Introduction
Oral food challenge (OFC) is the gold standard for diagnosing food allergies [1]. Some patients present with anaphylaxis and require intramuscular (IM) adrenaline injections. Previous studies reported that among pediatric patients with positive reactions during OFCs, 9–11% needed adrenaline injection [2, 3]. Furthermore, a previous study reported that 6% of reactions t­­reated with adrenaline required multiple IM adrenaline injections when the symptoms p­ersisted [4]. While most patients with anaphylaxis recover after IM adrenaline injection, patients requiring multiple doses are likely to require continuous adrenaline infusion [5]. In the Japanese food allergy guideline, the strategy is recommended is to be considered when response to treatment is not enough [6]”. Other guidelines for anaphylaxis recommend that only specialists use continuous adrenaline infusion because of adverse effects due to inappropriate dosage [7, 8]. Since patients who need continuous adrenaline infusion are limited, there are no randomized controlled trials or systematic reviews available. Recommendations for infusion doses are based on the physician’s experience.
We conducted a case-series study in the pediatric department in the Showa University Hospital. We aimed to analyze the patients who needed continuous adrenaline infusion during OFCs and suggest appropriate timing to start the therapy and the optimal dose.
Our hospital has provided OFCs with physicians and nurses trained in emergency interventions based on the pediatric advanced life support system. All medical equipment and infusion procedures were prepared according to the patients’ body weights before commencing the OFCs. A rapid response team consisting of medical emergency staff is arranged to be on call in the case of life-threatening events. IM adrenaline injection (0.01 mg/kg) was administered in accordance with the Japanese food allergy guideline [6]. In cases of anaphylactic shock, or symptoms requiring more than two doses of IM adrenaline, we immediately followed venous administration. Patients who required continuous adrenaline infusion were treated proactively if they showed severe symptoms refractory to IM adrenaline injection more than three times with appropriate support therapy, or if the effect of the medicine continued to incompletely improve the symptoms.
This study was approved by the ethics committee of the Showa University Hospital (approval number: 3486).