The long and the short of pediatric emergency department antibiotic prescribing: A retrospective observational study.

BACKGROUND: Most antibiotics prescribed to children are provided in the outpatient and emergency department (ED) settings, yet these prescribers are seldom engaged by antibiotic stewardship programs. We reviewed ED antibiotic prescriptions for three common infections to describe current prescribing practices. METHODS: Prescription data between 2018 and 2021 were extracted from the electronic records of children discharged from the Children's Hospital of Eastern Ontario ED with urinary tract infection (UTI), community acquired pneumonia (CAP), and acute otitis media ≥2 years of age (AOM). Antibiotic choice, duration, as well as the provider's time in practice and training background were collected. Antibiotic durations were compared with Canadian guideline recommendations to assess concordance. Provider-level prescribing practices were analyzed using k-means cluster analysis. RESULTS: 10,609 prescriptions were included: 2868 for UTI, 2958 for CAP, and 4783 for AOM. Guideline-concordant durations prescribed was generally high (UTI 84.9%, CAP 94.0%, AOM 52.8%), a large proportion of antibiotic-days prescribed were in excess of the minimally recommended duration for each infection (UTI 16.8%, 19.3%, AOM 25.5%). Cluster analysis yielded two clusters of prescribers, with those in one cluster more commonly prescribing durations at the lower end of recommended interval, and the others more commonly prescribing longer durations for all three infections reviewed. No statistically significant differences were found between clusters by career stage or training background. CONCLUSIONS: While guideline-concordant antibiotic prescribing was generally high, auditing antibiotic prescriptions identified shifting prescribing towards the minimally recommended duration as a potential opportunity to reduce antibiotic use among children for these infections.

Family caregivers' emotional and communication needs in Canadian pediatric emergency departments.

OBJECTIVES: To describe the extent to which caregivers' emotional and communication needs were met during pediatric emergency department (PED) visits. Secondary objectives included describing the association of caregiver emotional needs, satisfaction with care, and comfort in caring for their child's illness at the time of discharge with demographic characteristics, caregiver experiences, and ED visit details. STUDY DESIGN: Electronic surveys with medical record review were deployed at ten Canadian PEDs from October 2018 -March 2020. A convenience sample of families with children <18 years presenting to a PED were enrolled, for one week every three months, for one year per site. Caregivers completed one in-PED survey and a follow-up survey, up to seven days post-visit. RESULTS: This study recruited 2005 caregivers who self-identified as mothers (74.3%, 1462/1969); mean age was 37.8 years (SD 7.7). 71.7% (1081/1507) of caregivers felt their emotional needs were met. 86.4% (1293/1496) identified communication with the doctor as good/very good and 83.4% (1249/1498) with their child's nurse. Caregiver involvement in their child's care was reported as good/very good 85.6% (1271/1485) of the time. 81.8% (1074/1313) of caregivers felt comfortable in caring for their child at home at the time of discharge. Lower caregiver anxiety scores, caregiver involvement in their child's care, satisfactory updates, and having questions adequately addressed positively impacted caregiver emotional needs and increased caregiver comfort in caring for their child's illness at home. CONCLUSION: Approximately 30% of caregivers presenting to PEDs have unmet emotional needs, over 15% had unmet communication needs, and 15% felt inadequately involved in their child's care. Family caregiver involvement in care and good communication from PED staff are key elements in improving overall patient experience and satisfaction.

Nasal Suctioning Therapy Among Infants With Bronchiolitis Discharged Home From the Emergency Department: A Randomized Clinical Trial.

