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Background: Food allergies, particularly peanut, represent the predominant cause of anaphylaxis. Whereas early allergen introduction has emerged as a potential preventive strategy, the precise impact of recent guidelines on peanut-induced anaphylaxis rates in Canada remains unclear., Objective: To assess the impact of the 2017 Addendum Guidelines for the Prevention of Peanut Allergy on peanut-induced anaphylaxis rates in Canada., Methods: Using a comprehensive longitudinal registry capturing pediatric anaphylaxis presentations to the Montreal's Children's Hospital, we compared children with and without known peanut allergy who presented with peanut-induced anaphylaxis between 2011 and 2019 inclusive, excluding data beyond 2019 owing to the Coronavirus disease 2019 (COVID-19) pandemic. We calculated rates of peanut-induced anaphylaxis presentations per 100,000 age-adjusted all-cause emergency department visits using 4-month intervals. Interrupted time series analysis was used to compare anaphylaxis rate trends before and after 2017 for children ages 0 to 2 and 3 to 17 years., Results: We examined 2,011 cases of pediatric anaphylaxis, including 429 (21%) triggered by peanuts. Compared with pre-guideline estimates, the yearly rate of change of peanut anaphylaxis rates decreased by 7.96 (95% confidence interval -14.57 to -1.36; P = .018) after 2017 among patients with new-onset anaphylaxis in children 2 years of age or younger (n = 109). No significant changes were identified for older patients ages 3 to 17, or in patients with known peanut allergy., Conclusions: Early introduction guidelines in Canada are associated with a reduced risk of new-onset peanut-induced anaphylaxis in young children within a single center in Montreal. Further research is required to assess the impact on a wider population and other food allergens., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Egg is the third most common food allergy in children; however, data on pediatric egg-induced anaphylaxis are sparse., Objective: To describe the clinical characteristics, management, and outcomes of pediatric egg-induced anaphylaxis., Methods: Children presenting with anaphylaxis were recruited from 13 emergency departments as part of the Cross-Canada Anaphylaxis Registry, from which data on anaphylaxis triggered by egg were extracted. Multivariate logistic regression was used to determine factors associated with prehospital epinephrine autoinjector (EAI) use and to compare anaphylaxis triggered by egg with other triggers of food-induced anaphylaxis (FIA)., Results: We recruited 302 children with egg-induced anaphylaxis. The mean age was 2.6 years (SD = 3.6), and 55.3% were male. Only 39.4% had previously been diagnosed with an egg allergy. Prehospital EAI use was 32.1%, but this was not significantly lower than in other triggers of FIA (P = .26). Only 1.4% of patients required hospital admission. Relative to other triggers of FIA, patients with egg-induced anaphylaxis were significantly younger (P < .001) and exhibited more vomiting (P = .0053) and less throat tightness (P = .0015) and angioedema (P < .001)., Conclusion: To the best of our knowledge, this is the largest published cohort of pediatric egg-induced anaphylaxis. In this cohort, prehospital EAI use was very low. In addition, we identified certain symptoms that distinguish egg-induced from other triggers of FIA. Taken together, high suspicion is crucial in identifying egg-induced anaphylaxis, given the younger patient demographic and frequent lack of FIA history., Competing Interests: Disclosures The authors have no conflicts of interest to report., (Copyright © 2024 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Cow's milk is one of the most common and burdensome allergens in pediatrics, and it can induce severe anaphylactic reactions in children. However, data on cow's milk-induced anaphylaxis are sparse., Objective: To describe the epidemiology of pediatric cow's milk-induced anaphylaxis and to determine risk factors for repeat emergency department (ED) epinephrine administration., Methods: Between April 2011 and May 2023, data were collected on children with anaphylaxis presenting to 10 Canadian EDs. A standardized form documenting symptoms, triggers, treatment, and outcome was used. Multivariate logistic regression was used., Results: Of 3118 anaphylactic reactions, 319 milk-induced anaphylaxis cases were identified (10%). In the prehospital setting, 54% of patients with milk-induced anaphylaxis received intramuscular epinephrine. In those with milk-induced anaphylaxis, receiving epinephrine before presenting to the ED was associated with a reduced risk of requiring 2 or more epinephrine doses in the ED (adjusted odds ratio, 0.95 [95% CI, 0.90-0.99]). Children younger than 5 years of age were more likely to experience a mild reaction compared with that in older children, who experienced a moderate reaction more often (P < .0001). Compared with other forms of food-induced anaphylaxis, children presenting with milk-induced anaphylaxis were younger; a greater proportion experienced wheezing and vomiting, and less experienced angioedema., Conclusion: Prehospital epinephrine in pediatric milk-induced anaphylaxis is underused; however, it may decrease risk of requiring 2 ED epinephrine doses. Milk-induced anaphylaxis in children younger than 5 years of age may be less severe than in older children. Wheezing and vomiting are more prevalent in milk-induced anaphylaxis compared with that of other foods., Competing Interests: Disclosures The authors have no conflicts of interest to report., (Copyright © 2023 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Epinephrine is the first-line treatment for anaphylaxis but is often replaced with antihistamines or corticosteroids. Delayed epinephrine administration is a risk factor for fatal anaphylaxis. Convincing data on the role of antihistamines and corticosteroids in anaphylaxis management are sparse., Objective: To establish the impact of prehospital treatment with epinephrine, antihistamines, and/or corticosteroids on anaphylaxis management., Methods: Patients presenting with anaphylaxis were recruited prospectively and retrospectively in 10 Canadian and 1 Israeli emergency departments (EDs) between April 2011 and August 2022, as part of the Cross-Canada Anaphylaxis REgistry. Data on anaphylaxis cases were collected using a standardized form. Primary outcomes were uncontrolled reactions (>2 doses of epinephrine in ED), no prehospital epinephrine use, use of intravenous fluids in ED, and hospital admission. Multivariate regression was used to identify factors associated with primary outcomes., Results: Among 5364 reactions recorded, median age was 8.8 years (IQR, 3.78-16.9); 54.9% of the patients were males, and 52.5% had a known food allergy. In the prehospital setting, 37.9% received epinephrine; 44.3% received antihistamines, and 3.15% received corticosteroids. Uncontrolled reactions happened in 250 reactions. Patients treated with prehospital epinephrine were less likely to have uncontrolled reactions (adjusted odds ratio [aOR], 0.955 [95% CI, 0.943-0.967]), receive intravenous fluids in ED (aOR, 0.976 [95% CI, 0.959-0.992]), and to be admitted after the reaction (aOR, 0.964 [95% CI, 0.949-0.980]). Patients treated with prehospital antihistamines were less likely to have uncontrolled reactions (aOR, 0.978 [95% CI, 0.967-0.989]) and to be admitted after the reaction (aOR, 0.963 [95% CI, 0.949-0.977]). Patients who received prehospital corticosteroids were more likely to require intravenous fluids in ED (aOR, 1.059 [95% CI, 1.013-1.107]) and be admitted (aOR, 1.232 [95% CI, 1.181-1.286])., Conclusion: Our findings in this predominantly pediatric population support the early use of epinephrine and suggest a beneficial effect of antihistamines. Corticosteroid use in anaphylaxis should be revisited., (Copyright © 2023 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Anaphylaxis is an acute systemic and potentially fatal allergic reaction. We evaluated trends in yearly rates of anaphylaxis in a pediatric Emergency Department (ED) in Montreal, Canada., Methods: A prospective and retrospective recruitment process was used to find families of children who had presented with anaphylaxis at the Montreal Children's Hospital between April 2011 and April 2021. Using a uniform recruitment form, data were collected. Anaphylaxis patterns were compared to clinical triggers using descriptive analysis., Results: Among 830,382 ED visits during the study period, 2726 (26% recruited prospectively) presented with anaphylaxis. The median age was 6 years (IQR: 0.2, 12.00), and 58.7% were males. The relative frequency of anaphylaxis cases doubled between 2011-2015, from 0.22% (95% CI, 0.19, 0.26) to 0.42 March 2020, the total absolute number of anaphylaxis cases and relative frequency declined by 24 cases per month (p < 0.05) and by 0.5% of ED visits (p < 0.05)., Conclusions: The rate of anaphylaxis has changed over the years, representing modifications in food introduction strategies or lifestyle changes. The decrease in the frequency of anaphylaxis presenting to the ED during the COVID pandemic may reflect decreased accidental exposures with reduced social gatherings, closed school, and reluctance to present to ED.

