Pediatric Anaphylaxis Research Articles

Management of Pediatric Anaphylaxis in the Emergency Department in Low-Resource Settings: A Narrative Review

Management of Pediatric Anaphylaxis in the Emergency Department in Low-Resource Settings: A Narrative Review

Rare causes of pediatric anaphylaxis due to obscure allergens.

This review provides a comprehensive overview of rare causes of pediatric anaphylaxis related to obscure allergens. Anaphylaxis, a severe hypersensitivity reaction, can occur without typical symptoms, posing diagnostic challenges, especially in children. Idiopathic anaphylaxis, where no trigger is identified despite thorough evaluation, is notably challenging in this population. This review synthesizes current literature, highlighting obscure triggers such as food additives, spices like fenugreek, and cross-reactive allergens, including lupine and gelatin. These allergens are often overlooked and can lead to misdiagnosis of idiopathic cases. Understanding these uncommon triggers is crucial for clinicians to ensure accurate diagnosis and effective management of pediatric anaphylaxis, emphasizing the need for heightened clinical awareness and further research. This review raises awareness among health care providers about these lesser-known causes, aiming to improve outcomes and quality of life for pediatric patients at risk of anaphylactic reactions.

Trends of Peanut-Induced Anaphylaxis Rates Before and After the 2017 Early Peanut Introduction Guidelines in Montreal, Canada

Food allergies, particularly peanut, represent the predominant cause of anaphylaxis. Whereas early allergen introduction has emerged as a potential preventive strategy, the precise impact of recent guidelines on peanut-induced anaphylaxis rates in Canada remains unclear. To assess the impact of the 2017 Addendum Guidelines for the Prevention of Peanut Allergy on peanut-induced anaphylaxis rates in Canada. Using a comprehensive longitudinal registry capturing pediatric anaphylaxis presentations to the Montreal's Children's Hospital, we compared children with and without known peanut allergy who presented with peanut-induced anaphylaxis between 2011 and 2019 inclusive, excluding data beyond 2019 owing to the Coronavirus disease 2019 (COVID-19) pandemic. We calculated rates of peanut-induced anaphylaxis presentations per 100,000 age-adjusted all-cause emergency department visits using 4-month intervals. Interrupted time series analysis was used to compare anaphylaxis rate trends before and after 2017 for children ages 0 to 2 and 3 to 17 years. We examined 2,011 cases of pediatric anaphylaxis, including 429 (21%) triggered by peanuts. Compared with pre-guideline estimates, the yearly rate of change of peanut anaphylaxis rates decreased by 7.96 (95% confidence interval -14.57 to -1.36; P= .018) after 2017 among patients with new-onset anaphylaxis in children 2 years of age or younger (n= 109). No significant changes were identified for older patients ages 3 to 17, or in patients with known peanut allergy. Early introduction guidelines in Canada are associated with a reduced risk of new-onset peanut-induced anaphylaxis in young children within a single center in Montreal. Further research is required to assess the impact on a wider population and other food allergens.

Pediatric drug-induced anaphylaxis reports in the FDA Adverse Event Reporting System (FAERS)

Previous research indicated that antibiotics and NSAIDs are key drug categories associated with anaphylaxis in children. However, this study suggests that monoclonal antibodies have emerged as a leading category of drugs reported to the FDA as causing "anaphylaxis" in children. It remains unclear how many of these reports are common-infusion-related reactions rather than true anaphylaxis.

A retrospective audit of adult and paediatric anaphylaxis management from two Australian metropolitan mixed emergency departments

