Original articles
`
`Parental use of EpiPen for children with
`food allergies
`
`Jennifer S. Kim, MD,a James M. Sinacore, PhD,b and Jacqueline A. Pongracic, MDa
`Chicago and Maywood, Ill
`
`Background: EpiPen is often underused in children with food
`allergy experiencing anaphylaxis.
`Objective: We explored whether underuse of EpiPen might be
`attributed to parental discomfort with administration, as
`measured by a lack of parental empowerment and knowledge
`of proper administration.
`Methods: A written survey was mailed to parents of children
`with food allergy. Those children with physician-diagnosed food
`allergy who had been prescribed EpiPen were included in the
`analysis. Parents were recruited from a local food-allergy
`support group and private allergy practice. Perceived comfort
`with administering EpiPen was measured by using a 10-cm
`visual analog scale. Knowledge of EpiPen use and anaphylaxis
`was tested by using a series of multiple-choice questions.
`Empowerment was measured with a 16-item instrument that
`included statements from the Family Empowerment Scale.
`Multiple regression analysis was used to determine how much
`of the variance in the comfort ratings could be explained by
`knowledge, empowerment, and other factors assessed in the
`survey.
`Results: Of 360 mailed surveys, 165 (46%) completed surveys
`met the inclusion criteria and were analyzed. Anaphylaxis was
`reported in 42% of children (n = 70); 8% of parents (n = 14)
`had administered EpiPen to their child. Factors correlating
`with comfort included prior administration of EpiPen
`(P = .009), EpiPen training (P = .005), and empowerment
`(P < .0005). Neither a history of anaphylaxis nor knowledge
`correlated with an increased level of comfort with
`administration.
`Conclusions: Empowerment directly correlated with increased
`comfort with EpiPen use, but knowledge did not. Physicians
`should continue to instruct all parents on EpiPen
`administration because this correlated significantly with
`comfort. Other psychological factors beyond empowerment
`might contribute to underuse of EpiPen. (J Allergy Clin
`Immunol 2005;116:164-8.)
`
`From athe Departments of Pediatrics, Northwestern University Feinberg
`School of Medicine, Chicago, and bthe Department of Preventive Med-
`icine and Epidemiology, Loyola University Stritch, School of Medicine,
`Maywood.
`Supported by the Division of Allergy, Children’s Memorial Hospital.
`Disclosure of potential conflict of interest: All authors—none disclosed.
`Received for publication January 11, 2005; revised March 29, 2005; accepted
`for publication March 31, 2005.
`Available online May 24, 2005.
`Reprint requests: Jennifer S. Kim, MD, 2300 Children’s Plaza, #60, Chicago,
`IL 60614. E-mail: jskim@childrensmemorial.org.
`0091-6749/$30.00
`Ó 2005 American Academy of Allergy, Asthma and Immunology
`doi:10.1016/j.jaci.2005.03.039
`
`164
`
`Key words: Food allergy, anaphylaxis, self-injectable epinephrine,
`adrenaline, EpiPen, training, empowerment, comfort
`
`Food allergy affects up to 6% of children,1 and
`reactions can be fatal. Anaphylaxis is a serious and
`potentially life-threatening event. IgE-mediated food hy-
`persensitivity is the most common cause of anaphylaxis
`in children outside of the hospital setting.2 Mortality is
`uncommon but does occur.3 Appropriate treatment con-
`sists of early administration of injectable epinephrine,
`which might be life-saving by reversing, delaying, or
`halting the progression of anaphylaxis. Proper treatment
`depends on the following: (1) availability of the medica-
`tion in a convenient delivery system, such as EpiPen (Dey,
`Napa, Calif); (2) knowledge regarding indications for its
`use; and (3) technically accurate use of the device.
`Previous studies have revealed deficiencies in parental
`knowledge surrounding indications for EpiPen use, as
`well as methodological aspects of its administration.4-6
`Several studies have described infrequent use of EpiPen
`in children with recurrent episodes of anaphylaxis.4-6 In
`one retrospective telephone survey of children attending a
`specialist allergy service,4 EpiPen was used in only 29%
`of recurrent anaphylactic reactions. Parents were found to
`be deficient
`in their knowledge of the symptoms of
`anaphylaxis, as well as the use of the device itself.