Importance: Although nasal suctioning is the most frequently used supportive management for bronchiolitis, its benefit remains unknown. Objective: To evaluate the effectiveness of enhanced vs minimal nasal suctioning in treating infants with bronchiolitis after discharge from the emergency department (ED). Design, Setting, and Participants: This single-blind, parallel-group, randomized clinical trial was conducted from March 6, 2020, to December 15, 2022, at 4 tertiary-care Canadian pediatric EDs. Participants included otherwise healthy infants aged 1 to 11 months with a diagnosis of bronchiolitis who were discharged home from the ED. Interventions: Participants were randomized to minimal suctioning via bulb or enhanced suctioning via a battery-operated device before feeding for 72 hours. Main Outcomes and Measures: The primary outcome was additional resource use, a composite of unscheduled revisits for bronchiolitis or use of additional suctioning devices for feeding and/or breathing concerns. Secondary outcomes included health care utilization, feeding and sleeping adequacy, and satisfaction. Results: Of 884 screened patients, 352 were excluded for criteria, 79 declined participation, 81 were otherwise excluded, 372 were randomized (185 to the minimal suction group and 187 to the enhanced suction group), and 367 (median [IQR] age, 4 [2-6] months; 221 boys [60.2%]) completed the trial (184 in the minimal suction and 183 in the enhanced suction group). Additional resource use occurred for 68 of 184 minimal suction participants (37.0%) vs 48 of 183 enhanced suction participants (26.2%) (absolute risk difference, 0.11; 95% CI, 0.01 to 0.20; P = .03). Unscheduled revisits occurred for 47 of 184 minimal suction participants (25.5%) vs 40 of 183 enhanced suction participants (21.9%) (absolute risk difference, 0.04; 95% CI, -0.05 to 0.12; P = .46). A total of 33 of 184 parents in the minimal suction group (17.9%) used additional suctioning devices vs 11 of 183 parents in the enhanced suction group (6.0%) (absolute risk difference, 0.12; 95% CI, 0.05 to 0.19; P < .001). No significant between-group differences were observed for all bronchiolitis revisits (absolute risk difference, 0.07; 95% CI, -0.02 to 0.16; P = .15), ED revisits (absolute risk difference, 0.04; 95% CI, -0.03 to 0.12; P = .30), parental care satisfaction (absolute risk difference, -0.02; 95% CI, -0.10 to 0.06; P = .70), and changes from baseline to 72 hours in normal feeding (difference in differences, 0.03; 95% CI, -0.10 to 0.17; P = .62), normal sleeping (difference in differences, 0.05; 95% CI, -0.08 to 0.18; P = .47), or normal parental sleeping (difference in differences, 0.10; 95% CI, -0.02 to 0.23; P = .09). Parents in the minimal suction group were less satisfied with the assigned device (62 of 184 [33.7%]) than parents in the enhanced suction group (145 of 183 [79.2%]) (risk difference, 0.45; 95% CI, 0.36 to 0.54; P < .001). Conclusions and Relevance: Compared with minimal suctioning, enhanced suctioning after ED discharge with bronchiolitis did not alter the disease course because there were no group differences in revisits or feeding and sleeping adequacy. Minimal suctioning resulted in higher use of nonassigned suctioning devices and lower parental satisfaction with the assigned device. Trial Registration: ClinicalTrials.gov Identifier: NCT03361371.

Updated guidance regarding the risk of allergic reactions to COVID-19 vaccines and recommended evaluation and management: A GRADE assessment and international consensus approach.

This guidance updates 2021 GRADE (Grading of Recommendations Assessment, Development and Evaluation) recommendations regarding immediate allergic reactions following coronavirus disease 2019 (COVID-19) vaccines and addresses revaccinating individuals with first-dose allergic reactions and allergy testing to determine revaccination outcomes. Recent meta-analyses assessed the incidence of severe allergic reactions to initial COVID-19 vaccination, risk of mRNA-COVID-19 revaccination after an initial reaction, and diagnostic accuracy of COVID-19 vaccine and vaccine excipient testing in predicting reactions. GRADE methods informed rating the certainty of evidence and strength of recommendations. A modified Delphi panel consisting of experts in allergy, anaphylaxis, vaccinology, infectious diseases, emergency medicine, and primary care from Australia, Canada, Europe, Japan, South Africa, the United Kingdom, and the United States formed the recommendations. We recommend vaccination for persons without COVID-19 vaccine excipient allergy and revaccination after a prior immediate allergic reaction. We suggest against >15-minute postvaccination observation. We recommend against mRNA vaccine or excipient skin testing to predict outcomes. We suggest revaccination of persons with an immediate allergic reaction to the mRNA vaccine or excipients be performed by a person with vaccine allergy expertise in a properly equipped setting. We suggest against premedication, split-dosing, or special precautions because of a comorbid allergic history.

Epinephrine autoinjectors: individualizing device and dosage to optimize anaphylaxis management in the community setting.