BackgroundAnaphylaxis is a potentially life-threatening allergic reaction, with presentations to emergency departments (EDs) increasing across Australia. Understanding the features of those presenting with anaphylaxis and aspects related to its optimal clinical management across the admission, treatment and discharge settings is needed to minimise its impact. We aimed to evaluate the nature and management of presentations related to anaphylaxis across two Australian EDs.MethodsRetrospective audit of paediatric and adult patients presenting to a community or tertiary level ED with anaphylaxis from 1 May 2018 to 30 April 2019. Data extracted from medical records included demographic characteristics, causative agents, clinical features, treatments administered across community, ambulance or ED settings, as well as post-discharge care arrangements including provision of Adrenaline Auto-Injector (AAI) and Allergy/Anaphylaxis Action Plan (AAP).ResultsA total of 369 (107 paediatric and 262 adult) ED presentations were identified. A total of 94 (36%) adult and 46 (43%) paediatric patients received pre-hospital adrenaline, with a further 91 (35%) adult and 29 (27%) paediatric patients receiving a dose of adrenaline in the ED. The most commonly administered treatment in ED were corticosteroids, given to 157 (60%) adult and 55 (51%) paediatric patients. Among those requiring an AAI for discharge, 123/210 (59%) adult and 57/91 (63%) of paediatric patients left hospital with an AAI. In contrast, among those requiring an allergy/anaphylaxis action plan (AAP) on discharge, 61/206 (30%) adult and 30/90 (33%) of paediatric patients left hospital with one. Factors associated with an increased likelihood of receiving AAI on discharge in paediatric and adult patients included receipt of any adrenaline, receipt of two or more doses of adrenaline, and longer duration of hospital stay. Adults presenting within business hours were more likely to be discharged with AAI, but no such difference was observed for paediatric patients. Similar findings were evident for provision of AAP on discharge.ConclusionThese findings demonstrate the need to improve assessment and treatment in the ED. In particular, the observed large variability in provision of AAI and AAP on discharge presents opportunities to explore strategies to improve awareness and provision of these critical components of post-discharge care.

ТЯЖЕЛАЯ АНАФИЛАКСИЯ У ДЕТЕЙ: КЛИНИЧЕСКИЕ ОСОБЕННОСТИ И ТРИГГЕРЫ

Over a long period of time in Russia we had the lack of the anaphylaxis (AF) register problem as it sounds to be the most important tool for recording, analysis and monitoring of this group of patients. Then, starting 2022, the first “Moscow Pediatric Anaphylaxis Register” has been maintaining at the Morozov Children’s City Clinical Hospital (Moscow, Russia), which systematizes and analyzes all the patient data on the etiology, clinical picture, severity factors and risk of developing AF, which in its turn is undoubtedly extremely valuable for further management of this group of patients. The purpose of this research was to evaluate the severity of AF taking into account the age and gender factors, comorbidity, triggers and clinical symptoms among children among the Moscow agglomeration. Materials and methods used: within the framework of a single-center cohort prospective study, the questionnaire data of 69 pediatric patients aged 0 to 18 y/o, 28 girl/41 boys, who were included in the study in May 2022-Sept. 2023, were subjected to statistical analysis register for emergency hospitalization due to AF. Results: the proportion of patients with severe AF was 30%; two age-related peaks in its frequency were recorded in the groups of children 0 to 3 y/o and 13 to 18 y/o (44% and 35%, respectively). Food triggers were the most significant regardless of the severity of AF; severe food AF was induced by tree nuts in 31%, and cow's milk in 19%. The central nervous and cardiovascular systems in severe AF were involved statistically significantly more often in comparison with the mild/moderate AF groups (86% v 25% and 81% v 30%, respectively, p<0.001), in 63% of cases symptoms developed within 0 to 15 minutes. Statistically significant differences were revealed in the frequency of diagnosis of AF in severe and moderate AF (57% v 12%, p=0.001). Conclusion: severe anaphylactic reactions in children are most often induced by food triggers and are characterized by a high frequency of involvement of the cardiovascular and central nervous systems, rapid development of symptoms, which is extremely important to consider during emergency verification of the diagnosis and immediate administration of epinephrine.

Clinical characteristics and management of pediatric egg-induced anaphylaxis: A cross-sectional study

BackgroundEgg is the third most common food allergy in children; however, data on pediatric egg-induced anaphylaxis are sparse. ObjectiveTo describe the clinical characteristics, management, and outcomes of pediatric egg-induced anaphylaxis. MethodsChildren presenting with anaphylaxis were recruited from 13 emergency departments as part of the Cross-Canada Anaphylaxis Registry, from which data on anaphylaxis triggered by egg were extracted. Multivariate logistic regression was used to determine factors associated with prehospital epinephrine autoinjector (EAI) use and to compare anaphylaxis triggered by egg with other triggers of food-induced anaphylaxis (FIA). ResultsWe recruited 302 children with egg-induced anaphylaxis. The mean age was 2.6 years (SD = 3.6), and 55.3% were male. Only 39.4% had previously been diagnosed with an egg allergy. Prehospital EAI use was 32.1%, but this was not significantly lower than in other triggers of FIA (P = .26). Only 1.4% of patients required hospital admission. Relative to other triggers of FIA, patients with egg-induced anaphylaxis were significantly younger (P < .001) and exhibited more vomiting (P = .0053) and less throat tightness (P = .0015) and angioedema (P < .001). ConclusionTo the best of our knowledge, this is the largest published cohort of pediatric egg-induced anaphylaxis. In this cohort, prehospital EAI use was very low. In addition, we identified certain symptoms that distinguish egg-induced from other triggers of FIA. Taken together, high suspicion is crucial in identifying egg-induced anaphylaxis, given the younger patient demographic and frequent lack of FIA history.

