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Peer-reviewedCC BY-NC-NDThe Journal of Allergy and Clinical Immunology. in Practice

Prediction Model for Children With Anaphylaxis Who May Not Require Emergency Department Care: A Multicenter Retrospective Cohort Study

  • Timothy E. Dribin1
  • David Schnadower1
  • Hugh A. Sampson2
  • Yin Zhang3
  • Nanhua Zhang4
  • Stephen B. Freedman5
  • Mark I. Neuman6
  • David C. Brousseau7
  • Rakesh D. Mistry8
  • Stephanie Boyd1
  • Yonatan Wolnerman9
  • Patrick S. Walsh10
28 more authors
  • Craig Vander Wyst11
  • Vandana Thapar12
  • Jonathan Strutt13
  • Geetanjali Srivastava14
  • Nidhi V. Singh15
  • Christopher J. Russo7
  • Christian D. Pulcini16
  • Thuy L. Ngo17
  • Jo-Ann O. Nesiama18
  • Matthew M. Moake19
  • Ashley M. Metcalf20
  • Tamar R. Lubell21
  • Juhee Lee22
  • Chari D. Larsen23
  • Karen Y. Kwan24
  • Curtis L. Knoles25
  • Kajal Khanna26
  • Julia F. Freeman11
  • Justin R. Davis27
  • Alicia Daggett28
  • Joanna S. Cohen29
  • Ari R. Cohen30
  • Wee-Jhong Chua30
  • Sri S. Chinta10
  • Brittany Boswell26
  • Kelly R. Bergmann31
  • Paul L. Aronson8
  • Kenneth A. Michelson32
32 affiliations
  1. 1Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  2. 2Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
  3. 3Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  4. 4Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
  5. 5Departments of Pediatrics and Emergency Medicine, Division of Pediatric Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  6. 6Division of Emergency Medicine, Boston Children’s Hospital, Boston, Mass
  7. 7Department of Pediatrics, Nemours Children’s Health Delaware, Wilmington, Del
  8. 8Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Conn
  9. 9Albert Einstein College of Medicine / Jacobi Medical Center, Bronx, NY
  10. 10Section of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
  11. 11University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colo
  12. 12University of Texas-McGovern Medical School, Houston, Tex
  13. 13Department of Emergency Medicine, University of Minnesota, St. Paul and Minneapolis, Minn
  14. 14Department of Pediatrics, UT Southwestern, Dallas, Tex
  15. 15Department of Pediatrics, Division of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, Tex
  16. 16Department of Emergency Medicine and Pediatrics, University of Vermont Larner College of Medicine, Burlington, Vt
  17. 17Department of Pediatrics, Division of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, St. Petersburg, Fla
  18. 18Division of Pediatric Emergency Medicine, UT Southwestern Medical Center / Children’s Medical Center, Dallas, Tex
  19. 19Department of Pediatrics, Division of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, SC
  20. 20Rady Children’s Hospital, University of California San Diego, San Diego, Calif
  21. 21Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
  22. 22Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Philadelphia, Pa
  23. 23Department of Pediatrics, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah
  24. 24Division of Emergency Medicine and Transport, Los Angeles, Calif
  25. 25The Children’s Hospital at Oklahoma University Health, Oklahoma City, Okla
  26. 26Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Stanford University, Palo Alto, Calif
  27. 27Pediatric Emergency Medicine, University of Mississippi Medical Center, Jackson, Miss
  28. 28Department of Pediatrics at Children’s Mercy Kansas City, Kansas City, Mo
  29. 29The Johns Hopkins School of Medicine, Department of Pediatrics, Baltimore, Md
  30. 30Department of Emergency Medicine, Massachusetts General Brigham for Children, Harvard Medical School, Boston, Mass
  31. 31Department of Pediatric Emergency Medicine, Children’s Minnesota, St. Paul and Minneapolis, Minn
  32. 32Division of Emergency Medicine, Ann & Robert Lurie Children’s Hospital, Chicago, Ill
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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 less than 18 years who received 1 prehospital dose of epinephrine for allergic reactions between 2016 and 2019. The outcome was receipt of epinephrine after ED arrival. We used least absolute shrinkage and selection operator regression to derive the model in 70% of the patients to identify prehospital 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 (interquartile range, 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 nonspecific symptoms after epinephrine. In the external validation, 30% (65 of 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.