`Another survey of EpiPen use in patients with a history
`of anaphylaxis5 revealed that 84% of parents proved to
`know the circumstances for which EpiPen was indicated,
`but only a minority (37%) demonstrated proper adminis-
`tration. Yet another report6 found that only 21% of study
`families correctly demonstrated the use of EpiPen.
`In addition to deficiencies in knowledge, given the
`critical nature of anaphylaxis, there could be a psycho-
`logical component (eg, fear or anxiety) that contributes to
`the underuse of EpiPen. Prior studies7-9 suggest that there
`are psychological characteristics that have an effect on
`overall quality of life. The available studies in the medical
`literature exploring the effect of childhood food allergy
`report that quality of life appears to be diminished in this
`population. Primeau et al7 evaluated the psychological
`burden as perceived by parents of children with peanut
`allergy and compared them with parents of children with
`rheumatologic disease. Parents of children with peanut
`allergy were found to have significantly more disruption
`in their daily activities. Sicherer et al8 explored parental
`
`Food allergy, dermatologic
`diseases, and anaphylaxis
`
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`diseases,andanaphylaxis
`Foodallergy,dermatologic
`
`J ALLERGY CLIN IMMUNOL
`VOLUME 116, NUMBER 1
`
`Kim, Sinacore, and Pongracic 165
`
`Abbreviations used
`FES: Family Empowerment Scale
`IDDM: Insulin-dependent diabetes mellitus
`
`perceptions of their child’s physical and psychosocial
`functioning (by using the Children’s Health Questionnaire
`or CHQ-PF50, a generic instrument designed to measure
`health-related quality of life). Parents of children with
`food allergy scored lower on several scales. They had a
`lower perception of overall health and illness, and they had
`more distress and worry concerning the child’s condition.
`Parents of children with food allergy also reported inter-
`ruption in usual family activities and increased family
`tension as a result of the child’s health. Moreover, when
`compared with children with insulin-dependent diabetes
`mellitus (IDDM) in another study,9 children with peanut
`allergy reported being more fearful of an adverse event
`and having more anxiety about eating, especially away
`from home.
`Furthermore, a parent’s sense of empowerment as a
`psychological resource appears to contribute significantly
`to a higher level of adherence to treatment when examined
`among mothers of children with IDDM.10 Appropriate use
`of EpiPen constitutes proper treatment of food-induced
`anaphylaxis, although the outcome is more difficult to
`measure than glycosylated hemoglobin for patients with
`IDDM. The referenced Israeli study10 used, among other
`validated questionnaires, the Family Empowerment Scale
`(FES),11 an instrument originally designed for families of
`children with emotional disabilities. FES standardization
`was based on subjects solicited from organizations for
`parents of children with emotional, behavioral, or mental
`disorders. However,
`the questions and subscales also
`appear to have face validity for families whose children
`have chronic health conditions.
`Our study examined the extent to which experiential,
`historical, and psychological characteristics are related to
`the care of the child with food allergy, specifically in a
`projected crisis situation, such as anaphylaxis. Families
`living with food allergy are burdened by the task of strict
`avoidance, concern for potential cross-contamination, and
`fear of accidental exposure. We wondered whether the
`psychological effects of such a burden also interfered with
`the ability to carry out a predetermined emergency plan,
`specifically administration of epinephrine.
`We also examined parental knowledge of EpiPen
`administration and its indications. We sought to under-
`stand whether basic knowledge, prior experience, and
`psychological characteristics (eg, a sense of empower-
`ment) could identify parents who are and who are not likely
`to use epinephrine when necessary. We also attempted to
`characterize specific fears about administration. We hypo-
`thesized that parental empowerment in addition to knowl-
`edge of proper use are predictors for a higher comfort level
`with the administration of EpiPen to the child.
`
`METHODS
`
`Study participants
`
`Parents of children with food allergy were recruited through
`mailings to members of a local suburban food-allergy support group
`and to patients of a private pediatric allergist’s practice. Inclusion
`criteria required physician-diagnosed food allergy, and all patients
`must have been prescribed EpiPen for home use. Participants were
`limited to parents, and children were not surveyed. Survey data were
`limited to one child per parent; if surveys had been completed for
`multiple children from the same parent, only the oldest child’s data
`were included. The study was approved by the Children’s Memorial
`Hospital Institutional Review Board, and written informed consent
`was obtained.
