Original Article
Patterns of Carriage of Prescribed Adrenaline Autoinjectors in 10- to 14-Year-Old Food-Allergic Students: A Population-Based Study

https://doi.org/10.1016/j.jaip.2018.06.025Get rights and content

Background

Adolescence is well recognized as a period of increased risk for severe and fatal food-induced anaphylaxis. Current Australian adrenaline autoinjector (AAI) prescription guidelines therefore suggest that consideration be given to AAI prescription in all adolescents with a food allergy. To date, however, few studies have assessed the AAI carriage behavior of adolescents prescribed AAI devices.

Objective

To determine the carriage behavior of prescribed AAI devices in a population-based sample of young Australian adolescents.

Methods

Students aged 10 to 14 years (and their parents) from randomly selected schools in metropolitan Melbourne completed self-administered questionnaires regarding the history and management of food allergy, including prescription and carriage of AAI device in different domains of school and social life.

Results

A total of 9816 students completed the questionnaire (46% response): 620 students were assessed to have likely IgE-mediated food allergy and 234 (38%) of these had been prescribed an AAI. Most students (93%; 95% CI, 89%-96%) who were prescribed AAIs reported that they provided their AAI and anaphylaxis action plan to their school. Adherence to AAI carriage in other domains of social life was poor, with 49% (95% CI, 42%-56%) never carrying their AAI in 1 or more locations. Carriage of the AAI device was particularly poor when students were independent of parental supervision: 32% (95% CI, 25%-39%) never carried it when they were by themselves, 28% (95% CI, 22%-36%) never carried it while out with friends, and 36% (95% CI, 30%-43%) never carried their AAI to sporting activities.

Conclusions

Carriage of AAI devices is suboptimal in young adolescents prescribed AAIs, particularly when young adolescents are independent of parental supervision.

Introduction

In recent decades there has been a significant increase in the prevalence of documented food allergy1 and food-related anaphylaxis in industrialized2, 3, 4, 5 and developing countries.6 The adolescent age group has been identified as being at particularly high risk of severe and fatal food-related anaphylaxis.3, 7, 8 A recent Australian study has also provided preliminary evidence for an acceleration in the frequency of anaphylaxis in children aged 4 to 15 years,9 which may be expected to result in increased morbidity and mortality in adolescents and young adults. Consistent with this, anaphylaxis fatality rates had risen in parallel with hospital anaphylaxis admission rates in Australia between 1997 and 2013,10 and most food-related anaphylaxis fatalities have continued to occur in adolescents and young adults.10

An important part of adolescence is that children gradually become more autonomous in making decisions as they become more independent of their parents. Adolescence is particularly challenging for young people with food allergy11, 12 who must learn to balance the risk of food reactions with their emerging social identity.11 As children with food allergy progress into adolescence, they become increasingly responsible for food choices, especially outside the home, and at the same time engage in behaviors that may place them at risk.13 Adolescents have high rates of poor adherence to medical treatment and are more likely to have poorly controlled asthma,14, 15 which is a well-recognized risk factor for fatal anaphylaxis.3, 7 They are also less likely to carry their adrenaline autoinjectors (AAIs),16 which in the event of an anaphylactic reaction would delay treatment, another risk factor for fatal anaphylaxis.3 It is also possible that there may be age-related hormonal changes that contribute to the vulnerability of the adolescent age group.17

Although adolescents are at particular risk for fatal food-related anaphylaxis, few studies have explored the potential risk factors in this group. Indeed, adolescents currently represent the most understudied patient group in allergy research. In this study, we sought to describe AAI carriage behavior and document the factors associated with poor adherence to AAI carriage among young adolescent students prescribed an AAI using a large population-based study investigating food allergy in the general community—the SchoolNuts Study.

Section snippets

Study population

Students in the 2 final years of primary school and the first 2 years of secondary school (aged 10-14 years) were recruited from randomly selected government and independent (private and Catholic) schools in metropolitan Melbourne, Australia, as described previously.18 This age group was selected to allow assessment of children across the transition from primary to secondary school when greater autonomy and independence occur. A total of 9816 students (46% response rate) participated in the

Study population

A total of 9816 students completed the questionnaire. Of these, 831 reported a current food allergy, with 620 assessed to have a history consistent with a likely IgE-mediated food allergy. Of the students with a likely IgE-mediated food allergy, 234 (38%) reported having been prescribed an AAI and were therefore included in our analyses (Figure 1). Demographic and clinical characteristics of these students are presented in Table I.

Most students (93% [95% CI, 89%-96%]) who were prescribed an AAI

Discussion

This study is the first to look at patterns of AAI carriage in young adolescents prescribed an AAI for food allergy using a large and representative population-based sampling frame. Our findings are therefore expected to be reflective of the full range of behaviors in this age group rather than limited to higher risk patients attending hospital clinics and outpatient services. We found that although adherence was good at school and while attending school-related activities, adherence was much

Conclusions

The study highlights that AAI carriage in this high-risk young adolescent group is suboptimal. Ensuring regular review of adolescent patients to review their need for AAI devices and reinforce management plans may help address this issue. Further research is needed to develop strategies to improve AAI carriage among adolescents with food allergy. Food-allergic young adolescents need to be informed about the specific risks of eating out and about reaction risks outside of the family home. It

Acknowledgments

We thank the children, parents, and schools that participated in the SchoolNuts Study. We also thank the SchoolNuts Safety Committee that comprised Associate Professor Noel Cranswick (Australian Paediatric Pharmacology Research Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia), Dr Jo Smart (Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, Victoria, Australia), and Professor Jo Douglass (Department of Clinical Immunology and Allergy, Royal

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    The SchoolNuts Study was supported by funding from the National Health and Medical Research Council of Australia (grant no. 1047396) and the Victorian Government's Operational Infrastructure Support Program.

    Conflicts of interest: M. Robinson has given presentations for Mylan (unpaid) and has been on advisory boards for Nestle Health and GlaxoSmithKline (GSK) (did not receive financial incentives). V. McWilliam personally received payments for lectures from Nestle and Nutricia for other works. J. Douglass personally received consultancy fees from GSK, AstraZeneca, and Seqirus and payments for lectures from AstraZeneca, GSK, Stallergenes, Novartis, Alphapharm, Shire, Mundipharma, Stallergenes-Greer, and Seqirus. Her institution received grants from Novartis Pharmaceuticals and payment for the development of educational presentations from Alogaogarm for other works. M.L.K. Tang is on the Nestle Medical Advisory Board Oceania and the Danone Nutricia Global Scientific Advisory Board; received consultancy fees from Deerfield Consulting, GLG consulting, and Bayer; is employed by ProTATherapeutics; received payment for lectures from Danone Nutricia; receives royalties from Wilkinson Publishing; has a patent through Murdoch Children's Research Institute; and received payment for the development of educational presentations from MD Linx. K.J. Allen personally received consultancy fees from Nestle, ThermoFisher, and AspenCare, and is on the Before Brands Scientific Advisory Board. The rest of the authors declare that they have no relevant conflicts of interest.

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