Parents, grandparents, caregivers, what are your worries and concerns about allergic reactions like anaphylaxis? Let us know by leaving a voicemail at NemoursWellBeyond.org. While you’re there, check out our other episodes, subscribe to the podcast, and leave a review.
Anaphylaxis is a word that sends shivers down the spines of parents, grandparents, and caregivers everywhere, and with good reason — it can be life-threatening. Joining us to define anaphylaxis and give us an update on what’s happening in the research world to prevent and treat it is Timothy Dribin, MD, Associate Professor in the Division of Emergency Medicine at Cincinnati Children’s Hospital Medical Center. Dr. Dribin is one of the world’s leading researchers on anaphylaxis in children. He presented primary data on that subject at the 2023 Pediatric Academic Societies meeting in Washington, DC, where we spoke with him.
Carol Vassar, producer
Guest: Timothy Dribin, MD
Associate Professor, Division of Emergency Medicine
Cincinnati Children’s Hospital Medical Center
Subscribe, review, or let your voice be heard at NemoursWellBeyond.org.
Nemours Children’s Health, Well Beyond Medicine Episode 22, Transcript
Carol Vassar, podcast host/producer (00:00):
Welcome to Well Beyond Medicine, the Nemours Children’s Health Podcast. Each week we’ll explore anything and everything related to the 80% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar. And now that you’re here, let’s go.
Let’s go – well beyond medicine!
Carol Vassar, podcast host/producer
Anaphylaxis is a medical term derived from two Greek words. Ana, which means against. And phylaxis, which translates to guarding. It’s one of those words that sends shivers down the spines of parents, grandparents, and caregivers everywhere, and with good reason. It can be life-threatening.
Joining me to define anaphylaxis and give us an update on what’s happening in the research world to prevent it and treat it, is Dr. Timothy Dribin. He’s an associate professor in the Division of Emergency Medicine at Cincinnati Children’s Hospital Medical Center.
Dr. Dribin is one of the world’s leading researchers on anaphylaxis in children. He presented primary data on the subject at the Pediatric Academic Society’s Meeting in Washington, DC this year, where we spoke with him.
So what is anaphylaxis? Here’s Dr. Timothy Dribin.
Timothy Dribin, MD, Cincinnati Children’s (01:27):
That’s a great question and there’s a lot of debate about what anaphylaxis is still. I work with international anaphylaxis experts and there’s a new impetus to try to come up with consensus diagnostic criteria, based on the input of people from all over the world.
What I would say is anaphylaxis is a severe allergic reaction, so it has the potential to cause significant harm to patients and potentially to cause fatalities. However, fatal reactions are exceedingly, exceedingly rare.
But what we typically think of anaphylaxis is it’s an allergic reaction that can involve multiple parts of the body. So typically, a simple allergic reaction, someone may eat a peanut, or they may take a medicine and have a reaction, and they may have a rash here or there. The difference usually with anaphylaxis is it doesn’t just involve one thing, such as the skin. It would be having the skin involvement plus another part of the body, such as vomiting or diarrhea, abdominal pain, or troubled breathing or wheezing.
And then the most severe part of anaphylaxis is there’s a small subset of patients. It’s more common than adults, but they can actually develop low blood pressure and what we in medicine refer to as shock, where basically they’re not able to get blood to their vital organ symptoms. And that’s the most severe form of anaphylaxis, that if not intervened quickly, patients can die from and do die here in the US and globally.
Carol Vassar, podcast host/producer (02:53):
I’m not a medical professional. I’m a parent.
Timothy Dribin, MD, Cincinnati Children’s (02:55):
Carol Vassar, podcast host/producer (02:55):
I’m a grandparent. How do I know when I need to bring my child to my pediatrician, or to the hospital, to look and see if this might be anaphylaxis?
Timothy Dribin, MD, Cincinnati Children’s (03:07):
I think it’s really challenging, and this is one of the things that our group is trying to actually improve is how can we aid patients, their families, other caregivers, whether it’s a childcare worker, a school teacher, who may encounter these reactions because we know there are more and more kids that have food allergies in schools.
And one of the things we hear very commonly in the emergency department is, “I still struggle to recognize when this is a severe allergic reaction.” And more specifically, “When do I need to give that epinephrine autoinjector?” Because that’s what we try to reinforce, that epinephrine is the therapy that has to always be given. And if given in a prompt, timely way, can prevent bad outcomes.
So, I think the thing we always tell families is, if you’re not a medical expert, if you’re not a healthcare provider, we don’t want you to put so much pressure on yourself. If you’re concerned, we always say, “Go to the emergency department or call 911.”
