title: Do epinephrine auto-injectors have an unsuitable needle length in children and adolescents at risk for anaphylaxis from food allergy?
abstract: BACKGROUND
  Food allergy is the most common cause of anaphylaxis in children. Intramuscular delivery of epinephrine auto-injectors (EAI) is the standard of care for the treatment of anaphylaxis. We examined if children and adolescents at risk of anaphylaxis weighing 15-30 kg and >30 kg would receive epinephrine into the intramuscular space with the currently available EAI in North America and Europe.
  
  
  METHODS
  The distance from skin to muscle (STMD) and skin to bone (STBD) on the mid third anterolateral area of the right thigh was measured by ultrasound applying either high pressure (max) or slight pressure (min) in 102 children weighing 15-30 kg (group 1) and 100 children and adolescents, weighing more than 30 kg (group 2).
  
  
  RESULTS
  Using a high pressure EAI (HPEAI), Epipen Jr(®) and Auvi-Q(®)/Allerject(®) 0.15 mg, 11/102 (11 %) children in group 1 and 38/102 (38 %) using another HPEAI, Jext(®), had a STMDmax that showed a risk of intraosseous injection. There was a 1 % risk of subcutaneous injection with these devices. There was no risk of intraosseous injection using a low pressure EAI (LPEAI), Emerade(®). In group 2, the risk of intraosseous injection using a HPEAI was 3 % and no risk using a LPEAI. However, the risk of subcutaneous injection using HPEAI was 9 % and using LPEAI was 2 %.
  
  
  CONCLUSIONS
  There is a risk of intraosseous injection using HPEAI (Epipen(®)/Epipen Jr(®), Auvi-Q(®)/Allerject(®) and especially Jext(®)) in children at risk of anaphylaxis. There was also a risk of subcutaneous injection using the currently available HPEAI in children and adolescents.
authors.affiliation: Women's and Children's Health, University of Uppsala, Uppsala, Sweden.
authors.forename: Sten
authors.initials: S
authors.lastname: Dreborg
authors.affiliation: Faculty of Science, McGill University, Montreal, Canada.
authors.forename: Xia
authors.initials: X
authors.lastname: Wen
authors.affiliation: Faculty of Medicine, University British Columbia, Vancouver, Canada.
authors.forename: Laura
authors.initials: L
authors.lastname: Kim
authors.affiliation: Department of Medicine, Western University, London, Canada.
authors.forename: Gina
authors.initials: G
authors.lastname: Tsai
authors.affiliation: Goodman School of Business, Brock University, St. Catharines, Canada.
authors.forename: Immaculate
authors.initials: I
authors.lastname: Nevis
authors.affiliation: Farncombe Family Digestive Health Unit, McMaster University, Hamilton, Canada.
authors.forename: Ryan
authors.initials: R
authors.lastname: Potts
authors.affiliation: Department of Medicine, Western University, London, Canada.
authors.forename: Jack
authors.initials: J
authors.lastname: Chiu
authors.affiliation: Department of Medicine, McMaster University, Hamilton, ON Canada.
authors.forename: Arunmozhi
authors.initials: A
authors.lastname: Dominic
authors.affiliation: Department of Medicine, Western University, London, Canada ; Department of Medicine, McMaster University, Hamilton, ON Canada.
authors.forename: Harold
authors.initials: H
authors.lastname: Kim
keywords: Allergy; Anaphylaxis; Epimysium; Epinephrine; Epinephrine auto-injector; Food allergy; Intramuscular; Skin to bone distance; Skin to muscle distance; Subcutaneous