Anaphylaxis Treatment Guidelines

Recognition and Diagnosis

The American Academy of Pediatrics recommends recognizing anaphylaxis when any of the following criteria are met after exposure to a likely allergen: skin/mucosal involvement AND either respiratory compromise OR reduced blood pressure, or two or more of the following: skin/mucosal involvement, respiratory compromise, reduced blood pressure/associated symptoms, persistent GI symptoms 1
Common symptoms of anaphylaxis include skin: itching, redness, hives, swelling; respiratory: throat tightness, stridor, cough, difficulty breathing, wheezing; cardiovascular: tachycardia, hypotension, dizziness, collapse; gastrointestinal: nausea, abdominal pain, vomiting, diarrhea; neurological: behavioral changes, confusion, altered mental status 1

The American Academy of Pediatrics recommends first-line treatment with epinephrine 0.01 mg/kg (maximum 0.3 mg in a prepubertal child) injected intramuscularly in the mid-outer thigh as soon as anaphylaxis is recognized 2, 1
For a child, use epinephrine auto-injector 0.15 mg if weight is 10-25 kg or 0.3 mg if ≥25 kg 3
Call for emergency assistance (911/EMS) and position the patient on their back or in a position of comfort if respiratory distress/vomiting, with elevated lower extremities 2, 1
Monitor and repeat epinephrine if needed, with a second dose given 5-15 minutes after the first if symptoms persist 1, 3

The American Academy of Pediatrics recommends not delaying epinephrine administration, as delayed injection is associated with poor outcomes and fatality 2
Do not substitute antihistamines or asthma medications for epinephrine, as H1-antihistamines and bronchodilators provide adjunctive treatment but do not replace epinephrine 2, 3
Transport the child to an emergency department for further assessment and monitoring, even after successful treatment 2, 1
Observe for biphasic reactions, monitoring for at least 6 hours as symptoms may recur 4

Provide written anaphylaxis emergency action plan and educate the child and caregivers on recognition of symptoms and proper use of auto-injector 2
Consider medical identification jewelry and arrange referral to an allergist for further evaluation 2, 4

The American Academy of Pediatrics recommends dexamethasone 1-2 mg/kg IM for allergic reactions, which equals 13.5-27 mg for a 13.5 kg child, typically rounded to 15-25 mg as a practical dose 5
Epinephrine remains the first-line treatment for anaphylaxis, and the American Academy of Allergy, Asthma, and Immunology recommends administering epinephrine 0.01 mg/kg IM immediately for anaphylaxis, before or concurrent with dexamethasone 6

The American Academy of Pediatrics recommends administering dexamethasone 1-2 mg/kg IM using the acetate salt formulation, with a calculated dose of 13.5-27 mg for a 13.5 kg patient 5
The American Academy of Allergy, Asthma, and Immunology recommends administering dexamethasone as adjunctive therapy after or concurrent with epinephrine if anaphylaxis is present 6

The American Society of Hematology recommends monitoring patients for at least 15 minutes after dexamethasone administration 7
The American Academy of Allergy, Asthma, and Immunology recommends monitoring for biphasic reactions and observing patients for at least 6 hours as anaphylaxis symptoms may recur even after successful initial treatment, and notes that corticosteroids may help prevent late-phase reactions 6