Background: Anaphylaxis is the most severe manifestation of a systemic allergic reaction, and, in the community setting, the immediate administration of an epinephrine autoinjector (EAI) can be life-saving. Physicians are tasked with selecting the most appropriate EAI for each individual and counseling patients and/or their caregivers to maximize the likelihood of successful deployment of the EAI. Objective: To offer an evidence-based expert clinical perspective on how physicians might best tailor EAI selection to their patients with anaphylaxis. Methods: A group of eight adult and pediatric allergists with expertise in anaphylaxis management reviewed and assessed the published data and guidelines on anaphylaxis management and EAI device selection. Results: Personalized EAI selection is influenced by intrinsic individual factors, extrinsic factors such as the properties of the individual EAI (e.g., dose, needle length, overall design) as well as cost and coverage. The number and the variety of EAIs available have expanded in most jurisdictions in recent years, which provide a greater diversity of options to meet the characteristics and needs of patients with anaphylaxis. Conclusion: There currently are no EAIs with customizable dose and needle length. Although precise personalization of each patient's EAI remains an optimistic future aspiration, careful consideration of all variables when prescribing EAIs can support optimal management of anaphylaxis.

Canadian Anaphylaxis Network-Predicting Recurrence after Emergency Presentation for Allergic REaction (CAN-PREPARE): a prospective, cohort study protocol.

INTRODUCTION: Anaphylaxis is a severe, potentially fatal multiorgan system manifestation of an allergic reaction. The highest incidence of anaphylaxis is in children and adolescents. Biphasic anaphylaxis (BA) is defined as the recurrence of allergic symptoms after resolution of an initial reaction. It has been reported to occur in 10%-20% of cases within 1-48 hours from the onset of the initial reaction. The dilemma for physicians is determining which patients with resolved anaphylaxis should be observed for BA and for how long. Guidelines for duration of postanaphylaxis monitoring vary, are based on limited evidence and can have unintended negative impacts on patient safety, quality of life and healthcare resources. The objectives of this study are to derive a prognostic model for BA and to develop a risk-scoring system that informs disposition decisions of children who present to emergency departments (ED) with anaphylaxis. METHODS AND ANALYSIS: This prospective multicentre cohort study will enrol 1682 patients from seven paediatric EDs that are members of the Paediatric Emergency Research Canada network. We will enrol patients younger than 18 years of age with an allergic reaction meeting anaphylaxis diagnostic criteria. Trained ED research assistants will screen, obtain consent and prospectively collect study data. Research assistants will follow patients during their ED visit and ascertain, in conjunction with the medical team, if the patient develops BA. A standardised follow-up survey conducted following study enrolment will determine if a biphasic reaction occurred after ED disposition. Model development will conform to the broad principles of the PROGRESS (Prognosis Research Strategy) framework and reporting will follow the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis Statement. ETHICS AND DISSEMINATION: Ethics approval has been received from all participating centres. Our dissemination plan focuses on informing clinicians, policy makers and parents of the results through publication in peer-reviewed journals and broadcasting on multiple media platforms. TRIAL REGISTRATION NUMBER: NCT05135377.

The Revenge of Unintended Consequences of Anaphylaxis-Risk Overdiagnosis: How Far We Have Come and How Far We Have to Go.

Overdiagnosis of anaphylaxis risk is an underappreciated aspect of anaphylaxis prevention. Whereas the benefits of anaphylaxis-risk prevention are well known, potential harms resulting from preemptive approaches to mitigate anaphylaxis-risk are not insignificant. Still, great progress has been made in recent years to avoid the unintended consequences of anaphylaxis-risk overdiagnosis. Reflection on recent advances in the use of diagnostic testing, as well as the application of diagnostic labels, provides an important perspective to understand how far the specialty of allergy and immunology has come in improving the lives of patients and families. Examples of recent paradigm shifts in anaphylaxis-risk management include approaches to peanut allergy prevention without screening, deferral of corticosteroids to prevent biphasic anaphylaxis reactions, reevaluation of reflex use of emergency medical services for resolved community anaphylaxis, and an approach to penicillin allergy delabeling with direct oral challenge. Routine medical practices to decrease anaphylaxis risk can have lifelong impacts for patients-beyond just preventing anaphylaxis. As our understanding of these trade-offs evolves, it becomes necessary to weigh both the benefits and the harms of past management approaches. Because medicine remains a science of uncertainty and an art of probability, a critical approach to risk mitigation remains necessary to find the often-elusive balance in anaphylaxis prevention.

The Risk of Allergic Reaction to SARS-CoV-2 Vaccines and Recommended Evaluation and Management: A Systematic Review, Meta-Analysis, GRADE Assessment, and International Consensus Approach.

