Prediction model for children with anaphylaxis who may not require emergency department care: a multicenter retrospective cohort study

Timothy E Dribin; David Schnadower; Hugh A Sampson; Yin Zhang; Nanhua Zhang; Stephen B Freedman; Mark I Neuman; David C Brousseau; Rakesh D Mistry; Stephanie Boyd; Yonatan Wolnerman; Patrick S Walsh; Craig Vander Wyst; Vandana Thapar; Jonathan Strutt; Geetanjali Srivastava; Nidhi V Singh; Christopher J Russo; Christian D Pulcini; Thuy L Ngo; Jo-Ann O Nesiama; Matthew M Moake; Ashley M Metcalf; Tamar R Lubell; Juhee Lee; Chari D Larsen; Karen Y Kwan; Curtis L Knoles; Kajal Khanna; Julia F Freeman; Justin R Davis; Alicia Daggett; Joanna S Cohen; Ari R Cohen; Wee-Jhong Chua; Sri S Chinta; Brittany Boswell; Kelly R Bergmann; Paul L Aronson; Kenneth A Michelson

Prediction model for children with anaphylaxis who may not require emergency department care: a multicenter retrospective cohort study

Timothy E Dribin
, David Schnadower
, Hugh A Sampson
, Yin Zhang
, Nanhua Zhang
, Stephen B Freedman
, Mark I Neuman
, David C Brousseau
, Rakesh D Mistry
, Stephanie Boyd
, Yonatan Wolnerman
, Patrick S Walsh
, Craig Vander Wyst
, Vandana Thapar
, Jonathan Strutt
, Geetanjali Srivastava
, Nidhi V Singh
, Christopher J Russo
, Christian D Pulcini
, Thuy L Ngo

Jo-Ann O Nesiama, Matthew M Moake, Ashley M Metcalf, Tamar R Lubell, Juhee Lee, Chari D Larsen, Karen Y Kwan, Curtis L Knoles, Kajal Khanna, Julia F Freeman, Justin R Davis, Alicia Daggett, Joanna S Cohen, Ari R Cohen, Wee-Jhong Chua, Sri S Chinta, Brittany Boswell, Kelly R Bergmann, Paul L Aronson, Kenneth A Michelson

College of Medicine, University of Cincinnati
Cincinnati Children's Hospital Medical Center
University of Calgary
Harvard Medical School
Thomas Jefferson University
Yale School of Medicine
Medical College of Wisconsin
University of Colorado School of Medicine
University of Texas McGovern Medical School
University of Minnesota
Department of Pediatrics
Baylor College of Medicine
Larner College of Medicine at the University of Vermont
School of Medicine, Johns Hopkins University
Children's Medical Center/ UT Southwestern
Medical University of South Carolina
University of California San Diego
Columbia University Vagelos College of Physicians and Surgeons
The Children's Hospital of Philadelphia
University of Utah
The Children's Hospital at Oklahoma University Health
Stanford University
University of Mississippi Medical Center
University of Missouri-Kansas City School of Medicine
The Johns Hopkins School of Medicine
Children's Minnesota
Ann & Robert H. Lurie Children's Hospital

Producción científica › revisión exhaustiva

Resumen

BACKGROUND: The 2023 US Anaphylaxis Practice Parameter indicated that some patients receiving epinephrine in the community might avoid emergency department (ED) visits; however, the criteria and safety of this approach remain unproven.

OBJECTIVE: To derive and validate a clinical prediction model for identifying children at risk of receiving epinephrine after arriving at the ED.

METHODS: We conducted a 31-center retrospective cohort study of children aged 6 months to <18 years who received one pre-ED dose of epinephrine for allergic reactions between 2016 and 2019. The outcome was receipt of epinephrine after ED arrival. We used LASSO regression to derive the model in 70% of the patients to identify pre-ED factors associated with epinephrine administration. Internal and external validations included 20% and 10% of the cohort, respectively.