Background: Prompt epinephrine autoinjector (EAI) use is the primary treatment for anaphylaxis. However, limited Canadian data exist on the impact of reaction location on EAI use for food-induced anaphylaxis (FIA)., Objective: We sought to investigate the setting, management, and severity of pediatric FIA., Methods: We recruited children presenting with FIA from 11 Canadian emergency departments. Patient demographics and the setting, management, and symptoms of FIA were collected by standardized questionnaire. Factors associated with prehospital EAI use and reaction severity were determined by logistic regression., Results: We recruited 3,604 children; 60.2% were male and the median age was 5.0 years (interquartile range 1.8-11.0). Among cases with a known location of FIA (85.0%), home was the most common setting (68.1%), followed by school/daycare (12.8%), other locations (11.4%; eg, park, car), and restaurants (7.4%). In the prehospital setting, EAI was administered in 36.7% of reactions at home, 66.7% in school/daycare, 40.2% in other locations, and 44.5% in restaurants. Relative to reactions occurring at school/daycare, prehospital EAI use was less likely at home (adjusted odds ratio [aOR] 0.80; 95% CI 0.76-0.84), in restaurants (aOR 0.81; 95% CI 0.75-0.87), and in other settings (aOR 0.77; 95% CI 0.73-0.83), when data were adjusted for reaction severity, sex, age, comorbidities, and province. The FIA setting was not associated with reaction severity or hospitalization., Conclusions: Prehospital EAI use was higher at school/daycare than in other settings, potentially owing to the presence of policies and training on FIA. Setting-specific interventions including educational programs and policies/laws mandating training and stocking an EAI may improve anaphylaxis recognition and treatment., (Copyright © 2022 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Data are sparse regarding tree nut-induced anaphylaxis (TNA)., Objective: To characterize rate, clinical characteristics, and management of TNA in children (0-17 years old) across Canada and evaluate factors associated with severe reactions and epinephrine use., Methods: Between April 2011 and May 2020, data were collected on children presenting to 5 emergency departments in Canada. Multivariate logistic analysis was used to evaluate factors associated with severe reactions (stridor, cyanosis, circulatory collapse, or hypoxia) and epinephrine use., Results: Among 3096 cases of anaphylaxis, 540 (17%) were induced by tree nut. The median age was 5.2 (interquartile range, 2.5-9.5) years and 65.4% were of male sex. Among all reactions, 7.0% were severe. The major tree nuts accounting for anaphylaxis were cashew (32.8%), hazelnut (20.0%), and walnut (11.5%). Cashew-induced anaphylaxis was more common in British Columbia (14.0% difference [95% confidence interval (CI), 1.6-27.6]) vs Ontario and Quebec, whereas pistachio-induced anaphylaxis was more common in Ontario and Quebec (6.3% difference [95% CI, 0.5-12.2]). Prehospital and emergency department intramuscular epinephrine administration was documented in only 35.2% and 52.4% of cases, respectively. Severe reactions were more likely among of male sex (adjusted odds ratio [aOR], 1.05 [95% CI, 1.01-1.10]), older children (aOR, 1.00 [95% CI, 1.00-1.01]), and in reactions triggered by macadamia (aOR, 1.27 [95% CI, 1.03-1.57])., Conclusion: Different TNA patterns in Canada may be because of differences in lifestyle (higher prevalence of Asian ethnicity in British Columbia vs Arabic ethnicity in Ontario and Quebec). Intramuscular epinephrine underutilization urges for epinephrine autoinjector stocking in schools and restaurants, patient education, and consistent policies across Canada., (Copyright © 2022 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Sesame can cause severe allergic reactions and is a priority allergen in Canada., Objective: To assess clinical characteristics and management of pediatric sesame-induced anaphylaxis and identify factors associated with epinephrine treatment., Methods: Between 2011 and 2021, children with sesame-induced anaphylaxis presenting to 7 emergency departments (ED) in 4 Canadian provinces and 1 regional emergency medical service were enrolled in the Cross-Canada Anaphylaxis Registry. Standardized recruitment forms provided data on symptoms, severity, triggers, and management. Multivariate logistic regression evaluated associations with epinephrine treatment pre-ED and multiple epinephrine dosages., Results: Of all food-induced anaphylactic reactions (n = 3279 children), sesame accounted for 4.0% (n = 130 children), of which 61.5% were boys, and the average (SD) age was 5.0 (4.9) years. Hummus containing sesame paste triggered 58.8% of reactions. In the pre-ED setting, 32.3% received epinephrine, and it was more likely to be used in boys (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.08-1.50) and those with a known food allergy (aOR, 1.36; 95% CI, 1.11-1.68]). In the ED, 47.7% of cases received epinephrine, with older children more likely to receive multiple epinephrine doses (aOR, 1.00; 95% CI, 1.00-1.02)., Conclusion: In Canada, hummus is the major trigger of sesame-induced anaphylaxis. Knowledge translation focused on prompt epinephrine use and product-labeling policies are required to limit sesame reactions in communities., (Copyright © 2022 American College of Allergy, Asthma & Immunology. All rights reserved.)