`
`Survey
`
`The survey, mailed to 360 families, was self-administered, and
`parents were instructed to return the completed questionnaire in the
`provided self-addressed stamped envelope. The questionnaire col-
`lected demographic information and medical history, which included
`a prior self-reported history of anaphylaxis (defined as a ‘‘life-
`threatening allergic reaction’’), past experience with EpiPen use, and
`knowledge of indications for use. Data from completed surveys were
`collected between June and August of 2003.
`Knowledge about EpiPen use and anaphylaxis was based on
`answers to a set of multiple-choice and true-false queries, with a
`maximum possible score of 24 points. The questions addressed
`symptoms of anaphylaxis, actions taken after EpiPen is given, and
`technical steps necessary for proper administration.
`Perceived comfort with future EpiPen administration was mea-
`sured with a 10-cm visual analog scale that was anchored with
`‘‘uncomfortable’’ at one end and ‘‘very comfortable’’ at the other.
`Parents were instructed to place an ‘‘x’’ on the straight, unmarked line
`to indicate how comfortable they believed they would be in the event
`they had to administer an EpiPen to their own child should a crisis
`occur. The comfort score was defined as the distance from the
`beginning of the line to the denoted ‘‘x’’ measured to the nearest 0.1
`cm. The maximum possible comfort score was 10.0, which indicated
`that the parent was very comfortable with a future EpiPen adminis-
`tration.
`Parents were asked to respond to a set of 36 statements to assess
`empowerment. Eight of these were taken directly from the FES,11 a
`validated instrument. One of these statements is as follows: ‘‘When
`problems arise with my child, I handle them pretty well.’’ Another 5
`statements were modified from the FES to make them medically
`relevant. For example, the original FES statement ‘‘I am able to make
`good decisions about what services my child needs’’ was modified to
`read ‘‘I am able to make good decisions about what my child needs
`medically.’’ It should be noted that work by Koren et al11 has
`demonstrated good psychometric properties for the FES. They report
`the mean internal consistency (coefficient a) across all subscales as
`0.87 and the mean test-retest reliability as 0.83. In addition, they
`demonstrate the construct validity of the FES by showing how the
`instrument was able to differentiate families involved in advocacy-
`related activities from those who were not.
`The remaining 23 statements, modeled from the FES, were
`designed by the first author (JK) to assess one’s sense of empower-
`ment in handling a child who has the potential to have a life-
`threatening allergic reaction. Two examples of these statements are as
`follows: ‘‘I can calmly handle a crisis situation involving my child’’
`and ‘‘I am decisive and act quickly.’’ Responses to all 36 empower-
`ment statements were recorded on a 7-point scale anchored with ‘‘not
`characteristic of me’’ on one end and ‘‘very characteristic of me’’ on
`the other.
`
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`166 Kim, Sinacore, and Pongracic
`
`J ALLERGY CLIN IMMUNOL
`JULY 2005
`
`TABLE I. Statements that were added to the FES
`
`I can calmly handle a crisis situation involving my child.
`I am confident in my abilities to protect my child from danger.
`I trust my physician.
`I am decisive and act quickly.
`
`Responses to these statements were recorded on a 7-point scale anchored
`with ‘‘not characteristic of me’’ on one end and ‘‘very characteristic of
`me’’ on the other.
`
`The 36 items were used to compute Cronbach’s coefficient a, a
`measure of internal consistency, to develop an empowerment score.
`Items were dropped one by one until the coefficient was maximized.
`As a result, 16 statements remained that yielded an a value of .91.
`By using these 16 items, the maximal empowerment score was 112.
`Four of these statements were ones specifically designed for this
`study and are shown in Table I.
`
`Statistics
`
`Simple frequencies and percentages were computed to report most
`of the findings from the food-allergy survey. In addition, a multiple
`regression analysis was conducted to examine the relationship
`between perceived parental comfort with a future EpiPen adminis-
`tration and 6 predictor variables: (1) whether the parent was
`experienced with EpiPen administration, (2) whether the parent had
`made a prior EpiPen judgment error (ie, whether a physician told the
`parent that EpiPen should have been used in a prior situation but it
`was not), (3) history of anaphylaxis, (4) whether the parent was
`trained in the use of EpiPen, (5) parental knowledge of anaphylaxis
`symptoms and EpiPen use, and (6) parental empowerment. These
`predictors were chosen because they are experiential, historical, and
`psychological variables that were believed to be associated with
`parental comfort with a future EpiPen administration.
