Protecting our Teens: Anaphylaxis, EpiPens, High Risks

By: Haidy Marzouk, MD, MBA, FAAOA

In honor of kids ENT month, the AAOA would like to highlight a topic very important to our pediatric allergy population.  Anaphylaxis occurs in about 1.6%-5.1% of the US population.(1) Although known as a life-threatening rection, treatment with an epinephrine auto-injector (EpiPen or EA) can be a lifesaving treatment when given quickly.  Therefore, it is recommended that all patients at risk of anaphylaxis carry an EpiPen with them at all times in case of accidental exposure.  In studies of root cause analysis regarding death from anaphylaxis, delayed administration of epinephrine is high on the list.(3) 

The teenage years are a complex time in development when young people are gaining greater autonomy from their parents.  For teens with severe food or venom allergies, this evolution also entails them independently carrying and administering their EpiPens.  Food is the most common trigger for anaphylaxis episodes, and up to 8% of children in the US have food allergies. There are approximately 125,000 food-induced allergic reaction emergency department visits per year in the United States, 14,000 of which are due to anaphylaxis.  One study found that adolescents aged 13 to 19 are three to four times more likely to die from anaphylaxis than children. (2) Although a previous history of anaphylaxis, asthma and peanut allergy have been identified as risk factors for anaphylaxis, there is no reliable way of predicting who will have a life-threatening reaction. Teenagers are at particular risk with the peak incidence of deaths from anaphylaxis associated with peanut and tree nut allergy occurring in the 15 to 24 age group. (3) In one series, peanuts and tree nuts accounted for more than 90% of the fatalities. (4)

Despite these risk factors, data regarding carriage and use of EA among teens is surprising and shows a concerning trend.  There are many teenagers who do not regularly carry their EpiPens or even know how to properly use them. (1) Correct use of EA is surprisingly low, ranging from 16% to 32%, measured through both observational studies and patient reports. A recent meta-analysis of EA use found that the most common reasons for lack of use are availability, lack of education of parents/teens on how to administer the epinephrine, concern for systemic effects, misuse, and accidental administration. (1) Many parents are sometimes not comfortable with EA administration, much less teaching or encouraging their teens properly as they mature. (1) Previous studies suggest that teenagers and young adults take risks when managing their allergies. They do not always carry their emergency medication, eat foods labelled with “may contain” warnings, and don’t tell the people around them about their allergies. Teens with venom allergy tend to be more vigilant about carrying their EAs due to a perceived lack of exposure control.

Certain factors have been shown to influence adolescents’ decision making regarding EpiPens.  The size or bulk of the device was commented on by teens in survey studies saying that the size of the device influenced their decision not to carry it all the time.  Anxiety regarding needle and injection was present among several teenagers. Although fear of needles may impact usage, it was not necessarily shown to affect whether or not the teens carried the device.  Some teenagers suggested preferable alternatives to injections such as an oral medication.  Many adolescents also relied on other people to shoulder the responsibility of carrying the auto-injector. (3) Auto-injector training currently offered is often inadequate preparation for an emergency. (5) In another survey study of teens, only 66% of respondents reported always carrying their epinephrine auto-injectors; only 23% had ever used these. Adolescents did request more information regarding tips on eating out, traveling and food labels. Many were also concerned about the social stigma around their friends regarding their food allergies and carrying their EA. (6) More than half of teens surveyed in a study believed that educating other students at school about the seriousness of food allergies would make it easier to live with their food allergy. (7)

Given these findings, we have an onus of responsibility to our patients to help improve carriage and proper use of EA among our adolescent population.  Awareness and education regarding EA carriage and proper use is critical.  There are training videos and sheets geared towards teens available on-line to boost teen confidence with regards to EA administration.  Secondly, general education and awareness in schools regarding food allergies and EA will help decrease the stigma surrounding food allergies among teens.   Moreover, EAs needs to be easily accessible and low cost.  Currently, all 50 states have laws allowing students to carry and self-administer EpiPens.  Many states have also passed laws permitting schools to stock undesignated epinephrine for emergency use. (8) In addition, many providers fill out food allergy action plans for schools so that there is a plan in place should a teen have accidental exposure or ingestion of their allergen. The high cost of EAs is also a limiting step in accessibility for teens.  EpiPens range in cost between $650-750.  A generic two pack costs about $150. 

The AAOA provides extensive education to our membership regarding management of anaphylaxis and how to counsel patients regarding anaphylaxis.  We continue to advocate for our patient population young and old to keep them safe.

The upcoming Explorers Course 2025: Surgical & Medical Management of Airway Disease in Otolaryngology will have multiple lectures with pediatric focus. Learn more here.

References:

1. Glassberg B, Nowak-Wegrzyn A, Wang J. Factors contributing to underuse of epinephrine autoinjectors in pediatric patients with food allergy. Ann Allergy Asthma Immunol. 2021 Feb;126(2):175-179.e3. doi: 10.1016/j.anai.2020.09.012. Epub 2020 Sep 18. PMID: 32950683; PMCID: PMC7498408.
2. Lockey R. Adolescents and anaphylaxis. Prim Care Respir J. 2012 Dec;21(4):365-6. doi: 10.4104/pcrj.2012.00090. PMID: 23090435; PMCID: PMC6548055.
3. Macadam C, Barnett J, Roberts G, Stiefel G, King R, Erlewyn-Lajeunesse M, Holloway JA, Lucas JS. What factors affect the carriage of epinephrine auto-injectors by teenagers? Clin Transl Allergy. 2012 Feb 2;2(1):3. doi: 10.1186/2045-7022-2-3. PMID: 22409884; PMCID: PMC3299626.
4. Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001 Jan;107(1):191-3. doi: 10.1067/mai.2001.112031. PMID: 11150011.
5. Gallagher M, Worth A, Cunningham-Burley S, Sheikh A. Epinephrine auto-injector use in adolescents at risk of anaphylaxis: a qualitative study in Scotland, UK. Clin Exp Allergy. 2011 Jun;41(6):869-77. doi: 10.1111/j.1365-2222.2011.03743.x. Epub 2011 Apr 11. PMID: 21481022.
6. Worth A, Regent L, Levy M, Ledford C, East M, Sheikh A. Living with severe allergy: an Anaphylaxis Campaign national survey of young people. Clin Transl Allergy. 2013 Jan 22;3(1):2. doi: 10.1186/2045-7022-3-2. PMID: 23339770; PMCID: PMC3560150.
7. Monks H, Gowland MH, MacKenzie H, Erlewyn-Lajeunesse M, King R, Lucas JS, Roberts G. How do teenagers manage their food allergies? Clin Exp Allergy. 2010 Oct;40(10):1533-40. doi: 10.1111/j.1365-2222.2010.03586.x. Epub 2010 Aug 2. PMID: 20682004.
8. Allergyasthmanetwork.org Allergy & Asthma Advocacy: state laws