Background: There is a lack of data on seafood-induced anaphylaxis in children in Canada., Objective: To evaluate the rate, clinical features, and management of seafood-induced anaphylaxis in children presenting to emergency departments across Canada., Methods: Children with anaphylaxis were recruited at 6 emergency departments between 2011 and 2020 as part of the Cross-Canada Anaphylaxis REgistry. A standardized form documenting symptoms, triggers, comorbidities, and management was used to collect data., Results: There were 75 fish-induced and 71 shellfish-induced cases of suspected anaphylaxis, most of which were caused by salmon and shrimp, respectively. Mucocutaneous symptoms were most common, whereas respiratory symptoms were associated with patients with fish-induced reactions who have comorbid asthma (adjusted odds ratio [aOR], 1.18; 95% confidence interval [CI], 1.02-1.36). Prehospital epinephrine was underused (<35%), whereas in-hospital epinephrine was given to less than 60% of the patients. Among those with a known fish or shellfish allergy, prehospital epinephrine use was associated with known asthma (aOR 1.39 [95% CI, 1.05-1.84] and aOR 1.25 [95% CI, 1.02-1.54], respectively). Among children who were assessed by either skin test or specific immunoglobulin E, 36 patients (76.6%) with suspected fish-induced anaphylaxis and 19 patients (51.4%) with suspected shellfish-induced anaphylaxis tested positive., Conclusion: Prehospital epinephrine is underused in the management of seafood-induced anaphylaxis. Among children with known seafood allergy, prehospital epinephrine use is more likely if there is a known asthma comorbidity., (Copyright © 2022 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Data are sparse regarding the clinical characteristics and management of fruit-induced anaphylaxis., Objective: To assess clinical characteristics and management of patients with fruit-induced anaphylaxis and determine factors associated with severe reactions and epinephrine use., Methods: Over 9 years, children and adults presenting with anaphylaxis to seven emergency departments in four Canadian provinces and patients requiring emergency medical services in Outaouais, Quebec were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting symptoms, triggers, and management was collected. Multivariate logistic regression was used to identify factors associated with severe reactions and epinephrine treatment in the pre-hospital setting., Results: We recruited 250 patients with fruit-induced anaphylaxis, median age 10.2 years (interquartile range, 3.6-23.4 years); 48.8% were male. The most common fruit triggers were kiwi (15.6%), banana (10.8%), and mango (9.2%). Twenty-three patients reported having eczema (9.3%). Epinephrine use was low in both the pre-hospital setting and the emergency department (28.4% and 40.8%, respectively). Severe reactions to fruit were more likely to occur in spring and among those with eczema (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI], 1.03-1.23; and 1.17, 95% CI, 1.03-1.34, respectively). Patients with moderate and severe reactions (aOR = 1.23; 95% CI, 1.06-1.43) and those with a known food allergy (aOR = 1.38; 95% CI, 1.24-1.54) were more likely to be treated with epinephrine in the pre-hospital setting., Conclusions: Severe anaphylaxis to fruit is more frequent in spring. Cross-reactivity to pollens is a potential explanation that should be evaluated further., (Copyright © 2021 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: It is not established whether the risk of anaphylaxis induced by peanuts or tree nuts in children increases at specific times of the year. We aimed to evaluate the risk of peanut-and tree-nut-induced anaphylaxis during certain cultural holidays in Canadian children., Methods: We collected data on confirmed pediatric cases of anaphylaxis presenting to emergency departments in 4 Canadian provinces as part of the Cross-Canada Anaphylaxis Registry. We assessed the mean number of cases per day and incidence rate ratio (IRR) of anaphylaxis induced by unknown nuts, peanuts and tree nuts presenting during each of 6 holidays (Halloween, Christmas, Easter, Diwali, Chinese New Year and Eid al-Adha) versus the rest of the year. We estimated IRRs and 95% confidence intervals (CIs) using Poisson regression., Results: Data were collected for 1390 pediatric cases of anaphylaxis between 2011 and 2020. Their median age was 5.4 years, and 864 (62.2%) of the children were boys. During Halloween and Easter, there were higher rates of anaphylaxis to unknown nuts (IRR 1.66, 95% CI 1.13-2.43 and IRR 1.71, 95% CI 1.21-2.42, respectively) and peanuts (IRR 1.86, 95% CI 1.12-3.11 and IRR 1.57, 95% CI 0.94-2.63, respectively) compared to the rest of the year. No increased risk of peanut- or tree-nut-induced anaphylaxis was observed during Christmas, Diwali, Chinese New Year or Eid al-Adha. Anaphylaxis induced by unknown nuts, peanuts and tree nuts was more likely in children aged 6 years or older than in younger children., Interpretation: We found an increased risk of anaphylaxis induced by unknown nuts and peanuts during Halloween and Easter among Canadian children. Educational tools are needed to increase awareness and vigilance in order to decrease the risk of anaphylaxis induced by peanuts and tree nuts in children during these holidays., Competing Interests: Competing interests: Judy Morris received a grant from AllerGen Canada (Allergy, Genes and Environment Network), a Networks of Centres of Excellence research network, to allow the data for the project to be collected at her university hospital. AllerGen Canada is a not-for-profit network based at McMaster University. Julia Upton received advisor fees from Food Allergy Canada, ALK-Abelló, Kaléo and Bausch Health; research grant support from the Toronto SickKids Food Allergy and Anaphylaxis fund, DBV Technologies, Regeneron, the Canadian Institutes of Health Research and ALK-Abelló; and an in-kind contribution from Novartis, outside the submitted work. No other competing interests were declared., (© 2020 Joule Inc. or its licensors.)