Disparities in pediatric anaphylaxis triggers and management across Asia.

The epidemiology and management of anaphylaxis are not well-reported in Asia. A regional pediatric anaphylaxis registry was established by the Asia-Pacific Research Network for Anaphylaxis (APRA), using standardized protocols for prospective data collection, to evaluate the triggers and management of anaphylaxis in the Asia-Pacific region. Pediatric patients below 18 years presenting with anaphylaxis across four Asian countries/cities (Thailand, Singapore, Hong Kong (HK), and Qingdao) were included. Allergen triggers, symptoms, anaphylaxis severity, and management were compared. Between 2019 and 2022, 721 anaphylaxis episodes in 689 patients from 16 centers were identified. The mean age at anaphylaxis presentation was 7.0 years (SD = 5.2) and 60% were male. Food was the most common trigger (62%), particularly eggs and cow's milk in children aged 3 years and below. In school-age children, nut anaphylaxis was most common in HK and Singapore, but was rare in the other countries, and wheat was the top allergen in Bangkok. Shellfish anaphylaxis was most common in children aged 7-17. Adrenaline was administered in 60% of cases, with 9% given adrenaline before hospital arrival. Adrenaline devices were prescribed in up to 82% of cases in Thailand but none in Qingdao. The APRA identified food as the main trigger of anaphylaxis in children, but causative allergens differed even across Asian countries. Fewer than two-thirds of cases received adrenaline treatment, pre-hospital adrenaline usage was low, and adrenaline device prescription remained suboptimal. The registry recognizes an unmet need to strengthen anaphylaxis care and research in Asia-Pacific.

Characteristics of anaphylaxis from tertiary-care hospital in lower northern Thailand: A ten-year retrospective cross-sectional study.

The prevalence and etiology of anaphylaxis vary based on geographic regions, study design, and definition used. Anaphylaxis leading to emergency department visits and hospitalizations has increased worldwide. The prevalence and etiology of anaphylaxis vary based on geographic regions, study design, and definition used. Anaphylaxis leading to emergency department visits and hospitalizations has increased worldwide. A cross-sectional retrospective analysis of medical records from patients with ICD-10 confirmed anaphylaxis was performed at Naresuan University Hospital between March 2011 and February 2021. We identified 439 anaphylaxis episodes in 381 patients within 10 years. The average annual occurrence rates of anaphylactic episodes were 25.0 per 100,000 outpatient and emergency department visits and 11.2 per 100,000 inpatient visits. Both pediatric and adult anaphylaxis events increased annually, from 13.3 (children: 20.5, adults: 12.4) in 2012 to 46.6 (children: 52.6, adults: 46.1) episodes per 100,000 visits in 2021. Peak incidence was observed in adolescents and young adults. Food was the most common trigger, with shrimp and fried insects being predominant. Risk factors for severe anaphylaxis were underlying cardiovascular diseases, drug triggers, and wheezing. Epinephrine was administered in 98.4% of all episodes. Although, there were no fatalities, only 11.4% of patients received prescriptions for self-injectable epinephrine. The study underscores an increasing trend of anaphylaxis affecting both children and adults in lower northern Thailand, with shrimp and fried insects as common triggers.