And we say, for those families that they’re unsure about when to give an epinephrine autoinjector, “If you’re concerned and you think your child could potentially be sick and you have one at hand, give it, and then we’ll help you manage it from there,” because I think it’s still a very, very challenging thing to try to figure out when to give those medicines.
Carol Vassar, podcast host/producer (04:15):
And I bring up the topic of anaphylaxis, specifically because this is what you are presenting on here at PAS; optimizing anaphylaxis observation periods based on reaction severity. Talk about your results, if you would.
Timothy Dribin, MD, Cincinnati Children’s (04:29):
Yeah. So one of the biggest dilemmas in anaphylaxis is that once patients receive epinephrine, for the most part, most patients have their symptoms go away, and they do just fine. That occurs in probably 90% of patients.
There’s another subset of patients, though, that even after you give an epinephrine autoinjector, their symptoms can persist. And then there’s another weird phenomenon where there’s a group of patients where their symptoms can actually go away, and then after a period of time, they come back and we call that a biphasic reaction.
In the literature, there’s very little guidelines about, after you give an epinephrine autoinjector, how long do you need to watch patients? We don’t really know. Previous guidelines had said, “Hey, we need to have all children who receive an autoinjector be observed for at least four to six hours.” But when they published these guidelines, they said there’s really no data supporting this.
This study is the first study to look at a large population of children with anaphylaxis to figure out how long do we need to watch these children once they receive an epinephrine autoinjector? And what we think is really novel is we said, “Look, not all anaphylaxis is the same. There are mild reactions that go away quickly, and then there are more severe reactions.” So, we need to determine observation periods based on the reaction and how severe it is.
So we said, “We thought that kids who have less severe reactions probably need to be observed for a shorter period of time in the emergency department, versus those once more severe symptoms that may pretend a worse outcome, they should be observed for a longer period of time.” And that’s what our findings really reinforced.
Based on how we did this study though, we did chart reviews to look, to try to answer this question. So the best way we could try to figure out how long we need to watch patients is we actually used, at the time of when patients received epinephrine to inform how long we need to watch them.
And what we found was that for kids with the more mild reactions, they could be observed for less than two hours. And then for patients with more severe reactions, they probably need to be observed a little longer. And we also found that some pretty striking findings that for patients who only had skin findings or abdominal symptoms, that they could be observed for almost like five minutes or less. So, almost no time at all, which really kind of begs the question, is that we hypothesize that there’s some kids that their parent gives them an epinephrine autoinjector at home, and they do well. Do they even need to come to the emergency department?
This current recommendations are that if you give an EpiPen, everyone has to come to the emergency department. And the reason for that is just to make sure that kids don’t get sicker and they don’t have a bad outcome. But in the future, we think there is potential to say, “Hey, how can we limit emergency department utilization,” given those visits are stressful for families, they’re incredibly expensive, and not to mention our emergency departments are very busy and we don’t want families sitting in our lobbies when they could be at home and have good outcomes. So, that’s kind of the summary of our findings.
Carol Vassar, podcast host/producer (07:21):
That’s the 20,000-foot view of your findings. What do you do with that information moving forward? It sounds like if this is replicated several more times, you might be changing the recommendation. This may be long-term, down the road, that people don’t have to come and bring their children after they get the EpiPen.
Timothy Dribin, MD, Cincinnati Children’s (07:39):
Yeah, it’s a great point. I think one thing is, as a researcher, it always takes time before research findings are implemented into care to actually change care, and it takes a lot to do that.
So, I work with a lot of allergy colleagues in the US and globally, and I think studies like this when it is published because, again, I had to say these are preliminary findings that we have not yet published in a peer-reviewed journal, but hopefully, these findings would help with changes in modification, to practice parameters that are set forth by different bodies such as the American Academy of Pediatrics or the Asthma and Allergy Foundations but that will take some time, I think. But I think this is an important first step to try to say, “Look, that there’s potential that we could reduce observation periods.”
Additionally, given that this study we categorize as a retrospective study, we usually say the best evidence is for those studies where you’re collecting data in real-time, so when patients come in. Our group is currently conducting a study that is prospective, to try to figure out how long do patients have their symptoms for based on how sick they are. So we think that data will be probably even more robust and stronger to compliment the studies that we’re presenting here at the meet.
Carol Vassar, podcast host/producer(08:48):
Sounds like you’re doing a lot of research. In researching you, I found out that you had a study. You were the lead author of a study that was published in the Journal in the American Academy of Allergy Asthma Immunology, that looked to identify knowledge gaps around anaphylaxis. What were the findings of that particular article?