Background: Studies assessing the use of antihistamines and corticosteroids for the treatment of anaphylaxis have not supported a conclusive effect., Objective: To assess prehospital management of anaphylaxis by measuring the effect of epinephrine use compared with antihistamines and corticosteroids on negative outcomes of anaphylaxis (intensive care unit/hospital ward admission, multiple doses of epinephrine in the emergency department [ED], and intravenous fluids given in the ED)., Methods: The Cross-Canada Anaphylaxis Registry is a cohort study that enrolls anaphylaxis cases presenting to EDs in 5 Canadian provinces over a 6-year period. Participants were recruited prospectively and retrospectively and were excluded if the case did not meet the definition of anaphylaxis., Results: A total of 3498 cases of anaphylaxis, of which 80.3% were children, presented to 9 EDs across Canada. Prehospital treatment with epinephrine was administered in 31% of cases, whereas antihistamines and corticosteroids were used in 46% and 2% of cases, respectively. Admission to the intensive care unit/hospital ward was associated with prehospital treatment with corticosteroids (adjusted odds ratio, 2.84; 95% confidence interval [CI], 1.55, 6.97) while adjusting for severity, treatment with epinephrine and antihistamines, asthma, sex, and age. Prehospital treatment with epinephrine (adjusted odds ratio, 0.23; 95% CI, 0.14, 0.38) and antihistamines (adjusted odds ratio, 0.61; 95% CI, 0.44, 0.85) decreased the likelihood of receiving multiple doses of epinephrine in the ED, while adjusting for severity, treatment with corticosteroids, asthma, sex, and age., Conclusions: Prompt epinephrine treatment is crucial. Use of antihistamines in conjunction with epinephrine may reduce the risk of uncontrolled reactions (administration of 2 or more doses of epinephrine in the ED), although our findings do not support the use of corticosteroids., (Copyright © 2019 American Academy of Allergy, Asthma & Immunology. All rights reserved.)

Background: Anaphylaxis due to unknown trigger (AUT) is anaphylaxis not explained by a proved or presumptive cause or stimulus at the time of the reaction. Research describing the management and follow-up of AUT is limited., Objective: To assess and compare the demographic and clinical characteristics and the management of adult and pediatric AUT cases across Canada., Methods: Participants were identified between 2011 and 2018 in emergency departments at 8 centers across Canada as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting the reaction and management in children and adults was completed. Patients were contacted for follow-up to determine assessment by an allergist., Results: A total of 295 AUT cases (7.5%) were recruited among 3,922 cases of anaphylaxis. In the prehospital setting, children (adjusted odds ratio [aOR], 1.20; 95% CI, 1.05-1.37) and those with a known food allergy (aOR, 1.14; 95% CI, 1.02-1.28) were more likely to receive treatment with epinephrine. Children were also more likely to be assessed by an allergist after their reaction (aOR, 1.43; 95% CI, 1.13-1.81) and were more likely to have an identified trigger for their reaction (aOR, 1.35; 95% CI, 1.07-1.70). Among patients contacted for follow-up, food was identified as the cause of reaction in 11 of 76 patients. A new food allergy was diagnosed in 4 patients (2 children and 2 adults)., Conclusions: Our findings highlight important differences between management and follow-up of adult and pediatric AUT cases. It is crucial to follow up all cases of AUT and establish appropriate treatment and management guidelines., (Copyright © 2018 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Venom-induced anaphylaxis (VIA) accounts for severe reactions. However, little is known about the short- and long-term management of VIA patients., Objective: To assess the short- and long-term management of VIA., Methods: Using a national anaphylaxis registry (C-CARE), we identified VIA cases presenting to emergency departments in Montreal and to emergency medical services (EMSs) in western Quebec over a 4-year period. Data were collected on clinical characteristics, triggers, and management. Consenting patients were contacted annually regarding long-term management. Univariate and multivariate logistic regressions were used to identify factors associated with epinephrine use, allergist assessment, and administration of immunotherapy., Results: Between June 2013 and May 2017, 115 VIA cases were identified. Epinephrine was administered to 63.5% (95% confidence interval [CI], 53.9%-72.1%) of all VIA cases by a health care professional. Treatment of reactions without epinephrine was more likely in reactions occurring at home and in nonsevere cases (no hypotension, hypoxia, or loss of consciousness). Among 48 patients who responded to a follow-up questionnaire, 95.8% (95% CI, 84.6%-99.3%) were prescribed epinephrine auto-injector, 68.8% (95% CI, 53.6%-80.9%) saw an allergist who confirmed the allergy in 63.6% of cases, and 81.0% of those with positive testing were administered immunotherapy. Among cases with follow-up, seeing an allergist was less likely in patients with known ischemic heart disease., Conclusion: Almost 30% of patients with suspected VIA did not see an allergist, only two thirds of those seeing an allergist had allergy confirmation, and almost one fifth of those with confirmed allergy did not receive immunotherapy. Educational programs are needed to bridge this knowledge-to-action gap., (Copyright © 2018 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Introduction: Data is sparse on drug-induced anaphylaxis (DIA) and there have not been studies assessing the differences in clinical characteristics and management of DIA between adults and children., Objective: We assessed the percentage, diagnosis, and management of DIA among all anaphylaxis visits in three pediatric and one adult emergency departments (ED) across Canada., Methods: Children presenting to the Montreal Children's Hospital (MCH), British Columbia Children's Hospital (BCCH), and Children's Hospital at London Health Sciences Center and adults presenting to Hôpital du Sacré-Coeur with anaphylaxis were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized data form documenting the reaction and management was completed and patients were followed annually to determine assessment by allergist and use of confirmatory tests., Results: From June 2012 to May 2016, 51 children were recruited from the pediatric centers and 64 adults from the adult center with drug-induced anaphyalxis. More than half the cases were prospectively recruited. The percentage of DIA among all cases of anaphylaxis was similar in all three pediatric centers but higher in the adult center in Montreal. Most reactions in children were triggered by non-antibiotic drugs, and in adults, by antibiotics. The majority of adults and a third of children did not see an allergist after the initial reaction. In those that did see an allergist, diagnosis was established by either a skin test or an oral challenge in less than 20% of cases., Conclusions: Our results reveal disparities in rate, culprit, and management of DIA in children versus adults. Further, most cases of suspected drug allergy are not appropriately diagnosed. Guidelines to improve assessment and diagnosis of DIA are required., (© 2017 The Authors. Immunity, Inflammation and Disease Published by John Wiley & Sons Ltd.)

