Using Evidence to Inform Care for Children Cut Hospitalizations for Anaphylaxis

After revising and implementing evidence-based guidelines (EBGs), a team at Boston Children’s Hospital was able to cut anaphylaxis-related hospitalizations among children by 17.3% without creating an increase in repeat visits.

The study, published Thursday in Pediatrics, showed that unnecessary hospitalizations can be safely avoided, according to the authors, who were on the team.

Emergency department (ED) visits for anaphylaxis—a serious, life-threatening allergic reaction—have doubled in the past decade while hospitalizations have increased 7-fold, with children’s cases increasing the most. US hospitalizations are as high as 98% in some locations, with a median of 40% to 50%, and children are also frequently hospitalized to observe biphasic reactions, which usually occurs within 4 hours of the initial allergic reaction and are often mild in nature.

In the United States, these hospitalizations also fuel health care spending and cause stress for families, while in other countries, such as Canada and Australia, pediatric hospitalization rates for anaphylaxis are less than 10%.

Besides looking to reduce hospitalizations, the team also wanted to see if they could optimize adjunctive treatment. In treating life-threatening allergic reactions, epinephrine is the only first-line therapy. The evidence on corticosteroids is mixed or lacking, yet it is prescribed as frequently or more so as epinephrine.

On the other hand, the evidence on nonsedating cetirizine (Zyrtec) to manage symptoms instead of diphenhydramine (Benadryl) is stronger, and yet, its uptake as an adjunctive treatment is variable. In addition to being nonsedating, cetririzine lasts longer, requiring less frequent dosing, and is as effective as diphenhydramine.

Boston Children's Hospital had previously implemented an EBG targeting hospitalizations for anaphylaxis and successfully reduced them from 54% to 36%. The hospital, which has a strong culture of using EBGs, then planned a second revision to the anaphylaxis EBG to take into account new best practices, including adjunctive treatments.

By implementing the revised EBG, the hospital aimed for ED clinicians to further cut hospitalization rates safely to 10%, increase the use of cetirizine as the first-line adjunctive antihistamine to 90%, and decrease corticosteroid use by 50%.

The revised EBG recommended that patients coming into the ED for anaphylaxis with continuing symptoms receive epinephrine and oral cetirizine, and that those with wheezing also receive albuterol and dexamethasone (the previous EBG included diphenhydramine and corticosteroids).

In addition, the revision recommended "hospitalization for patients with hypotension at any time, persistent wheezing or other system involvement without improvement, and/or 3 or more doses of intramuscular epinephrine." The previous EBG called for hospitalization when 2 or more doses of epinephrine were used, and if hypotension or wheezing occurred at any time.

To study the effects of the revisions, the authors examined all ED visits for patients with anaphylaxis between the ages 6 months and 18 years between January 1, 2014, and December 31, 2019. Outcomes were compared between the prerevision phase of the EBG (January 1, 2014, to May 22, 2018) with the implementation phase (May 23, 2018, to December 31, 2019). The team analyzed data from 1447 encounters.

Before the revision, 28.5% of children were hospitalized, compared with 11.2% in the implementation phase. For medication utilization, use of cetirizine increased from 4.2% to 59.7%, and the use of corticosteroids in patients without asthma fell from 72.6% to 32.4%. All of the results were statistically significant, although fell a bit short of the percentage decreases the hospital had set as targets.

"Importantly, we did not observe an increase in 72-hour revisits to the ED, suggesting there was not an associated increase in clinically significant cases of biphasic reaction despite the decrease in corticosteroid use," the authors noted. "On the contrary, the observed decrease in 72-hour revisits suggests improved control that may be enhanced by the accompanying education, follow-up, and medication provision recommended by the EBG."

Reference

Gaffney LK, Porter J, Gerling M, et al. Safely reducing hospitalizations for anaphylaxis in children through an evidence- based guideline. Pediatrics. Published online January 20, 2022. doi:10.1542/peds.2020-045831