Milk-induced anaphylaxis among children presenting to Canadian emergency departments

BackgroundCow's milk is one of the most common and burdensome allergens in pediatrics, and it can induce severe anaphylactic reactions in children. However, data on cow's milk-induced anaphylaxis are sparse. ObjectiveTo describe the epidemiology of pediatric cow's milk-induced anaphylaxis and to determine risk factors for repeat emergency department (ED) epinephrine administration. MethodsBetween April 2011 and May 2023, data were collected on children with anaphylaxis presenting to 10 Canadian EDs. A standardized form documenting symptoms, triggers, treatment, and outcome was used. Multivariate logistic regression was used. ResultsOf 3118 anaphylactic reactions, 319 milk-induced anaphylaxis cases were identified (10%). In the prehospital setting, 54% of patients with milk-induced anaphylaxis received intramuscular epinephrine. In those with milk-induced anaphylaxis, receiving epinephrine before presenting to the ED was associated with a reduced risk of requiring 2 or more epinephrine doses in the ED (adjusted odds ratio, 0.95 [95% CI, 0.90-0.99]). Children younger than 5 years of age were more likely to experience a mild reaction compared with that in older children, who experienced a moderate reaction more often (P < .0001). Compared with other forms of food-induced anaphylaxis, children presenting with milk-induced anaphylaxis were younger; a greater proportion experienced wheezing and vomiting, and less experienced angioedema. ConclusionPrehospital epinephrine in pediatric milk-induced anaphylaxis is underused; however, it may decrease risk of requiring 2 ED epinephrine doses. Milk-induced anaphylaxis in children younger than 5 years of age may be less severe than in older children. Wheezing and vomiting are more prevalent in milk-induced anaphylaxis compared with that of other foods.

Impact of Reaction Setting on the Management, Severity, and Outcome of Pediatric Food-Induced Anaphylaxis: A Cross-Sectional Study.

Impact of Reaction Setting on the Management, Severity, and Outcome of Pediatric Food-Induced Anaphylaxis: A Cross-Sectional Study.

Characteristics of Pediatric Emergency Department Presentations of Anaphylaxis in Spain.

This study aimed to identify the triggers of pediatric anaphylaxis in Spain and to analyze the circumstances of the episode. Planned secondary analysis of a prospective observational multicenter study endorsed by the Spanish Society of Pediatric Emergencies including children aged younger than 18 years diagnosed with anaphylaxis in 7 Spanish pediatric emergency departments (EDs) between 2016 and 2018. We analyzed factors related to the anaphylaxis episode and its management. Four hundred fifty-three cases were registered, happening mainly at home (295 [65.1%]), school (65 [14.3%]), and street (61 [13.5%]). The median age was 5 years, 143 (31.6%) had previous episodes, and 165 (36.4%) had previously been prescribed an epinephrine autoinjector, used in 40 (24.2% of those prescribed). Two thirds were well-appearing when arriving to the pediatric ED. Food was the trigger in 396 (87.4%). In 349 with a single food involved, the most frequent were milk (108 [30.4%]), nuts (103 [29.0%]), hen's egg (40 [11.3%]), and fish (31 [8.7%]), with variations related to the age of the child. Food, especially milk and nuts, are responsible for most anaphylaxis diagnosed in Spanish pediatric EDs. Consideration should be given to improving health education due to the low use of epinephrine autoinjectors.

Pediatric wheat-induced anaphylaxis from the Cross-Canada Anaphylaxis Registry: Clinical characteristics and management.

Pediatric wheat-induced anaphylaxis from the Cross-Canada Anaphylaxis Registry: Clinical characteristics and management.

Anaphylaxis management in a French pediatric emergency department: Lessons from the ANA-PED study.

Anaphylaxis is a serious systemic hypersensitivity reaction that requires immediate recognition and prompt administration of epinephrine/adrenaline. The present study aimed to assess the appropriateness of epinephrine/adrenaline use in children identified as allergic by physicians in the emergency department (ED) at the time of the reaction, and to identify factors that are possibly associated with epinephrine/adrenaline administration, auto-injector prescription, and further referral to an allergist. We performed a retrospective cross-sectional study at the pediatric ED of the University Hospital of Montpellier, France. We included all consecutive children who attended the ED between 2016 and 2020 with an allergy-related diagnosis at discharge. We included 1056 allergy-related visits, including 224 (21.2%) with a diagnosis of anaphylaxis at discharge; only 17.0% of them received an epinephrine/adrenaline injection, and 57.1% consulted an allergist after the acute episode. An auto-injector was prescribed to 63 (28.1%) patients at discharge from the ED. Besides the severity of the clinical presentation, factors associated with a guidelines-based management of the anaphylactic reaction and with an increased administration rate of epinephrine/adrenaline included presence of asthma symptoms and presence of extended skin reactions. Our study underlines persistent gaps in the management of pediatric anaphylaxis in ED, focusing on hereby identified levers. By disseminating current knowledge and guidelines on anaphylaxis and allergies, specialists could work together with emergency physicians to establish effective management algorithms and improve anaphylaxis management and care pathways for children experiencing allergic reactions, especially anaphylaxis. Clinical Trials, number NCT05112367.