`To estimate the required sample size for the regression analysis,
`we assumed that the 6 predictor variables collectively would explain
`about 25% of the variance in comfort ratings. Moreover, we estimated
`that each predictor variable would account for about 4% of the
`variance in those ratings. With an a level of .05, computations
`indicated that 154 subjects were required to have 80% power for
`detecting the expected associations.
`
`RESULTS
`
`Surveys were returned by 170 families. Three surveys
`were returned without signed consent forms, and 2
`subjects had food allergy but had not been prescribed
`EpiPen. These surveys were not included in the data
`analysis. Hence 165 completed surveys with signed
`consent were included in the study, for a response rate
`of 46% (165/360).
`The vast majority of respondents were married white
`mothers who held college or graduate degrees (Table II).
`The only minority represented were Asians, who made up
`5% of our sample. There were no Hispanics or African-
`Americans among the respondents. The mean parental age
`was 37.4 years (SD, 4.64; range, 29.6-55.8 years).
`The children were ages 1 to 19 years, the majority
`of whom were male and younger than 5 years of age
`(Table II). Only 2 of the children were in high school.
`Anaphylaxis was reported in 42% of children (n = 70),
`most of whom had a single experience. Of those, 29 (41%
`
`TABLE II. Demographic characteristics of respondents
`and children
`
`Respondent
`Mother
`White
`Married
`College or graduate degree
`Full-time homemaker
`Prior EpiPen administration
`Child
`Male
`Age <5 y
`History of anaphylaxis
`Allergic to > 1 food
`
`N
`
`161
`155
`160
`153
`88
`14
`
`106
`96
`70
`131
`
`TABLE III. Frequency of specific food allergies reported
`by parents
`
`Allergen
`
`Peanut
`Tree nut
`Egg
`Cow’s milk
`Soy
`Shellfish
`Fish
`Wheat
`Other*
`
`N
`
`140
`87
`78
`69
`24
`24
`21
`20
`52
`
`%
`
`98
`94
`97
`93
`53
`8
`
`64
`58
`42
`79
`
`%
`
`85
`53
`47
`42
`15
`15
`13
`12
`32
`
`*Sesame was most commonly reported (n = 10).
`
`of 70) children had 2 or more total episodes of anaphylaxis
`(one parent reported 7). Fourteen (8%) parents reported
`they had administered EpiPen to their child. Fourteen
`parents also reported that their physicians told them they
`should have used EpiPen in a prior situation when they did
`not. The most commonly cited reasons for not using
`EpiPen were ‘‘I recognized the symptoms but gave
`Benadryl first’’ (71%, n = 10) and ‘‘I did not think the
`reaction was serious’’ (50%, n = 7).
`The most common food allergen reported was peanut
`(85%), followed by tree nuts (53%; Table III). Thirty-two
`percent of parents reported a food allergy in their child
`other than or beyond the 8 most common, which included
`peanut, tree nuts, egg, milk, soy, shellfish, fish, and wheat.
`The most commonly reported food in the ‘‘other’’ cate-
`gory was sesame seed (n = 10), followed by mustard
`(n = 3). Other foods were reported singly.
`One hundred thirty-seven (83%) parents reported that
`they had been trained on how to use EpiPen (109 had been
`educated with an EpiPen trainer). Physicians and nurses
`were responsible for 47% and 36%, respectively, of
`parents’ initial education. Only 48% of parents reported
`having reviewed EpiPen administration within the prior
`12 months, most commonly with a nurse (44%) or a
`physician (35%). Seventy-eight percent of parents re-
`ported carrying EpiPen with them always or almost
`
`Food allergy, dermatologic
`diseases, and anaphylaxis
`
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`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00685
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`diseases,andanaphylaxis
`Foodallergy,dermatologic
`
`J ALLERGY CLIN IMMUNOL
`VOLUME 116, NUMBER 1
`
`Kim, Sinacore, and Pongracic 167
`
`TABLE IV. Frequency of parents who correctly answered
`items about EpiPen administration
`
`Item
`
`Cannot reuse after initial injection
`No refrigeration needed
`Cannot store in glove compartment of car
`Remove grey cap before administration
`Clothing need not be removed prior
`Inject in outside part of thigh
`Replace if liquid appears brown
`Press until clicking sound is heard
`Hold for 10 seconds after injection
`
`N
`
`165
`165
`157
`157
`153
`151
`146
`131
`115
`
`%
`
`100
`100
`95
`95
`93
`92
`88
`79
`70
`
`always, whereas 7% admitted to hardly ever having
`EpiPen with them.