RESULTS: The 2318 eligible patients had a median age of 8.4 years (IQR, 3.8-13.4), and 15.7% (n = 364) received epinephrine after ED arrival. Prehospital factors associated with the receipt of additional epinephrine included a history of asthma, cardiovascular symptoms before epinephrine, persistent symptoms after epinephrine, and any new/recurrent respiratory, cardiovascular, gastrointestinal, or non-specific symptoms after epinephrine. In the external validation, 30% (65/216) of encounters were classified as low risk. The presence of any risk factor had a sensitivity of 0.93 (95% CI 0.80, 0.98), specificity of 0.35 (95% CI 0.28, 0.43), positive predictive value of 0.25 (95% CI 0.18, 0.33), and negative predictive value of 0.95 (95% CI 0.87, 0.99) for identifying patients who received epinephrine after ED arrival.

CONCLUSION: We developed and validated a clinical prediction model to identify children treated with a single prehospital dose of epinephrine who may not require ED care. Implementation of the model could reduce avoidable ED visits for children with anaphylaxis.

Idioma original	English
Publicación	Journal of Allergy and Clinical Immunology: In Practice
Fecha en línea anticipada	24 jun 2026
Estado	Published - 24 jun 2026

Otros archivos y enlaces

Citar esto

Dribin, T. E., Schnadower, D., Sampson, H. A., Zhang, Y., Zhang, N., Freedman, S. B., Neuman, M. I., Brousseau, D. C., Mistry, R. D., Boyd, S., Wolnerman, Y., Walsh, P. S., Wyst, C. V., Thapar, V., Strutt, J., Srivastava, G., Singh, N. V., Russo, C. J., Pulcini, C. D., ... Michelson, K. A. (2026). Prediction model for children with anaphylaxis who may not require emergency department care: a multicenter retrospective cohort study. Journal of Allergy and Clinical Immunology: In Practice.

@article{9c2cede26d324439beacfca5dd27dc9e,

title = "Prediction model for children with anaphylaxis who may not require emergency department care: a multicenter retrospective cohort study",

abstract = "BACKGROUND: The 2023 US Anaphylaxis Practice Parameter indicated that some patients receiving epinephrine in the community might avoid emergency department (ED) visits; however, the criteria and safety of this approach remain unproven.OBJECTIVE: To derive and validate a clinical prediction model for identifying children at risk of receiving epinephrine after arriving at the ED.METHODS: We conducted a 31-center retrospective cohort study of children aged 6 months to <18 years who received one pre-ED dose of epinephrine for allergic reactions between 2016 and 2019. The outcome was receipt of epinephrine after ED arrival. We used LASSO regression to derive the model in 70\% of the patients to identify pre-ED factors associated with epinephrine administration. Internal and external validations included 20\% and 10\% of the cohort, respectively.RESULTS: The 2318 eligible patients had a median age of 8.4 years (IQR, 3.8-13.4), and 15.7\% (n = 364) received epinephrine after ED arrival. Prehospital factors associated with the receipt of additional epinephrine included a history of asthma, cardiovascular symptoms before epinephrine, persistent symptoms after epinephrine, and any new/recurrent respiratory, cardiovascular, gastrointestinal, or non-specific symptoms after epinephrine. In the external validation, 30\% (65/216) of encounters were classified as low risk. The presence of any risk factor had a sensitivity of 0.93 (95\% CI 0.80, 0.98), specificity of 0.35 (95\% CI 0.28, 0.43), positive predictive value of 0.25 (95\% CI 0.18, 0.33), and negative predictive value of 0.95 (95\% CI 0.87, 0.99) for identifying patients who received epinephrine after ED arrival.CONCLUSION: We developed and validated a clinical prediction model to identify children treated with a single prehospital dose of epinephrine who may not require ED care. Implementation of the model could reduce avoidable ED visits for children with anaphylaxis.",

keywords = "Acute allergic reactions, Anaphylaxis, Epinephrine, Prehospital, Refractory anaphylaxis",