Concerns for anaphylaxis may hamper severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunization efforts. We convened a multidisciplinary group of international experts in anaphylaxis composed of allergy, infectious disease, emergency medicine, and front-line clinicians to systematically develop recommendations regarding SARS-CoV-2 vaccine immediate allergic reactions. Medline, EMBASE, Web of Science, the World Health Organizstion (WHO) global coronavirus database, and the gray literature (inception, March 19, 2021) were systematically searched. Paired reviewers independently selected studies addressing anaphylaxis after SARS-CoV-2 vaccination, polyethylene glycol (PEG) and polysorbate allergy, and accuracy of allergy testing for SARS-CoV-2 vaccine allergy. Random effects models synthesized the data to inform recommendations based on the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach, agreed upon using a modified Delphi panel. The incidence of SARS-CoV-2 vaccine anaphylaxis is 7.91 cases per million (n = 41,000,000 vaccinations; 95% confidence interval [95% CI] 4.02-15.59; 26 studies, moderate certainty), the incidence of 0.15 cases per million patient-years (95% CI 0.11-0.2), and the sensitivity for PEG skin testing is poor, although specificity is high (15 studies, very low certainty). We recommend vaccination over either no vaccination or performing SARS-CoV-2 vaccine/excipient screening allergy testing for individuals without history of a severe allergic reaction to the SARS-CoV-2 vaccine/excipient, and a shared decision-making paradigm in consultation with an allergy specialist for individuals with a history of a severe allergic reaction to the SARS-CoV-2 vaccine/excipient. We recommend further research to clarify SARS-CoV-2 vaccine/vaccine excipient testing utility in individuals potentially allergic to SARS-CoV2 vaccines or their excipients.

Skin Testing for Penicillin Allergy: a Review of the Literature.

PURPOSE OF REVIEW: Self-reported penicillin allergies are frequently reported, though more than 95% of those are not truly allergic when challenged. These patients are more likely to receive alternative antibiotic regimens resulting in the use of broad-spectrum antibiotics that may be less effective, more toxic, and/or more expensive than preferred agents. Given the significant burden on patient outcomes and the healthcare system, the ability to reconcile an allergy and broaden future antibiotic options is essential. RECENT FINDINGS: This is a narrative review describing risk stratification for penicillin skin testing, practical advice for implementation, and future directions. A summary of studies within the last 5 years is provided. The trend over the past several years has been to offer oral drug challenges to low-risk patients and skin testing to high-risk patients with a reported penicillin allergy. This review provides support for risk stratification assessment of reported penicillin allergy to optimize antibiotic use and prevent emergence of antimicrobial resistance.

Development and Assessment of a Pictographic Pediatric Constipation Action Plan.

OBJECTIVE: To assess the Uniformed Services Constipation Action Plan (USCAP) as an evidence-based, personalized, clinical action tool with pictograms to aid clinicians and families in the management of functional constipation. STUDY DESIGN: The USCAP facilitates the management functional constipation by using a health literacy-informed approach to provide instructions for pharmacotherapies and lifestyle modifications. This study included part 1 (pictogram validation) and part 2 (assessment). For part 1, pictogram transparency, translucency, and recall were assessed by parent survey (transparency ≥85%, mean translucency score ≥5, recall ≥85% required for validation). For part 2, the USCAP was assessed by parents, clinical librarians, and clinicians. Parental perceptions (n = 65) were assessed using the Consumer Information Rating Form (17 questions) to gauge comprehensibility, design quality and usefulness. Readability was assessed by 5 formulas and a Readability Composite Score was calculated. Clinical librarians (n = 3) used the Patient Education Materials Assessment Tool to measure understandability (19 questions) and actionability (7 questions) (>80% rating was acceptable). Suitability was assessed by clinicians (n = 34) using Doak's Suitability Assessment of Materials (superior ≥70% rating). RESULTS: All 12 pictograms demonstrated appropriate transparency, translucency, and recall. Parental perceptions reflected appropriate comprehensibility, design quality, and usefulness. The Readability Composite Score was consistent with a fifth-grade level. Clinical librarians reported acceptable understandability and actionability. Clinicians reported superior suitability. CONCLUSIONS: The USCAP met all criteria for clinical implementation and future study of USCAP implementation for treating children with chronic functional constipation.

Management of pediatric allergic reaction: Practice patterns of Canadian pediatric emergency physicians.

