Communicating anaphylaxis risk in pediatric allergy consultations: A conversation analytic study

Allergy in children is increasing. Reactions vary, with severe cases involving potentially fatal anaphylaxis which is treated with adrenaline. At-risk patients are prescribed adrenaline auto-injectors. However, due to limited specialist UK allergy clinics, risk discussions often take place with non-specialists (e.g., General Practitioners in primary care and general paediatricians in secondary care) who may lack confidence discussing risk and determining treatment suitability. Systematic examination of strategies for discussing risk is needed.

To identify, for the first time, strategies for communicating risk and negotiating adrenaline auto-injector prescribing decisions in actual paediatric allergy consultations.

We examined 23 video-recorded consultations in the U.K., involving one consultant paediatric allergy specialist, 23 patients (age 2-10) and caregivers. We identified 11 risk discussions, applying the rigorous method of conversation analysis to explicate practices for communicating risk of anaphylaxis and reaching adrenaline auto-injector prescription decisions. Data in British English.

Our novel and detailed findings demonstrate risk communication via categories such as low, moderate, and high risk, animated with gestures, explained with reassuring and worrying factors, and with reference to caregiver anxiety. However, risk assessments were tempered by raising uncertainty - concerns around the quality of the medical evidence. Further, severity of risk was carefully modified, individually tailored to each interactional context.

Our findings offer significant and new insights into how expert knowledge can be made available to patients/caregivers. Reasoning around risk was made explicit when adrenaline auto-injectors were proposed but not "pushed." This practice levelled each party's access to knowledge, flattening the epistemic gradient between doctor and patient/caregiver. As such patient/caregiver input in collaborative decision-making is facilitated.

Our findings offer specific, nuanced, and contextualised communication practices for conveying risk from an experienced specialist. These are available to significantly contribute to practice/education toolkits aimed at nonspecialists and those practising infrequently in this area.