author = "Dribin, \{Timothy E\} and David Schnadower and Sampson, \{Hugh A\} and Yin Zhang and Nanhua Zhang and Freedman, \{Stephen B\} and Neuman, \{Mark I\} and Brousseau, \{David C\} and Mistry, \{Rakesh D\} and Stephanie Boyd and Yonatan Wolnerman and Walsh, \{Patrick S\} and Wyst, \{Craig Vander\} and Vandana Thapar and Jonathan Strutt and Geetanjali Srivastava and Singh, \{Nidhi V\} and Russo, \{Christopher J\} and Pulcini, \{Christian D\} and Ngo, \{Thuy L\} and Nesiama, \{Jo-Ann O\} and Moake, \{Matthew M\} and Metcalf, \{Ashley M\} and Lubell, \{Tamar R\} and Juhee Lee and Larsen, \{Chari D\} and Kwan, \{Karen Y\} and Knoles, \{Curtis L\} and Kajal Khanna and Freeman, \{Julia F\} and Davis, \{Justin R\} and Alicia Daggett and Cohen, \{Joanna S\} and Cohen, \{Ari R\} and Wee-Jhong Chua and Chinta, \{Sri S\} and Brittany Boswell and Bergmann, \{Kelly R\} and Aronson, \{Paul L\} and Michelson, \{Kenneth A\}",

note = "Copyright {\textcopyright} 2026. Published by Elsevier Inc.",

year = "2026",

month = jun,

day = "24",

language = "English",

journal = "Journal of Allergy and Clinical Immunology: In Practice",

issn = "2213-2198",

publisher = "American Academy of Allergy, Asthma and Immunology",

}

Dribin, TE, Schnadower, D, Sampson, HA, Zhang, Y, Zhang, N, Freedman, SB, Neuman, MI, Brousseau, DC, Mistry, RD, Boyd, S, Wolnerman, Y, Walsh, PS, Wyst, CV, Thapar, V, Strutt, J, Srivastava, G, Singh, NV, Russo, CJ, Pulcini, CD, Ngo, TL, Nesiama, J-AO, Moake, MM, Metcalf, AM, Lubell, TR, Lee, J, Larsen, CD, Kwan, KY, Knoles, CL, Khanna, K, Freeman, JF, Davis, JR, Daggett, A, Cohen, JS, Cohen, AR, Chua, W-J, Chinta, SS, Boswell, B, Bergmann, KR, Aronson, PL & Michelson, KA 2026, 'Prediction model for children with anaphylaxis who may not require emergency department care: a multicenter retrospective cohort study', Journal of Allergy and Clinical Immunology: In Practice.

TY - JOUR

T1 - Prediction model for children with anaphylaxis who may not require emergency department care