OBJECTIVES: Anaphylaxis is a severe allergic reaction that can be life-threatening. The literature indicates that the incidence of anaphylaxis is increasing and that there are deficiencies in both recognition and management. We aimed to examine the magnitude of these gaps in Canadian pediatric emergency medicine (PEM). METHODS: We conducted a self-administered survey of the Pediatric Emergency Research Canada (PERC) physician database. The survey tool was developed through a literature review to identify recurring themes of gaps in anaphylaxis diagnosis and management. The final tool contained four scenarios; three scenarios featured each of the National Institute of Allergy and Infectious Diseases (NIAID) anaphylaxis criteria, separately, and a fourth case of non-anaphylactic allergy. Multiple-choice questions associated with each scenario addressed diagnosis, management, and disposition. Additional questions focused on epinephrine prescribing, observation durations, and respondent demographics. RESULTS: Of the 214 members invited to participate in the survey, 152 (71%) responded. Anaphylaxis was accurately recognized 93%, 82%, and 99% of the time for the NIAID criteria one through three, respectively. When anaphylaxis was recognized, epinephrine was prescribed for each case 96%, 95%, and 72% of the time, respectively. Of all respondents, 115 (76%) accurately diagnosed all three cases of anaphylaxis and 82 (54%) treated anaphylaxis with epinephrine each time it was indicated. CONCLUSION: Most respondents recognized cases of anaphylaxis; however, a substantial number demonstrated gaps in management that may adversely impact this vulnerable population. The recognition of anaphylaxis without urticaria or pulmonary findings and treatment of anaphylaxis with epinephrine, where indicated, were the main gaps identified.

The Canadian anaphylaxis action plan for kids: development and validation.

OBJECTIVES: We designed a written Canadian Anaphylaxis Action Plan for Kids (Kids' CAP) which incorporates validated pictograms with written instructions. Using a patient-centered approach, we aimed to validate the Kids' CAP and assess its impact on anaphylaxis recognition and treatment, and to determine its' perceived usefulness. PATIENT INVOLVEMENT: Children and their parents were involved in appraising the design and written contents of the Kids' CAP. METHODS: The design process consisted of a development phase and clinical validation phase. First, we assessed the readability and understandability of the Kids' CAP using validated instruments. Then, patients (12-17 years of age) and parents of patients (<12 years of age) were given the Kids' CAP during the first consultation with allergy specialists or an Emergency Department visit for anaphylaxis. Subsequently, we conducted a phone interview 2-3 weeks later to assess their comprehension of anaphylaxis management. We also used the Consumer Information Rating Form to measure the participants' perception of the design quality and usefulness of the Kids' CAP. RESULTS: Of the 230 participants enrolled, 205 (89%) completed the follow-up interview. The written contents of the Kid's CAP were modified to match grade 7 readability level. The total mean score of the Consumer Information Rating Form for comprehensibility was 23.1 (SD 2.4), and 25.1 (SD 2.3) for design quality. The mean comprehension score was 11.3 (SD 1.8) (reference range 0-12), with no significant difference between participants with and without previous experience with anaphylaxis, or high vs. low literacy level. CONCLUSION: Engaging children and parents in the design and contents of written anaphylaxis action plan is an innovative approach to produce a useful document for the end-users. PRACTICE IMPLICATIONS: The Kids' CAP is a valid tool that can be used in emergency departments and allergy clinics to improve patient's comprehension of anaphylaxis manifestations and treatment.

Bilateral Temporal Extradural Hematoma on Top of Bilateral Temporal Arachnoid Cyst: First Case Report and Extensive Literature Review.

BACKGROUND: The traumatic complication of an arachnoid cyst (AC) with intracystic and subdural hematoma has been reported in many cases. However, a unilateral extradural hematoma (EDH) as a complication of AC is extremely rare. Most arachnoid cysts are unilateral and are located in the middle cranial fossa. Bilateral temporal AC alone is an extremely rare condition, and a bilateral EDH on top of a bilateral temporal AC has never been reported in the literature, to our knowledge. CASE DESCRIPTION: We report the case of a 25-year-old man with a known bilateral AC who was involved in a motor vehicle accident and developed a bilateral temporal EDH. The brain computed tomography scan also showed fractures in the skull on both temporal areas. The patient was treated conservatively. He was discharge with Glasgow Coma Scale score of 5. CONCLUSIONS: Bilateral temporal EDH in a bilateral temporal AC has never been reported in the literature. The presence of an AC may predispose a patient to complications because of the anatomic changes in the area. It is important to educate asymptomatic patients and their families about these cysts and the importance of avoiding head injury and not being involved in contact sports or military service.

Do Corticosteroids Prevent Biphasic Anaphylaxis?