`Knowledge of the symptoms of anaphylaxis is pre-
`sented in Table E1 (available in the Journal’s Online
`Repository at www.mosby.com/jaci). Parents were asked
`to consider each item as if it was the only symptom or sign
`present at the time of their decision to administer EpiPen.
`More than 75% of parents were able to identify most
`laryngeal or respiratory symptoms, although less than half
`cited hoarseness or repetitive cough as symptoms of
`anaphylaxis. One quarter of parents indicated that urticaria
`was a symptom of anaphylaxis.
`When surveyed regarding the technical aspects of
`EpiPen administration, the vast majority of parents an-
`swered these questions correctly (Table IV). Knowledge
`of what
`to do after EpiPen administration also was
`assessed. Most parents correctly answered ‘‘call 911’’
`(77%), ‘‘go to the emergency department’’ (65%), or both.
`Multiple answers were allowed. Only 1% (n = 2) claimed
`they would self-monitor the child’s response to the
`injection before taking further action.
`Knowledge scores ranged from 8 to 24 (mean, 16.5;
`SD, 3.5). Empowerment scores ranged from 76 to 112
`(mean, 95.7; SD, 10.2), and perceived comfort ratings
`spanned the full width of the 10-cm visual analogue scale
`(range, 0-10 cm; mean, 6.6 cm; SD, 2.9). There were 75
`parents who, in addition to their comfort rating, believed
`that they would feel outright uncomfortable in adminis-
`tering EpiPen to their child. Of those, 38 (51% of 75) noted
`that the reason for discomfort would stem from their not
`being able to recognize the symptoms of anaphylaxis.
`Thirty (40%) feared hurting their child, and 27 (36%)
`thought they would forget how to use EpiPen in a high-
`pressure situation.
`The multiple regression analysis revealed that an
`adjusted 28% of the variance in parents’ comfort ratings
`was explained collectively by the set of predictor variables
`(F [6,156] = 11.22, P < .0005). The negative regression
`coefficients in Table V show that those who had not
`administered EpiPen in the past and those who had not
`been trained on its use had lower comfort ratings. On the
`basis of the partial correlation coefficients, the strongest
`association was found with empowerment. In fact, em-
`powerment (partial r = 0.39) accounted for about half of
`the total explained variance in comfort ratings (0.392/
`
`TABLE V. Results of the multiple regression analysis
`explaining the variance in patients’ comfort with
`a future EpiPen administration
`
`Predictor
`
`b
`
`Partial r
`
`t
`
`P value
`
`Prior EpiPen administration 20.196 20.21 22.64
`.009
`.076
`Prior EpiPen judgment error
`0.125
`0.14
`1.79
`20.009 20.00 20.12
`.907
`History of anaphylaxis
`20.199 20.22 22.83
`.005
`Trained to use EpiPen
`.107
`Knowledge
`0.113
`0.13
`1.62
`5.33 <.0005
`Empowerment
`0.365
`0.39
`
`The analysis of variance for regression was significant: F (6, 156) = 11.22,
`P < .0005, and adjusted R2 = 0.28.
`
`0.28 = 0.54). As one would expect, parents with higher
`empowerment scores had higher comfort ratings.
`Knowledge of anaphylaxis symptoms and EpiPen use,
`as well as history of anaphylaxis, was not significantly
`associated with comfort ratings. Prior EpiPen judgment
`error was near significance (P = .076), but the partial
`correlation coefficient (partial r = 0.14) was too low to
`consider the variable important.
`
`DISCUSSION
`
`Self-injectable epinephrine, currently available in the
`form of EpiPen and EpiPen Jr in the United States, is a
`critical element of the treatment plan for IgE-mediated
`food allergies. There are an estimated 150 deaths per year
`in the United States attributed to anaphylaxis caused by
`food allergy.3 The median time to respiratory or cardiac
`arrest was found by one study12 to be 30 minutes for food
`anaphylaxis. Bock et al3 reported on 32 fatalities, but it
`could be confirmed that epinephrine was available for use
`at the time of the reaction in only 10% (3/32) of the cases.
`Other retrospective studies confirm underuse of epineph-
`rine, as well as inappropriate dosing or administration.13
`Knowledge regarding administration among our cohort
`was surprisingly not a significant factor contributing to a
`parent’s comfort in administering EpiPen. We acknowl-
`edge, however, that a self-administered survey might not
`be as sensitive a measure as a face-to-face interview or
`demonstration.
