Development of a validated, updated North American pediatric food allergy anaphylaxis management plan.

Abstract

Background: Current North American anaphylaxis action plans (AAPs) lack updated anaphylaxis guidelines that conditionally recommend "immediate activation of emergency medical services" after epinephrine use for patients experiencing a "prompt, complete, and durable response" to treatment. This offers a contextualized "watchful waiting" approach. AAPs may not include newly approved nasal epinephrine or differentiate anaphylaxis presentations by age.

Objective: To develop an updated AAP.

Methods: A prototype AAP was iteratively developed incorporating a "watchful waiting" approach, the nasal epinephrine option, and age-specific anaphylaxis symptom presentations among a team of anaphylaxis experts and patient and advocacy stakeholders to assess medical accuracy, readability, clarity, and bias. This underwent validated assessment of decisional acceptability, decisional conflict, and decisional self-efficacy in a sample of stakeholders with children at risk for anaphylaxis, or at risk themselves.

Results: We developed a 2-page written plan (Flesch-Kincaid reading level 5.9) explaining management choices for severe and nonsevere reactions, indications for watchful waiting vs emergency medical services activation after epinephrine use, updated medication options, and age-based symptom differentiation. A total of 229 stakeholders assessed the AAP, noting good acceptability, high decisional self-efficacy (mean score 86.2/100, SD 15.9), and moderate decisional conflict (mean score 43.7/100, SD 18.8). Decisional conflict was unrelated to past anaphylaxis or epinephrine use. Information content was clear and sufficiently explained options with balanced and without a "best choice" bias. Overall, 86% of the respondents would recommend using this AAP.

Conclusion: This is the first validated AAP incorporating preference-sensitive post-epinephrine management options consistent with updated North American guidelines, newly approved nasal epinephrine, and age-specific anaphylaxis presentation.