T2 - a multicenter retrospective cohort study

AU - Dribin, Timothy E

AU - Schnadower, David

AU - Sampson, Hugh A

AU - Zhang, Yin

AU - Zhang, Nanhua

AU - Freedman, Stephen B

AU - Neuman, Mark I

AU - Brousseau, David C

AU - Mistry, Rakesh D

AU - Boyd, Stephanie

AU - Wolnerman, Yonatan

AU - Walsh, Patrick S

AU - Wyst, Craig Vander

AU - Thapar, Vandana

AU - Strutt, Jonathan

AU - Srivastava, Geetanjali

AU - Singh, Nidhi V

AU - Russo, Christopher J

AU - Pulcini, Christian D

AU - Ngo, Thuy L

AU - Nesiama, Jo-Ann O

AU - Moake, Matthew M

AU - Metcalf, Ashley M

AU - Lubell, Tamar R

AU - Lee, Juhee

AU - Larsen, Chari D

AU - Kwan, Karen Y

AU - Knoles, Curtis L

AU - Khanna, Kajal

AU - Freeman, Julia F

AU - Davis, Justin R

AU - Daggett, Alicia

AU - Cohen, Joanna S

AU - Cohen, Ari R

AU - Chua, Wee-Jhong

AU - Chinta, Sri S

AU - Boswell, Brittany

AU - Bergmann, Kelly R

AU - Aronson, Paul L

AU - Michelson, Kenneth A

PY - 2026/6/24

Y1 - 2026/6/24

N2 - BACKGROUND: The 2023 US Anaphylaxis Practice Parameter indicated that some patients receiving epinephrine in the community might avoid emergency department (ED) visits; however, the criteria and safety of this approach remain unproven.OBJECTIVE: To derive and validate a clinical prediction model for identifying children at risk of receiving epinephrine after arriving at the ED.METHODS: We conducted a 31-center retrospective cohort study of children aged 6 months to <18 years who received one pre-ED dose of epinephrine for allergic reactions between 2016 and 2019. The outcome was receipt of epinephrine after ED arrival. We used LASSO regression to derive the model in 70% of the patients to identify pre-ED factors associated with epinephrine administration. Internal and external validations included 20% and 10% of the cohort, respectively.RESULTS: The 2318 eligible patients had a median age of 8.4 years (IQR, 3.8-13.4), and 15.7% (n = 364) received epinephrine after ED arrival. Prehospital factors associated with the receipt of additional epinephrine included a history of asthma, cardiovascular symptoms before epinephrine, persistent symptoms after epinephrine, and any new/recurrent respiratory, cardiovascular, gastrointestinal, or non-specific symptoms after epinephrine. In the external validation, 30% (65/216) of encounters were classified as low risk. The presence of any risk factor had a sensitivity of 0.93 (95% CI 0.80, 0.98), specificity of 0.35 (95% CI 0.28, 0.43), positive predictive value of 0.25 (95% CI 0.18, 0.33), and negative predictive value of 0.95 (95% CI 0.87, 0.99) for identifying patients who received epinephrine after ED arrival.CONCLUSION: We developed and validated a clinical prediction model to identify children treated with a single prehospital dose of epinephrine who may not require ED care. Implementation of the model could reduce avoidable ED visits for children with anaphylaxis.

AB - BACKGROUND: The 2023 US Anaphylaxis Practice Parameter indicated that some patients receiving epinephrine in the community might avoid emergency department (ED) visits; however, the criteria and safety of this approach remain unproven.OBJECTIVE: To derive and validate a clinical prediction model for identifying children at risk of receiving epinephrine after arriving at the ED.METHODS: We conducted a 31-center retrospective cohort study of children aged 6 months to <18 years who received one pre-ED dose of epinephrine for allergic reactions between 2016 and 2019. The outcome was receipt of epinephrine after ED arrival. We used LASSO regression to derive the model in 70% of the patients to identify pre-ED factors associated with epinephrine administration. Internal and external validations included 20% and 10% of the cohort, respectively.RESULTS: The 2318 eligible patients had a median age of 8.4 years (IQR, 3.8-13.4), and 15.7% (n = 364) received epinephrine after ED arrival. Prehospital factors associated with the receipt of additional epinephrine included a history of asthma, cardiovascular symptoms before epinephrine, persistent symptoms after epinephrine, and any new/recurrent respiratory, cardiovascular, gastrointestinal, or non-specific symptoms after epinephrine. In the external validation, 30% (65/216) of encounters were classified as low risk. The presence of any risk factor had a sensitivity of 0.93 (95% CI 0.80, 0.98), specificity of 0.35 (95% CI 0.28, 0.43), positive predictive value of 0.25 (95% CI 0.18, 0.33), and negative predictive value of 0.95 (95% CI 0.87, 0.99) for identifying patients who received epinephrine after ED arrival.CONCLUSION: We developed and validated a clinical prediction model to identify children treated with a single prehospital dose of epinephrine who may not require ED care. Implementation of the model could reduce avoidable ED visits for children with anaphylaxis.

KW - Acute allergic reactions

KW - Anaphylaxis

KW - Epinephrine

KW - Prehospital

KW - Refractory anaphylaxis

UR - https://nemours.elsevierpure.com/en/publications/9c2cede2-6d32-4439-beac-fca5dd27dc9e

UR - https://www.scopus.com/pages/publications/105045128671

M3 - Article

C2 - 42342031

SN - 2213-2198

JO - Journal of Allergy and Clinical Immunology: In Practice

JF - Journal of Allergy and Clinical Immunology: In Practice

ER -

Prediction model for children with anaphylaxis who may not require emergency department care: a multicenter retrospective cohort study

Resumen

Otros archivos y enlaces

Huella

Citar esto