Comparison of anaphylaxis epidemiology between urban and suburban pediatric emergency departments

BackgroundAnaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. To date, there are no published data on epidemiology of pediatric anaphylaxis in Michigan. Our objective was to describe and compare the time trends in incidence of anaphylaxis in urban and suburban populations of Metro Detroit.MethodsWe performed a retrospective study of Pediatric Emergency Department (ED) anaphylaxis visits from January 1, 2010, to December 1, 2017. The study was conducted at 1 suburban ED (SED) and 1 urban ED (UED). We identified cases using an International Classification of Diseases (ICD) 9 and 10 query of the electronic medical record. Patients were included if they aged 0–17 years and met the 2006 National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network diagnostic criteria for anaphylaxis. The anaphylaxis rate was calculated as the number of detected cases divided by the total number of pediatric emergency room visits for that month. Anaphylaxis rates were compared between the two EDs using Poisson regression.ResultsA total of 8,627 patient encounters had ICD codes for anaphylaxis, of which 703 visits fulfilled the inclusion criteria and were used in subsequent analyses. Overall, the incidence of anaphylaxis was more common in males and in children < 4 years of age in both centers. Although the total number of anaphylaxis related visits was higher at UED over the eight-year time frame for this study, the anaphylaxis rate (cases per 100,000 ED visits) throughout the study was higher at the SED. While the observed anaphylaxis rate at UED was 10.47 – 162.05 cases per 100,000 ED visits, the observed anaphylaxis rate at SED was 0 – 556.24 cases per 100,000 ED visits.ConclusionPediatric anaphylaxis rates differ significantly between urban and suburban populations in metro Detroit EDs. The rate of anaphylaxis related visits to the ED has significantly increased over the past 8 years in the metro Detroit area, with significantly higher rise in suburban compared to urban ED. More studies are needed to explore the reasons for this observed difference in increase rates.

Incidence of and risk factors for pediatric perioperative anaphylaxis in the United States, 2005-2014

Incidence of and risk factors for pediatric perioperative anaphylaxis in the United States, 2005-2014

Trends and Variation in Pediatric Anaphylaxis Care From 2016 to 2022

Variation in the use of treatments and hospitalization for anaphylaxis would suggest a lack of consensus in therapeutic approach. To evaluate trends and practice variation in the emergency department (ED) care of children with anaphylaxis in a large US cohort. We conducted a 48-site retrospective cohort study using the Pediatric Health Information System from January 2016 through September 2022. Children younger than 18 years with a primary diagnosis of anaphylaxis were included. Care trends were assessed using negative binomial regression modeling. Rates of medication use, hospitalizations, and revisits were reported as medians with interquartile ranges (IQRs). There were 42,909 ED visits for anaphylaxis, with a 4.2% per-year increase in visit incidence (95% CI, 1.8-6.7) during the study period. The median hospitalization rate was 3.5% (IQR, 2.2-6.0), and the 3-day ED revisit rate was 0.6% (IQR, 0.4-0.9). The hospital-level median use of therapies included intramuscular epinephrine (55.3%; IQR, 50.1-59.9), systemic steroids (73.8%; IQR, 63.9-81.4), antihistamines (59.9%; IQR, 53.5-65.5), H2-receptor antagonists (56.8%; IQR, 42.3-66.2), bronchodilators (15.1%; IQR, 12.5-17.0), inhaled epinephrine (1.1%; IQR, 0.6-1.9), and fluid boluses (19.8%; IQR, 11.3-29.3). Severe reactions requiring intensive care unit admission (1.5%; IQR, 0.8-2.2), vasopressors (0.3%; IQR, 0.0-0.6), and intubation (0.2%; IQR, 0.0-0.3) were rare. ED visits for anaphylaxis increased during the study period, but hospitalization rates were low. Substantial variation exists between EDs regarding the use of anaphylaxis therapies, supporting the need for future research to evaluate the efficacy of these medications.

Management Of Anaphylaxıs In Pedıatrıc Populatıon.