`Although knowledge did not prove to be a significant
`contributor to parental comfort, our study shows that
`training parents how to use EpiPen is an important compo-
`nent to improving parental comfort in treating their child.
`We highly recommend using an EpiPen trainer as a visual
`and tactile tool to demonstrate administration. One survey
`of physicians14 revealed that 81% of participants did not
`have a placebo trainer to educate their patients. Physicians
`and their staff in the outpatient office setting should give
`priority to such instruction, and a demonstration with each
`return visit would reinforce correct technique and promote
`discussion regarding use.
`Although parental knowledge of the symptoms of
`anaphylaxis and use of EpiPen was not a significant
`variable in our survey, we still believe that arming parents
`
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`168 Kim, Sinacore, and Pongracic
`
`J ALLERGY CLIN IMMUNOL
`JULY 2005
`
`with such information is vital for the proper care of the
`child with food allergy. The influence of a pediatric allergy
`clinic has been shown to significantly improve parental
`knowledge of EpiPen use.15
`In this study parental comfort with EpiPen use
`correlated the strongest with parental empowerment.
`Psychological factors are likely to be important
`in a
`scenario such as impending anaphylaxis, but these are not
`fully understood and, consequently, difficult to assess.
`Interestingly, although prior parental EpiPen administra-
`tion significantly correlated with parental comfort, a prior
`history of anaphylaxis in the child did not. These parents
`recognized that
`their child had experienced a life-
`threatening allergic reaction, yet they were uncomfortable
`with the idea of administering EpiPen. This suggests that
`fear might be a psychological component that paralyzes
`instead of enables a parent to act accordingly in the event
`of anaphylaxis in their child. Prior studies7,8 have con-
`firmed the psychological effect that food allergy has on
`quality of life. These intellectual and emotional burdens
`that affect aspects of daily living might also impair a
`parent’s response to an acute life-threatening event.
`Admittedly, our cohort was not a representative group
`because the vast majority were characterized as well-
`educated, married white mothers who were mostly
`members of a suburban food-allergy support group.
`However, our study sample was similar to the one used
`to norm the FES; a majority of parents in the sample were
`white women with a mean age of 40 years. We were
`surprised that knowledge did not affect comfort, even in a
`well-educated group of parents, despite adjunctive col-
`laboration with a support group. Perhaps there are psy-
`chological factors specific to socioeconomic status or
`support group participation.
`In addition to the homogeneity of our sample, there
`was a paucity of the number of adolescents represented in
`this study. Only 2 children were in high school. Of note,
`adolescence is a risk factor for fatal anaphylaxis.3 Our
`study focused on parental attitudes, but the young adult
`and teenage group would be of particular interest to direct
`future investigations.
`This is the first study that sought to identify psycho-
`logical factors that might influence EpiPen administra-
`tion by parents to their children with food allergy.
`Previous cross-sectional surveys and evaluative studies
`have frequently reported that parents use epinephrine
`auto-injectors incorrectly,4-7,12 despite education at the
`time of EpiPen prescription.4 Our findings in this self-
`administered survey suggest that parental sense of em-
`powerment might also significantly affect
`the use of
`epinephrine.
`for
`food allergy and the potential
`In conclusion,
`anaphylaxis is a significant problem that has no easy
`
`solution. Families must balance daily living with the
`constant threat of a potentially life-threatening exposure.
`Being prepared to face such an event requires acceptance
`that anaphylaxis might occur and taking ownership of
`knowing how to administer treatment, which includes
`EpiPen. This study explored how parents projected them-
`selves to feel and respond to this situation. We have shown
`that there are factors that can improve on parental comfort,
`such as training the parents in proper use of the EpiPen
`device. We would encourage all health care providers to
`ensure that such instruction is given at every opportunity.
`Other means to help parents empower themselves will
`need to be explored in future studies.
`
`We thank Denise Bunning and Mothers of Children Having Food
`Allergies (MOCHA), Dr Sai Nimmagadda, and Lisa Amoruso.
`
`REFERENCES
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`2. Yocum MW, Butterfield JH, Klein JS, Volcheck GW, Schroeder DR,
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`
`Food allergy, dermatologic
`diseases, and anaphylaxis
`
`Opiant Exhibit 2186
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00685
`Page 5
`
`