Objectives: To determine the recurrence rate of anaphylaxis in children medically attended in an emergency department (ED), we performed a prospective cohort study to evaluate prehospital and ED management of children with recurrent anaphylaxis and to assess factors associated with recurrent anaphylaxis., Study Design: As part of the Cross-Canada Anaphylaxis Registry, parents of children with anaphylaxis identified prospectively in 3 EDs and through an emergency medical response service were contacted annually after presentation and queried on subsequent reactions. Cox regression analysis determined factors associated with recurrence., Results: Among 292 children who were registered as having had medical attended anaphylaxis, 68.5% completed annual follow-up questionnaires. Forty-seven patients experienced 65 episodes of anaphylaxis during 369 patient-years of follow-up. Food was the trigger in 84.6% of cases, and epinephrine was used in 66.2%. In 50.8%, epinephrine was used outside the health care facility, and 81.7% were brought to a health care facility for treatment. Asthma, reaction triggered by food, and use of epinephrine during the index episode increased the odds of recurrent reaction. Patients whose initial reaction was triggered by peanut were less likely to have a recurrent reaction., Conclusions: We report a yearly anaphylaxis recurrence rate of 17.6% in children. There is substantial underuse of epinephrine in cases of anaphylaxis. Educational programs that promote effective avoidance strategies and prompt use of epinephrine are required., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The diagnosis of anaphylaxis currently relies on suggestive clinical history after exposure to a potential triggering factor because no reliable diagnostic marker is available to confirm the diagnosis., Objectives: We aimed to evaluate tryptase levels in children with anaphylaxis and to examine predictors of elevated tryptase level (defined as ≥11.4 μg/L during reaction and for those with a baseline level, defined as a reaction level of at least 2 ng/mL + 1.2 × [postreaction tryptase level])., Methods: Children presenting with anaphylaxis to the Montreal Children's Hospital were recruited over a 4-year period. Symptoms, triggers, and management of anaphylaxis were documented. Levels during the reaction and approximately 9 months after the reaction were compared on the basis of paired means using the t distribution. Multivariate linear and logistic regressions were used to evaluate the association between tryptase levels and risk factors., Results: Over a 4-year period, 203 children had serum tryptase levels measured. Among these, 39 children (19.2%; 95% CI, 14.1%-25.4%) had elevated levels. Only severe reactions were associated with reaction levels of 11.4 μg/L or more (odds ratio, 6.5; 95% CI, 2.2-19.0). Milk-induced anaphylaxis and severe reactions were more likely associated with increased tryptase levels (beta-adjusted, 4.0; 95% CI, 0.95-7.0, and 7.5; 95% CI, 4.8-10.3, respectively). Reaction levels exceeding the threshold level of 2 ng/mL + 1.2 × (postreaction tryptase level) detected most of the anaphylactic reactions, particularly if baseline levels were taken within 2 months of the reaction., Conclusions: Tryptase levels are particularly useful for the diagnosis of severe and/or milk-induced anaphylaxis. Assessing the difference between reaction and postreaction tryptase levels may improve diagnostic sensitivity., (Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: The Cross-Canada Anaphylaxis Registry (C-CARE) assesses the triggers and management of anaphylaxis and identifies predictors of the development of severe allergic reactions and of epinephrine use. Here, we present data from an urban adult tertiary care emergency department (ED) in Montreal, Canada., Methods: Potential anaphylaxis cases were identified using ICD-10 codes related to anaphylaxis or allergic reactions. Putative cases underwent chart review to ensure they met anaphylaxis diagnostic criteria. Demographic, clinical and management data were collected. Multivariate logistic regressions were conducted to assess the effect of demographic characteristics, triggers, and comorbidities on severity and management of reactions., Results: Among 37,730 ED visits, 0.26% (95% CI 0.21, 0.32) fulfilled the definition of anaphylaxis. Food was the suspected trigger in almost 60% of cases. Epinephrine was not administered in almost half of moderate-to-severe cases, and similar numbers of individuals with moderate-to-severe reactions were not prescribed an epinephrine autoinjector. Reaction to shellfish was associated with more severe reactions (OR 13.9; 95% CI 2.2, 89.4). Older individuals and those not receiving steroids were more likely managed without epinephrine (OR 1.04; 95% CI 1.01, 1.07 and OR 2.97; 95% CI 1.05, 8.39, respectively)., Conclusions: Anaphylaxis accounted for a substantial number of ED visits in adults, and the most common trigger was food. There is non-adherence to guidelines recommending epinephrine use for all cases of anaphylaxis. We postulate that this may be related to concerns regarding the side effects of epinephrine in adults., (© 2014 S. Karger AG, Basel.)

The risk perception research is widely focused on children as targets of risk. To date, very few studies have consulted with the impacted group to assess the perceptions of risk associated with the exposures of interest. Much less research has investigated the experiences of children at risk for anaphylaxis, their concerns, and the psychosocial stresses associated with risk. The present study explores the perceptions and experiences of Ontario students with anaphylaxis, and their parents regarding school as a safe place in order to inform school policy around risk management and coping. A "child-centered" analytical framework incorporating illustrative techniques within interpretative analysis is outlined. Five prominent themes: (a) social and environmental barriers to safety, (b) coping strategies, (c) emotional burden of responsibility, (d) balance of responsibility (transitions), and (e) redefining "normal" are discussed. Results found that "child-centered" techniques empowered children in a process that is meaningful and relevant to their lives. A preliminary framework for understanding what risk means to children highlighted the differences in how they cope in the public sphere of school., (© 2010 Society for Risk Analysis.)

We present two cases of catecholamine-refractory and vasopressin-refractory vasoplegic syndrome associated with intraoperative anaphylaxis during cardiac surgery. One case was related to the administration of protamine and the other case to the administration of aprotinin. Both cases were successfully managed using intravenous methylene blue. The use of methylene blue blocks accumulation of cyclic guanosine monophosphate by competitively inhibiting the enzyme guanylate cyclase. This results in reduced responsiveness of the vasculature to cyclic guanosine monophosphate-mediated vasodilators, such as nitric oxide. This report provides a description of severe anaphylaxis induced by different agents, in which the use of methylene blue was associated with a significant clinical response.

