an editorial in the Journal of Allergy and Clinical Immunology, has six steps. The first step is the same as the standard protocol: Inject epinephrine immediately upon signs and symptoms of anaphylaxis, keeping a telephone within reach. Note the time the dose was given.
It helps to remain as calm as possible. Prompt treatment with epinephrine, also called adrenaline, is associated with better outcomes. Anaphylaxis can be unpredictable, causing a range of signs and symptoms including shortness of breath, wheezing, hoarseness, trouble breathing or swallowing. Other symptoms may include abdominal pain, vomiting, faintness, dizziness, hives, and confusion or a feeling of doom.
After the first injection, alert a housemate or neighbor to the patient’s distress to recruit assistance. Next, the patient should lie down with legs elevated near an unlocked or open doorway to allow easy access in case people need to enter to help, according to the modified protocol.
Patients and caregivers should know they can call 911 any time after initial epinephrine use if symptoms escalate or they feel additional medical intervention is needed, said Casale, first author of the paper.
Families should not let fear of Covid-19 paralyze them, said Wang, also an author of the modified protocol. “If a patient needs to go to the hospital emergency room, there are enhanced measures in place” for safety. “We do not want patients to avoid seeing doctors…because of this concern.”
At this point, patients sticking with the home management plan can be administered an oral antihistamine such as cetirizine, although be aware it takes much longer to work and doesn’t work as well as epinephrine, Casale said. Patients with respiratory symptoms can use their prescribed albuterol inhaler for relief.
The final step is monitoring symptoms. Families that have home blood pressure monitors are encouraged to use them. If the top number (systolic) of the reading drops below 90 and the low number (diastolic) dips below 60, that’s typically low for a patient over age three, Casale said. Low blood pressure combined with a high pulse rate are warning signs of a more severe reaction, he said.
Don’t have a blood pressure monitor at home or don’t have a child size cuff? Watch for signs of low blood pressure, including dizziness or lightheadedness; nausea; fainting; lack of concentration; blurred vision; and cold, clammy, pale skin.
If symptoms improve after the first epinephrine injection, call your doctor on a non-urgent basis, according to the algorithm. If there is no improvement after five minutes, give the second injection, Casale said. “If symptoms don’t resolve after five minutes, then call 911. If they do, then notify your physician this has happened.”
Recovering patients need to be monitored for a potential biphasic reaction, a recurrence of symptoms within four to six hours after recovery. Caregivers may need to call the doctor once the patient’s initial severe reaction has resolved to request a refill of epinephrine autoinjectors to prepare for this possibility.
Plan ahead to reduce anxiety
Even before the pandemic, FARE has offered a Food Allergy & Anaphylaxis Emergency Care Plan and algorithm that doctors can customize for patients with known allergies. It can be used as a benchmark for recommended treatment in case a child has an allergic reaction. Some schools require students with allergies to keep a copy at the office or to go along on field trips. The American Academy of Pediatrics has a similar customizable document that can walk people through what to do in case of a mild to severe allergic reaction.
The last thing you want is added anxiety when minutes count. Planning ahead can ease the mental load during a crisis. Epinephrine autoinjectors are dispensed in sets of two in case the patient needs to have a second dose, so keep them stored together in original packaging where they’re easy to find and ready for use. Make sure they’re not expired.
The pandemic protocol modifications aren’t for everyone, and patients considering this route should seek input from their doctor, Casale said.
“You need to discuss this with your physician ahead of time so you’re not making these decisions when you’re having an acute problem,” he said.