CONCLUSIONS:: 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.

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Cite

BibTeXRIS
BibTeX
@article{dribin2026prediction,
  title = {{Prediction Model for Children With Anaphylaxis Who May Not Require Emergency Department Care: A Multicenter Retrospective Cohort Study}},
  author = {Timothy E. Dribin and David Schnadower and Hugh A. Sampson and Yin Zhang and Nanhua Zhang and Stephen B. Freedman and Mark I. Neuman and David C. Brousseau and Rakesh D. Mistry and Stephanie Boyd and Yonatan Wolnerman and Patrick S. Walsh and Craig Vander Wyst and Vandana Thapar and Jonathan Strutt and Geetanjali Srivastava and Nidhi V. Singh and Christopher J. Russo and Christian D. Pulcini and Thuy L. Ngo and Jo-Ann O. Nesiama and Matthew M. Moake and Ashley M. Metcalf and Tamar R. Lubell and Juhee Lee and Chari D. Larsen and Karen Y. Kwan and Curtis L. Knoles and Kajal Khanna and Julia F. Freeman and Justin R. Davis and Alicia Daggett and Joanna S. Cohen and Ari R. Cohen and Wee-Jhong Chua and Sri S. Chinta and Brittany Boswell and Kelly R. Bergmann and Paul L. Aronson and Kenneth A. Michelson},
  journal = {The Journal of Allergy and Clinical Immunology. in Practice},
  year = {2026},
  month = jun,
  doi = {10.1016/j.jaip.2026.06.021},
  url = {https://europepmc.org/article/PMC/PMC13730628},
  note = {CC BY-NC-ND},
}
RIS
TY  - JOUR
TI  - Prediction Model for Children With Anaphylaxis Who May Not Require Emergency Department Care: A Multicenter Retrospective Cohort Study
AU  - Timothy E. Dribin
AU  - David Schnadower
AU  - Hugh A. Sampson
AU  - Yin Zhang
AU  - Nanhua Zhang
AU  - Stephen B. Freedman
AU  - Mark I. Neuman
AU  - David C. Brousseau
AU  - Rakesh D. Mistry
AU  - Stephanie Boyd
AU  - Yonatan Wolnerman
AU  - Patrick S. Walsh
AU  - Craig Vander Wyst
AU  - Vandana Thapar
AU  - Jonathan Strutt
AU  - Geetanjali Srivastava
AU  - Nidhi V. Singh
AU  - Christopher J. Russo
AU  - Christian D. Pulcini
AU  - Thuy L. Ngo
AU  - Jo-Ann O. Nesiama
AU  - Matthew M. Moake
AU  - Ashley M. Metcalf
AU  - Tamar R. Lubell
AU  - Juhee Lee
AU  - Chari D. Larsen
AU  - Karen Y. Kwan
AU  - Curtis L. Knoles
AU  - Kajal Khanna
AU  - Julia F. Freeman
AU  - Justin R. Davis
AU  - Alicia Daggett
AU  - Joanna S. Cohen
AU  - Ari R. Cohen
AU  - Wee-Jhong Chua
AU  - Sri S. Chinta
AU  - Brittany Boswell
AU  - Kelly R. Bergmann
AU  - Paul L. Aronson
AU  - Kenneth A. Michelson
PY  - 2026
DA  - 2026/06/24
JO  - The Journal of Allergy and Clinical Immunology. in Practice
DO  - 10.1016/j.jaip.2026.06.021
UR  - https://europepmc.org/article/PMC/PMC13730628
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 less than 18 years who received 1 prehospital dose of epinephrine for allergic reactions between 2016 and 2019. The outcome was receipt of epinephrine after ED arrival. We used least absolute shrinkage and selection operator regression to derive the model in 70% of the patients to identify prehospital 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 (interquartile range, 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 nonspecific symptoms after epinephrine. In the external validation, 30% (65 of 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.  CONCLUSIONS:: 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.
SN  - 2213-2198
SN  - 2213-2201
ER  -