Sesame is an important global allergen affecting ~0.1% of the North American population. It is a major cause of anaphylaxis in the Middle East and is the third most common food allergen in Israel. We conducted a systematic review of original articles published in the last 10 years regarding the diagnosis and management of sesame allergy. Skin prick testing appears to be a useful predictor of sesame allergy in infants, although data are less consistent in older children and adults. The diagnostic capacity of serum-specific immunoglobulin E is poor, especially in studies that used oral food challenges to confirm the diagnosis. Doubleblind, placebo-controlled food challenge thus remains the diagnostic gold standard for sesame allergy. The cornerstone of sesame allergy management is allergen avoidance, though accidental exposures are common and patients must be prepared to treat the consequent reactions with epinephrine. Novel diagnostic and treatment options such as component-resolved diagnostics, basophil activation testing, and oral immunotherapy are under development but are not ready for mainstream clinical application. [ABSTRACT FROM AUTHOR]

Background: There are no data on the percentage of visits due to anaphylaxis in the emergency department (ED), triggers, and management of anaphylaxis across different provinces in Canada. Objective: To compare the percentage of anaphylaxis cases among all ED visits, as well as the triggers and management of anaphylaxis between two Canadian pediatric EDs (PEDs). Methods: As part of the Cross-Canada Anaphylaxis Registry (C-CARE), children presenting to the British Columbia Children's Hospital (BCCH) and Montreal Children's Hospital (MCH) EDs with anaphylaxis were recruited. Characteristics, triggers, and management of anaphylaxis were documented using a standardized data entry form. Differences in demographics, triggers, and management were determined by comparing the difference of proportions and 95% confidence interval. Results: Between June 2014 and June 2016, there were 346 visits due to anaphylaxis among 93,730 PED visits at the BCCH ED and 631 anaphylaxis visits among 164,669 pediatric visits at the MCH ED. In both centers, the majority of cases were triggered by food (BCCH 91.3% [88.7, 94.0], MCH 82.4% [79.7, 85.3]), of which peanuts were the most common culprit (24.7% [20.9, 29.9] and 19.0% [15.8, 22.7], respectively). Pre-hospital administration of epinephrine (BCCH 27.7% [23.2, 32.8], MCH 33.1% [29.5, 37.0]) and antihistamines (BCCH 50.6% [45.2, 56.0], MCH 47.1% [43.1, 51.0]) was similar. In-hospital management differed in terms of increased epinephrine, antihistamine, and steroid use at the BCCH (59.2% [53.9, 64.4], 59.8% [54.4, 65.0], and 60.1% [54.7, 65.3], respectively) compared to the MCH (42.2% [38.3, 46.2], 36.2% [32.5, 40.1], and 11.9% [9.5, 14.8], respectively). Despite differences in management, percentage of cases admitted to the intensive care unit was similar between the two centers. Conclusion: Compared to previous European and North American reports, there is a high percentage of anaphylaxis cases in two PEDs across Canada with substantial differences in hospital management practices. It is crucial to develop training programs that aim to increase epinephrine use in anaphylaxis. [ABSTRACT FROM AUTHOR]

In 2006, 3 years after the tragic death of 13-year-old Sabrina Shannon, the Province of Ontario (Canada) passed Sabrina's Law ushering in a new era of focus and concern for severe food allergic children at risk of anaphylaxis. Questions were raised at the time regarding the potential of doing more harm than good with the new legislation. This paper reports the experiences of health-related stigma among food allergic children at risk of anaphylaxis who were required to disclose their health status under this new legislation. In 2008, in-depth interviews were conducted with 20 children and youth and their parents in order to explore the experiences living with a severe food allergy. This particular study explores their experiences of felt and enacted stigma in the school setting as a result of the disclosure process. Interviews were tape recorded with permission and transcribed for subsequent thematic analysis using NVIVO, a qualitative analysis software package. Results indicate that participants were stigmatised as a result of protective school policies under the law, and that created tension between their physical safety and social well-being. Sabrina's Law also led to a cultural shift in awareness of food allergies that resulted in some participants normalising their health status, offering promising directions for the future. [ABSTRACT FROM AUTHOR]

Data on anaphylaxis cases in pre-hospital settings is limited. As part of the Cross Canada Anaphylaxis Registry (C-CARE), we assessed anaphylaxis cases managed by paramedics in Outaouais, Quebec. A software program was developed to prospectively record demographic and clinical characteristics as well as management of cases meeting the definition of the anaphylaxis. Univariate and multivariate logistic regressions were compared to assess factors associated with severity of reactions and epinephrine use. Among 33,788 ambulance calls of which 23,486 required transport, 104 anaphylaxis cases were identified (anaphylaxis rate of 0.31% [95%CI, 0.25%, 0.37%] among all ambulance calls and 0.44% [95%CI, 0.36%, 0.54%] among those requiring transport). The median age was 46.8 years and 41.3% were males. The common triggers included food (32.7% [95%CI, 24.0%, 42.7%]), drugs (24.0% [16.4%, 33.6%]), and venom (17.3% [10.8%, 26.2%]). Among all reactions, 37.5% (95%CI, 28.4%, 47.6%) were severe. Epinephrine was not administered in 35.6% (95%CI, 26.6%, 45.6%) of all cases. Males were more likely to have severe reactions (Odds ratio [OR]: 2.50 [95%CI, 1.03, 6.01]). Venom-induced reactions and severe anaphylaxis were more likely to be managed with epinephrine (OR: 6.9 [95%CI, 1.3, 35.3] and 4.2 [95%CI, 1.5, 12.0], respectively). This is the first prospective study evaluating anaphylaxis managed by paramedics. Anaphylaxis accounts for a substantial proportion of the cases managed by paramedics in Outaouais, Quebec and exceeds prior reports of the proportion of Quebec emergency room visits attributed to anaphylaxis. Although guidelines recommend prompt use of epinephrine for all cases of anaphylaxis, more than a third of cases did not receive epinephrine. It is crucial to develop educational programs targeting paramedics to promote the use of epinephrine in all cases of anaphylaxis regardless of the specific trigger. [ABSTRACT FROM AUTHOR]