Timothy Dribin, MD, Cincinnati Children’s (09:09):
Yeah, that article, we convened a panel of 25 experts in the US, and then there are three international panelists, as well. I think the big message is that anaphylaxis is really understudied, that there’s a paucity of data and research to try to figure out how can we best manage patients.
One of the first things is that there’s need to improve the terminology about how we communicate around anaphylaxis. So what our group did was we also published another complimentary study to standardize how we define these different outcomes.
So what is a biphasic reaction, and what does it mean to have a persistent reaction? And that’s a really important step for researchers so that we can try to harmonize our outcomes so that when we conduct research going forward, that different investigators and research teams use the same term. So that’s very, very, very helpful.
We also published another study where it’s used to assess the severity of reactions because a severe reaction, for me, may be very different than a severe reaction for a clinician in Canada or in England. So, we want to standardize how we define severity, and that will also help us better understand outcomes and potentially, if we develop new therapies, to standardize that as well.
One of the big things though that I think is missing with anaphylaxis is anaphylaxis is a clinical diagnosis. So it means we have to examine patients. We have to listen to what symptoms they’re having to figure out, do we think this is anaphylaxis? However, there’s still a lot of disagreement among clinicians about what it means to have anaphylaxis.
So, I think one of the biggest things from more of a basic science or translational science aspect is there’s still need to understand what is really happening from a mechanistic standpoint. There’s no blood test that we can draw to say you have anaphylaxis or you don’t. And there’s definitely not something that we can test rapidly to inform our decisions.
So, I think that will be one of the biggest challenges going forward is, is there a way to identify what we call a biomarker, either in the blood or urine, or combinations of biomarkers, that we can use to confirm when someone’s really hand having anaphylaxis and also to inform other stuff such as how long we need to watch, or potentially to develop new therapies to target some of those biomarkers. So, there’s a lot of work that needs to be done in that realm.
The challenge, though, of studying anaphylaxis is that it’s really hard. The emergency department’s a great place to study it, but it’s really hard when kids come in with anaphylaxis. They’re scared. Their parents are scared. How do we enroll them in a research study? How do we get them to say, “Hey, yeah, we’ll provide blood sample and all that.” So, it’s really, really hard to study, and our group is one of the groups that’s trying to make strides, to develop the infrastructure that we can study this in real-time, to advance our understanding of these outcomes.
Carol Vassar, podcast host/producer (11:52):
And that, of course, goes to the issue of informed consent. And parents are, I guess, as you said, in a stressful situation. Can you get them to sign that piece of paper to enroll them in a study? These are difficult questions, but you’re working on them.
Timothy Dribin, MD, Cincinnati Children’s (12:05):
We’re working on it. And you know what? I think one of the things that I love studying about anaphylaxis is that patients and their families, and whether it’s the primary caregivers or grandparents, they’re so invested in this research because, for a lot of people, these are lifelong things that they struggle with. A child with a peanut allergy they’re probably not going to outgrow that. So, that’s a fear for that family, for that patient, the rest of their life. Their kid goes to college. It’s not something they’re going to outgrow.
So, we’ve been humbled by the commitment of patients and families to participate in this research more than we have in some other studies. And for our studies, we’ve found a high number of families that want to participate in this research and are really committed to it, so I think that’s very encouraging for our team and other investigators going forward.
Carol Vassar, podcast host/producer(12:52):
Are you still practicing clinically?
Timothy Dribin, MD, Cincinnati Children’s (12:54):
I do practice clinically. I do. I have about one shift a week in the emergency department at Cincinnati Children’s, and I think that’s really important to still practice clinically because it makes sure that I still know what’s going on. As a clinician, I love it. But also, from a scientific standpoint, I always want to make sure the questions I have as an investigator are meeting the needs of patients and families. And the only way you can do that is sit at the bedside of a patient before they go home, or in the moment, to ask them those questions. ‘What is this like for you? What are we missing? What are we not doing? What would be a tool we could develop that you would use when you go home?”
And I think that’s key to driving science is to make sure that patients and families are involved in the research process from the beginning and are really driving what we do, to make sure that our outcomes are patient and family-centered.
Carol Vassar, podcast host/producer (13:43):
In terms of your clinical work, is there a patient story, a family story, of course, respecting privacy, that sticks with you, that informs your work, that inspires you as you move forward?
Timothy Dribin, MD, Cincinnati Children’s (13:53):
I think it’s a combination of patients and families. I think the thing that always amazes me is just to see the fear and the concern in a patient and the parents when they come in and see us. When they come in and they’re really sick, they have to go to our resuscitation room and they’re surrounded by 10, 15 people, and we’re potentially giving their child an epinephrine autoinjector, and that’s a really stressful time for that parent. And you can see it in their eyes.
