In my last two articles in this series on raising children with food allergies, I talked about how to develop confidence in our children despite the natural cautiousness that comes with lifelong allergies, and how to maintain their safety once they start leaving the nest and going out into the world on their own. A major block on the road to independence for these children is the need for a shot of epinephrine should they have an anaphylactic reaction following exposure to an allergen so this week I want to look at how you decide when your child is able to be responsible for administering their own epinephrine.
The medical community has been trying to establish recommendations to determine the appropriate age for children to carry and administer a self-injectable epinephrine – mostly commonly known as an Epi-Pen. However, current guidelines do not specify the age at which the responsibility of administering epinephrine should be transferred from the adult caregiver to the child. This is because children with anaphylactic foods allergies should be able to identify their symptoms and the need for epinephrine as well as being able to correctly use the Epi-Pen during an anaphylactic reaction. This is a complex picture that requires a cool head and certain level of maturity and, as all children develop at their own speed, it is hard to give a definitive age at which all children will have the skill and judgement to be able to do this.
Studies that have reviewed the data suggest that children should be ready for this responsibility between 9 and 11 years old. Most pediatric allergists will expect children to be old enough somewhere between the ages of 12 and 14. So what is the appropriate age for our children to be responsible for their own administration of an Epi-Pen, and how can we, as parents tell when our child is ready?
At eight years old, my son has not yet reached the age where he is able to administer his own medication. However, I am beginning to prepare him: we discuss it; I have explained how the spring-loaded Epi-Pen auto-injector works and how it is important to hold the needle in the thigh for a minute to deliver all of the medication; and he has practiced injecting the Epi-Pen training pen into his thigh. Intellectually, he understands how to use an Epi-Pen but, like most 8-year olds, he is not yet mature enough to self-administer the medication when it is needed.
How Can You Tell If Your Child Is Ready?
The next level of independence for our children is being able to leave the safety of their parent’s watchful eyes and experience activities with their friends and peers. As a parent, I feel a sense of comfort in knowing that my child will soon be able to handle his food reactions independently from an adult. At the same time, there is always an underlying fear that, if and when the time comes, my child won’t know what to do and will fail to administer his medicine in a timely fashion. In an anaphylactic reaction time is truly of the essence; the sooner the medication is delivered into the body, the more effective it is in preventing throat swelling, shock and maybe even death. You have to be pretty confident in your child’s ability to remember everything, stay calm and administer the epinephrine correctly before you hand the responsibility over to them. So how do you judge? Here are some factors you need to take into account – regardless of how old your child is:
- Do they recognize the symptoms of anaphylaxis?
- Can they demonstrate the correct use of an Epi-Pen?
- Are they comfortable carrying their medication with them at all times?
- Have they injected themselves before using an Epi-Pen?
- Do they feel confident they can self-inject in an emergency?
- Do they suffer from developmental delay , autism spectrum disorder, ADHD or depression
- How mature are they?
- Does their school or community provide adequate treatment? Will they be in a school with many adults who have access to an Epi-Pen and are skilled at using it, or will they be in a rural environment such as a small town, camping or in the woods with limited medical access?
Even though every child develops according to their own schedule it is recommended that we begin training our children at an early school age, well before the teenage years which have been identified as a period when there is a higher risk of non-compliance, as well as greater risk-taking behaviors. These factors contribute to a greater risk for severe and fatal anaphylaxis. Simple education should therefore start in kindergarten and first grade then, as the child gets older, they can begin to carry their medicine with them before progressing to self-administering their Epi-Pen. Discuss with your allergist or family physician when this gradual shift in self-carrying and injecting the Epi-Pen should occur.
Bear in mind that different school districts will have different policies regarding where Epi-Pens are kept. Many schools require Epi-Pens to be kept in the nurse’s office and not with child, even in high school. This can pose a problem in large high schools where classrooms may be some distance from the nurse’s office. If you live in a district where this is the case, it is possible to get a doctor’s note that requires your child to carry their own Epi-Pens, especially during the high school years.
For children who attend camps and after school care it may be necessary for them to carry their Epi-Pens on them. As a parent I have experienced camps in which the counselors are either not allowed to administer an Epi-Pen or are not skilled at doing so. Instructing your child on using their Epi-Pens at a young age can be critical in situations where they may have more knowledge about the signs and treatment of an anaphylactic reaction than the adults around them.
As parents, it is our job to keep our children safe. When our children have severe food allergies this includes teaching them how to carry and administer epinephrine while experiencing an anaphylactic reaction. An anaphylactic reaction is scary for everyone involved and the key to recovery is a quick, skillful administrator of an Epi-Pen so it is vital that both you, and your child, are completely confident in their ability to respond well under pressure. Your child’s physician will help you make the decision as to when they are ready for this transition and the age at which this happens will vary from child to child. But, by age 14 the family should feel comfortable with the teenager being able to carry and administer their Epi-Pen correctly in the event of an anaphylactic food exposure.
There will, of course, be factors and circumstances that will change the age at which children are ready for self-administration; for some it will be at 9 years old while for others it may not be until the child is 15. As a parent, I know I will feel more comfortable knowing that, if my son is ever alone with no adult in the vicinity, he will be able to administer his own medication should the need arise.
As we have already said, epinephrine is most effective when given in the first few minutes of an anaphylactic food reaction; this means that training the person who is allergic to identify their symptoms as soon as they feel them coming on, and administer their epinephrine in a timely fashion reduces the risk of a fatal reaction. Along with the avoidance of allergens, helping them be skilled and confident at knowing when and how to administer their epinephrine during an anaphylactic reaction is the best way to protect our children and ensure they have a long, healthy life.
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In the meantime, look for my next article as I continue this series on how to raise children living with deadly food allergies.