The aim of this study was to explore experiences and coping strategies of low-income families affected by food allergies. Of particular interest were experiences of allergy-related stigma within the context of poverty stigma. A secondary objective was to offer suggestions for refining a conceptual model of disease stigma. In-depth interviews with 23 individuals (10 key informants and 13 low-income adults affected by food allergies in southwestern Ontario, Canada) were conducted in 2012–2013. Participants reported feeling forced to adopt income-related stigmatized behaviors to obtain food and perceived difficulty in obtaining medication. Participants adopted cognitive distancing strategies to separate themselves from other low-income families affected by food allergies. Key informants frequently perceived low-income allergic individuals to be less vigilant than higher income individuals and attributed higher rates of allergy among higher income individuals to fewer unhygienic exposures and infections in early childhood. Both low-income participants and key informants perceived that inadequate education was a barrier to allergy management: key informants perceived a lack of education as an individual-level failure, while low-income participants perceived the lack of education as a system-level failure. Our findings revealed intersections between allergy stigma and poverty stigma. Results can be used to suggest additions to a conceptual model of disease stigma. Differing perspectives between key informants and low-income individuals have implications for strategies to improve access to education, safe food, and medication for low-income families affected by food allergies. [ABSTRACT FROM PUBLISHER]

Objectives. Low-income families may face financial barriers to management and treatment of chronic illnesses. No studies have explored how low-income individuals and families with anaphylactic food allergies cope with financial barriers to anaphylaxis management and/or treatment. This study explores qualitatively assessed direct, indirect, and intangible costs of anaphylaxis management and treatment faced by low-income families. Methods. In-depth, semistructured interviews with 23 participants were conducted to gain insight into income-related barriers to managing and treating anaphylactic food allergies. Results. Perceived direct costs included the cost of allergen-free foods and allergy medication and costs incurred as a result of misinformation about social support programs. Perceived indirect costs included those associated with lack of continuity of health care. Perceived intangible costs included the stress related to the difficulty of obtaining allergen-free foods at the food bank and feeling unsafe at discount grocery stores. These perceived costs represented barriers that were perceived as especially salient for the working poor, immigrants, youth living in poverty, and food bank users. Discussion. Low-income families report significant financial barriers to food allergy management and anaphylaxis preparedness. Clinicians, advocacy groups, and EAI manufacturers all have a role to play in ensuring equitable access to medication for low-income individuals with allergies. [ABSTRACT FROM AUTHOR]

Background: While a central role for the T helper (Th) 1/Th2 axis in food allergy has been established, the Th17 response in food-allergic humans has not been addressed. Methods: Th17 responses in 18 peanut-allergic children, who were also allergic to at least one additional food allergen, were assessed relative to 15 age-matched healthy controls. To account for the atopy background in the allergic children, 7 atopic, but not food-allergic, individuals and their age-matched controls were included in this study. PBMCs were analyzed by flow cytometry ex vivo or were stimulated in vitro with peanut allergens, gliadin, or tetanus toxoid followed by analysis of proliferation and cytokine production in antigen-responsive cells. Results: We observed a significantly lower interleukin (IL) 17 production in CD4+ T cells of food-allergic individuals ex vivo (p < 0.02). In vitro, we found that IL-17 production in CD4+ T cells in response to all antigens tested was significantly impaired in food-allergic subjects compared to healthy controls (Ara: p < 0.005; gliadin: p < 0.004; TT: p < 0.03). No significant differences were observed between atopic and nonatopic individuals with no food allergy. Conclusion: Our results thus reveal a systemic, non-allergen-specific defect in Th17 responses to antigen stimulation in food allergic individuals, suggesting a role for Th17 cells in the control of food allergy and implicating IL-17 as a potential biomarker for tolerance to food antigens. © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Several contributions to understanding the emotional aspects of everyday lives have been made by geographers. What we undertake in this research is to focus that lens on the emotional context of experiences ofchildren at riskand in particular on anaphylactic risk-scapes, particularly within the school environment. This research attempts to go beyond the policy response by privileging the voices of the affected children (and their parents) in order to understand the emotionality of their risk experience; how it is articulated and negotiated in place, and how bodily boundaries are interrupted. Qualitative methods were used to explore children's perceptions of, and experiences with, anaphylactic allergy in the school environment. In-depth interviews were conducted with 10 children (aged 8–12 years) and 10 adolescents (aged 13–17 years) and their parents. Children were also asked to draw a picture of ‘what it was like to live with a severe food allergy’ and to then explain their illustration. Results revealed how the spaces of children at risk of anaphylaxis were interrupted; social spaces were interrupted through their bodily experiences of risk as they negotiated in and through school environments. These findings suggest allergic children contest school and policy constructions of ‘safe place’ through the interrupted spaces and bodily disruptions of emotion. [ABSTRACT FROM PUBLISHER]

To cite this article: Nguyen-Luu NU, Ben-Shoshan M, Alizadehfar R, Joseph L, Harada L, Allen M, St-Pierre Y, Clarke A. Inadvertent exposures in children with peanut allergy. Pediatr Allergy Immunol 2011: Doi: 10.1111/j.1399-3038.2011.01235.x Abstract Objectives: To determine the annual incidence, characterize the severity and management, and identify predictors of accidental exposure among a cohort of children with peanut allergy. Methods: From 2004 to November 2009, parents of Canadian children with a physician-confirmed peanut allergy completed entry and follow-up questionnaires about accidental exposures over the preceding year. Logistic regression analyses were used to examine potential predictors. Results: A total of 1411 children [61.3% boys, mean age 7.1 yr (SD, 3.9)] participated. When all children were included, regardless of length of observation, 266 accidental exposures occurred over 2227 patient-years, yielding an annual incidence rate of 11.9% (95% CI, 10.6-13.5). When all accidental exposures occurring after study entry and patients providing <1 yr of observation were excluded, 147 exposures occurred over a period of 1175 patient-years, yielding a rate of 12.5% (95% CI, 10.7-14.5). Only 21% of moderate and severe reactions were treated with epinephrine. Age ≥13 yr at study entry (OR, 2.33; 95% CI, 1.20-4.53) and a severe previous reaction to peanut (OR, 2.04; 95% CI, 1.44-2.91) were associated with an increased risk of accidental exposure, and increasing disease duration (OR, 0.88; 95% CI, 0.83-0.92) with a decreased risk. Conclusion: The annual incidence rate of accidental exposure for children with peanut allergy is 12.5%. Children with a recent diagnosis and adolescents are at higher risk. Hence, education of allergic children and their families is crucial immediately after diagnosis and during adolescence. As many reactions were treated inappropriately, healthcare professionals require better education on anaphylaxis management. [ABSTRACT FROM AUTHOR]