Although an increase in the incidence of childhood anaphylaxis has been reported, it remains underdiagnosed. Foods are the most common triggers for anaphylaxis, particularly cow's milk, hen's egg, and nuts. Other common causes of anaphylaxis in children and adolescents include venom and drugs. The skin is the most commonly affected organ, but approximately 10% of patients with anaphylaxis may present without skin symptoms, which can lead to misdiagnosis. Recognition of anaphylaxis is a great challenge in children, possibly due to a lack of vigilance among patients, caregivers, and healthcare professionals, but also in part due to discrepancies in the clinical definition of anaphylaxis. In addition, anaphylaxis in infants often poses a distinct challenge because the wide spectrum of clinical manifestations and the inability of infants to describe their symptoms may hinder prompt diagnosis and treatment. Given the rapid onset of anaphylaxis and its unpredictable severity, rapid assessment and appropriate treatment are critical. Although the morbidity and mortality associated with anaphylaxis are potentially preventable with the timely administration of life-saving epinephrine, anaphylaxis is still undertreated worldwide. Long-term management of pediatric anaphylaxis is a patient-centered, multidimensional approach that focuses on the recognition of anaphylaxis, the use of epinephrine auto-injectors, and prevention of recurrences. Therefore, close communication and collaboration between the child, caregivers, healthcare professionals, and schools is the cornerstone of long-term care. This paper is designed to provide a comprehensive overview of current perspectives and concepts related to anaphylaxis in the pediatric population in light of recent guidelines and literature.

Children at risk of anaphylaxis: A mixed-studies systematic review of parents' experiences and information needs.

To explore parents' self-reported experiences and information needs regarding recognition and management of pediatric anaphylaxis. We searched Ovid Medline, Ovid PsychInfo, CINAHL Plus, the Cochrane Library, and grey literature to identify primary studies in English or French published since 2000. We used a mixed-method appraisal tool and convergent integrated approach to assess quality and synthesize data, respectively. 43 studies were included (22 quantitative, 19 qualitative, and 2 mixed-method); 77% of studies had high methodological quality. Parents' experiences were categorized as: recognizing an anaphylactic reaction; managing and responding to a reaction; emotional impact of caring for a child at risk of anaphylaxis; and interaction with the health system and healthcare providers. Parents' information needs were categorized into themes relating to: gaps in knowledge and information; type of information desired; information sources; and information delivery format. Negative emotional experiences and a general lack of information were commonly reported by parents of included studies. Provision of relevant and comprehensible information may help parents to make informed decisions and manage reactions promptly. The findings of this review are guiding the development of an innovative knowledge translation tool (KT) as part of a larger initiative of developing a suite of parent-focused KT tools for acute childhood conditions.

Utilising in situ simulation within translational simulation programmes to evaluate and improve multidisciplinary response to anaphylaxis in the paediatric emergency department.

The prevalence of paediatric anaphylaxis is rising in Australia. Treatment requires timely administration of intramuscular (IM) adrenaline. Study goals included utilising in situ simulation (ISS) within a translational simulation (TS) programme as a diagnostic tool to identify the frequency and cause of IM adrenaline errors in a paediatric ED, and utilising ISS to evaluate multidisciplinary emergency team response to anaphylaxis. A prospective observational study was conducted in the Royal Children's Hospital Melbourne ED utilising an ISS anaphylaxis scenario with a debrief pro forma within an established ISS/TS programme. Twenty-three anaphylaxis ISS were delivered over 16 months. One hundred and sixty-four multidisciplinary staff participated (mean of 8 per session). Median times (in minutes) for the total ISS were 12:33 (interquartile range [IQR] 9:06-15:19), consisting of the scenario 4:07 (IQR 3:33-4:44) and debriefing 9:00 (IQR 5-11). IM adrenaline was administered in all ISS within 5min, median 2:57 (IQR 2:30-3:40). Adrenaline medication errors occurred in 30% ISS (7/23). Errors included three (13%) administrations and four (17%) potential or 'near misses' associated with a verbal order or medication preparation error. A weight-based medication cognitive aid was utilised in 56% (13/23) ISS but was not utilised in all three administration errors. ISS within TS programmes was successfully utilised as a diagnostic tool in identifying that medication errors were common during anaphylaxis management in the ED. Improving access to adrenaline in dosing boxes and promoting the utilisation of weight-based cognitive aids alongside ISS education will likely reduce errors and improve patient safety.