Anaphylaxis is a severe hypersensitivity reaction that is rapid in onset and can result in death. The pattern of an anaphylactic reaction can be uniphasic (or monophasic), biphasic (also called delayed or late phase), or refractory in nature. The most widely cited definition of biphasic anaphylaxis is a recurrence of anaphylactic symptoms after initial resolution despite no further exposure to the trigger. Corticosteroids are thought by some to prevent the development of biphasic symptoms and, therefore, commonly used in the emergency treatment of anaphylaxis but this has not been systemtically analyzed. In this review, Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus were searched for articles using "anaphylaxis" combined with the key terms "biphasic" and/or "corticosteroids" and/or "epinephrine." A total of 31 appropriate studies were identified. Biphasic anaphylactic reactions are more likely to occur in moderate to severe anaphylaxis or when anaphylaxis is not treated with timely epinephrine. Because of the potential detrimental adverse effects of corticosteroids and lack of compelling evidence demonstrating an effective role in reducing anaphylaxis severity or preventing biphasic anaphylaxis, we do not advocate for their routine use in anaphylaxis.

Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis.

BACKGROUND: Epidemiologic data regarding biphasic reactions in children with anaphylaxis are sparse. OBJECTIVE: To investigate the incidence and clinical predictors of biphasic reactions in children presenting to the emergency department (ED) with anaphylaxis. METHODS: A health records review of ED visits at 2 large Canadian academic pediatric EDs was conducted. All visits that satisfied anaphylaxis diagnostic criteria of the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network were included. Predictors of biphasic reaction were analyzed using univariate and multiple logistic regression analyses. RESULTS: Of 1,749 ED records reviewed, 484 visits met the study inclusion criteria. Seventy-one patients (14.7%) developed biphasic reactions. The median age was 6 years (interquartile range 2.7-10.1) and 51 (71.8%) were boys. Forty-nine of the 71 (69%) delayed reactions involved respiratory and/or cardiovascular manifestations and 35 (49%) were treated with epinephrine. Five independent predictors for biphasic reactions were found: age 6 to 9 years (odds ratio [OR] 3.60, 95% confidence interval [CI] 1.5-8.58), delay in presentation to the ED longer than 90 minutes after the onset of the initial reaction (OR 2.58, 95% CI 1.47-4.53), wide pulse pressure at triage (OR 2.92, 95% CI 1.69-5.04), treatment of the initial reaction with more than 1 dose of epinephrine (OR 2.7, 95% CI 1.12-6.55), and administration of inhaled ß-agonists in the ED (OR 2.39, 95% CI 1.24-4.62). CONCLUSION: Biphasic reactions seem to be associated with the severity of the initial anaphylactic reactions. We identified clinical predictors that could ultimately be used to identify patients who would benefit from prolonged ED monitoring and enable better utilization of ED resources.

Design and validation of pictograms in a pediatric anaphylaxis action plan.

BACKGROUND: Current anaphylaxis action plans (AAPs) are based on written instructions without inclusion of pictograms. OBJECTIVES: To develop an AAP with pictorial aids and to prospectively validate the pictogram components of this plan. METHODS: Participants recruited from the emergency department and allergy clinic participated in a questionnaire to validate pictograms depicting key counseling points of an anaphylactic reaction. Children ≥ 10 years of age and caregivers of children < 10 years with acute anaphylaxis or who carried epinephrine auto-injector for confirmed allergy were eligible. Guessability, translucency, and recall were assessed for 11 pictogram designs. Pictograms identified as correct or partially correct by at least 85% of participants were considered valid. Three independent reviewers assessed these outcome measures. RESULTS: Of the 115 total participants, 73 (63%) were female, 76 (66%) were parents/guardians, and 39 (34%) were children aged 10-17. Overall, 10 pictograms (91%) reached ≥ 85% for correct guessability, translucency, and recall. Four pictograms were redesigned to reach the preset validation target. One pictogram depicting symptom management (5-min wait time after first epinephrine treatment) reached 82% translucency after redesign. However, it reached 98% and 100% of correct guessability and recall, respectively. CONCLUSIONS: We prospectively designed and validated a set of pictograms to be included in an AAP. The incorporation of validated pictograms into an AAP may potentially increase comprehension of the triggers, signs and symptoms, and management of an anaphylactic reaction.

A simple case of a small elbow effusion.

An 11-month-old child presented with what initially appeared to be 2 simple problems, a small elbow effusion followed 1 week later by croup. This case history is presented to remind emergency medicine physicians of the importance of index of suspicion and recognition of the difference between common events occurring in a normal host versus common events occurring in an abnormal host.