Management of Anaphylaxis in Pediatric Patients

Recognition and Diagnosis

Anaphylaxis can be diagnosed when any of the following criteria are met: acute onset of symptoms involving skin/mucosal tissue PLUS either respiratory compromise OR reduced blood pressure, according to the American Academy of Pediatrics 3
Two or more of the following occurring rapidly after allergen exposure: skin-mucosal involvement, respiratory compromise, reduced blood pressure or associated symptoms, or persistent gastrointestinal symptoms, as recommended by the American Academy of Pediatrics 3

The American Academy of Pediatrics recommends prompt administration of intramuscular epinephrine into the lateral thigh as the first-line treatment for anaphylaxis in pediatric patients, which must be given immediately upon recognition of symptoms to reduce mortality and morbidity 1, 2
Intramuscular injection into lateral thigh (vastus lateralis) is the preferred route, with dosing of 0.15 mg epinephrine autoinjector for children weighing 10-25 kg and 0.30 mg epinephrine autoinjector for children weighing ≥25 kg, as recommended by the American Academy of Pediatrics 1, 4
The American Academy of Pediatrics also recommends that epinephrine may be repeated every 5-15 minutes if symptoms persist 5, 6

The American Academy of Pediatrics recommends the use of bronchodilator (albuterol) as an adjunctive treatment, with a dose of 4-8 puffs for children using an MDI or 1.5 mL for children using a nebulized solution 5, 6
The American Academy of Pediatrics also recommends the use of H1 antihistamine (diphenhydramine) as an adjunctive treatment, with a dose of 1-2 mg/kg per dose (maximum 50 mg) 5, 6
Supplemental oxygen and IV fluids for hypotension may also be used as adjunctive treatments, as recommended by the American Academy of Pediatrics 5, 6

All patients who receive epinephrine should be transported to an emergency facility for observation, with an observation period of 4-6 hours for most patients, as recommended by the American Academy of Pediatrics 5
The American Academy of Pediatrics recommends a longer observation or hospital admission for severe or refractory symptoms 5

The American Academy of Pediatrics recommends that all patients who have experienced anaphylaxis should be discharged with an anaphylaxis emergency action plan, two doses of epinephrine autoinjector, a plan for monitoring autoinjector expiration dates, and a referral for further evaluation 1, 5, 7
Education on allergen avoidance is also recommended, as well as a written individualized emergency action plan, as recommended by the American Academy of Pediatrics and the Mayo Clinic 1, 7

The American Academy of Pediatrics notes that current autoinjector doses may be too high for infants and young children <15 kg, presenting a clinical dilemma, and recommends careful consideration in these cases 1
Patients with asthma are at higher risk for severe reactions and require close monitoring, as recommended by the American Academy of Pediatrics 3, 5
Biphasic reactions can occur in 1-20% of cases, typically around 8 hours after initial reaction but may occur up to 72 hours later, as noted by the American Academy of Pediatrics 5, 6

The American Academy of Pediatrics recommends confirmation of trigger allergen, education on strict allergen avoidance, and a written individualized emergency action plan as prevention strategies 1, 7
Education of supervising adults on recognition and treatment, as well as a comprehensive management approach involving families, schools, and other organizations, is also recommended by the American Academy of Pediatrics 1