And I think the thing is that that fear, even when their child gets better and we’re able to send them home, or they’re doing better, that anxiety does not leave them, and I think it changes them for the rest of their lives, where they go to a restaurant and they’re worried that there could be cross-contamination. They could go to their friend’s house, and they could get exposed to this.
So, it’s a pervasive concern, and that’s the thing that drives me is to say, “Look, we need to try to figure out solutions that can reduce that anxiety, that can reduce that stress.” And hopefully, my colleagues, who I always say are much, much smarter than me, the basic scientists, can really try to figure out how can we cure allergies, especially food allergies.
Right now, there’s no cure for this. There’s novel therapies, but there’s no cure to make it go away, and I think that’s hopefully, the amazing collaborators that I work with, they can try to address those problems to ultimately reduce that so the patients, their parents don’t have to have that anxiety, to live with day in and day out.
Carol Vassar, podcast host/producer (15:15):
Let me change the topic just ever so slightly. I know Nemours is in every healthcare institution that I’ve ever spoken to these days, is all about health equity. As you do your research, as you do your clinical work, how do you bring health equity principles into all that you do?
Timothy Dribin, MD, Cincinnati Children’s (15:33):
It’s a great question, and I’ve been very impressed that when we recruit patients for our other studies, that we have incredible diversity with the patients and families that we see. So, that’s number one.
I think that thing, I think in terms of a health equity point related to anaphylaxis and specifically food allergies for kids, is access. Right? When people leave our emergency department, are they able to access the care they need? So, the care they need is are they able to see an allergist in a timely manner? Are they able to get transportation to go see those allergists? If they have barriers, the parents are working or something like that, how can we make sure that they get to see the allergists and that they receive the therapy as they do?
I think there’s very little data. We don’t know how good we are in ensuring that access to care once children are seen in the emergency department. We’re the first-line service, but we don’t know if people are seeing an allergist, and that’s critical.
The other thing, if you think about access, is, are patients picking up prescriptions for epinephrine autoinjectors? One of the great things that our hospital has done we have a new critical care building and a new emergency department. We have a 24-hour pharmacy in our emergency department, so I know that when I send someone home, they’re going to have an epinephrine autoinjector at home. It’s very different if you send someone away at midnight and you don’t know if that parent is able to afford or even pick up that prescription for that epinephrine autoinjector, and if that child were to have a reaction, what would happen?
Now, hopefully, they would be able to call 911, but I think that’d be a disparity in care if they aren’t able to access that autoinjector and potentially have a bad outcome. So for me, I think access is one of the biggest things with health equity, and we are looking at that as well. So, we’re able to follow patients when we enroll them in the emergency department. We’re able to see are they following up with allergists. And then we also like to do some in-depth interviews with patients and their caregivers to try to figure out how we can deliver equitable care.
Carol Vassar, podcast host/producer (17:23):
Sounds like you’re thinking about the big questions when it comes to health equity, which is much appreciated.
Timothy Dribin, MD, Cincinnati Children’s (17:27):
Carol Vassar, podcast host/producer (17:28):
Anything else that you’d like to talk about on the podcast that I haven’t asked you about?
Timothy Dribin, MD, Cincinnati Children’s (17:32):
No. It’s just an honor to be here, and I think it’s really important that, as researchers, we always have our typical ways of conveying information, which is usually academic meetings like this or publications. But I always worry that patients’ families are not reading those publications. Right? It’s not getting out there. So, I think technology and podcasts like this are critical to making sure that people are hearing the most recent evidence and hopefully that they see that we’re trying to address these burdensome conditions to move science forward and to improve patient outcomes and care delivery in the US and abroad.
Well Beyond Medicine!
Carol Vassar, podcast host/producer (18:08):
Thanks for listening to our conversation on anaphylaxis and the research being done to prevent and treat it, with me, Carol Vassar, and our guest, Dr. Timothy Dribin, from Cincinnati Children’s Hospital Medical Center.
Parents, grandparents, caregivers, what are your worries and concerns about allergic reactions like anaphylaxis? Let us know by leaving a voicemail at nemourswellbeyond.org. That’s nemourswellbeyond.org. While you’re there, check out our other episodes, subscribe to the podcast, and leave a review.
Thanks to Che Parker, Cheryl Munn, and Susan Masucci, for production assistance this week. Join us next time as we preview Nemours Brand 2.0.
Until then, remember, together we can change children’s health for good, Well Beyond Medicine.