The risk perception research is widely focused on children as targets of risk. To date, very few studies have consulted with the impacted group to assess the perceptions of risk associated with the exposures of interest. Much less research has investigated the experiences of children at risk for anaphylaxis, their concerns, and the psychosocial stresses associated with risk. The present study explores the perceptions and experiences of Ontario students with anaphylaxis, and their parents regarding school as a safe place in order to inform school policy around risk management and coping. A 'child-centered' analytical framework incorporating illustrative techniques within interpretative analysis is outlined. Five prominent themes: (a) social and environmental barriers to safety, (b) coping strategies, (c) emotional burden of responsibility, (d) balance of responsibility (transitions), and (e) redefining 'normal' are discussed. Results found that 'child-centered' techniques empowered children in a process that is meaningful and relevant to their lives. A preliminary framework for understanding what risk means to children highlighted the differences in how they cope in the public sphere of school. [ABSTRACT FROM AUTHOR]

Background: Recent studies suggest an increased prevalence of food-induced allergy and an increased incidence of food-related anaphylaxis. However, prevalence estimates of food allergies vary considerably between studies. Objectives: To determine the prevalence of peanut, tree nut, fish, shellfish, and sesame allergy in Canada. Methods: Using comparable methodology to Sicherer et al in the United States in 2002, we performed a cross-Canada, random telephone survey. Food allergy was defined as perceived (based on self-report), probable (based on convincing history or self-report of physician diagnosis), or confirmed (based on history and evidence of confirmatory tests). Results: Of 10,596 households surveyed in 2008 and 2009, 3666 responded (34.6% participation rate), of which 3613 completed the entire interview, representing 9667 individuals. The prevalence of perceived peanut allergy was 1.00% (95% CI, 0.80%-1.20%); tree nut, 1.22% (95% CI, 1.00%-1.44%); fish, 0.51% (95% CI, 0.37%-0.65%); shellfish, 1.60% (95% CI, 1.35%-1.86%); and sesame, 0.10% (95% CI, 0.04%-0.17%). The prevalence of probable allergy was 0.93% (95% CI, 0.74%-1.12%); 1.14% (95% CI, 0.92%-1.35%); 0.48% (95% CI, 0.34%-0.61%); 1.42% (95% CI, 1.18%-1.66%); and 0.09% (95% CI, 0.03%-0.15%), respectively. Because of the infrequency of confirmatory tests and the difficulty in obtaining results if performed, the prevalence of confirmed allergy was much lower. Conclusion: This is the first nationwide Canadian study to determine the prevalence of severe food allergies. Our results indicate disparities between perceived and confirmed food allergy that might contribute to the wide range of published prevalence estimates. [Copyright &y& Elsevier]

Introduction: Anaphylaxis is a severe allergic reaction which can be difficult to diagnose. Two strategies evaluating changes in tryptase levels were proposed for diagnosing anaphylaxis. Strategy 1 established a threshold of tryptase levels during reaction exceeding 2 ng/mL + 1.2* (baseline tryptase levels) as a rule for detecting anaphylaxis, while strategy 2 established the ratio of tryptase levels during reaction versus baseline tryptase exceeding a threshold of 1.685. We aimed to compare the diagnostic test accuracy of the two strategies in pediatric anaphylaxis. Methods: We conducted a case-control study. Cases consisted of 89 patients with anaphylaxis who had reaction tryptase and subsequent baseline tryptase measured. Controls consisted of 25 patients with chronic urticaria who had two tryptase measurements. Sensitivity and specificity for each of the strategies were computed and compared using McNemar test. The area under the curve (AUC) between the two strategies was compared using the DeLong test. Results: The sensitivity and specificity for strategy 1 was 53.3% and 95.0%, respectively. For strategy 2, the sensitivity and specificity was 54.4% and 85.0%, respectively. There was no significant difference between both strategies’ sensitivity and specificity. The Delong test determined that the AUC was significantly (p < 0.05) higher for strategy 1 (0.69) than strategy 2 (0.64). Conclusion: The Delong test determined that strategy 1 was slightly better in validating anaphylaxis diagnosis than strategy 2. However, both strategies demonstrated a low sensitivity <55%. [ABSTRACT FROM AUTHOR]

The article offers information on food-induced anaphylaxis. It states that the diagnosis of an Immunoglobulin E (IgE)-mediated food allergy requires corroboration of the patient's clinical history with appropriate confirmatory tests, including skin prick tests, food-specific IgE levels and food challenges. It mentions that delay in the administration of epinephrine is associated with poor outcome and the benefits of epinephrine use far outweigh the risks in healthy people.

Abstract Background There has been no large study characterizing selection bias in allergy and evaluating school personnel’s ability to use an epinephrine auto-injector (EpiPen®). Our objective was to determine if the consent process introduces selection bias by comparing 2 methods of soliciting participation of school personnel in a study evaluating their ability to demonstrate the EpiPen®. Methods School personnel from randomly selected schools in Quebec were approached using a 1) partial or 2) full disclosure approach and were assessed on their ability to use the EpiPen® and identify anaphylaxis. Results 343 school personnel participated. In the full disclosure group, the participation rate was lower: 21.9% (95%CI, 19.0%-25.2%) versus 40.7% (95%CI, 36.1%-45.3%), but more participants achieved a perfect score: 26.3% (95%CI, 19.6%-33.9%) versus 15.8% (95%CI, 10.8%-21.8%), and identified 3 signs of anaphylaxis: 71.8% (95%CI, 64.0%-78.7%) versus 55.6% (95%CI, 48.2%-62.9%). Conclusions Selection bias is suspected as school personnel who were fully informed of the purpose of the assessment were less likely to participate; those who participated among the fully informed were more likely to earn perfect scores and identify anaphylaxis. As the process of consent can influence participation and bias outcomes, researchers and Ethics Boards need to consider conditions under which studies can proceed without full consent. Despite training, school personnel perform poorly when asked to demonstrate the EpiPen®.