What type of EpiPen (epinephrine auto-injector) do you prescribe to pediatric patients?

EpiPen Selection for Pediatric Patients

For pediatric patients, prescribe EpiPen Jr (0.15 mg) for children weighing 7.5-25 kg and EpiPen (0.3 mg) for children weighing ≥25 kg to ensure optimal intramuscular delivery of epinephrine during anaphylaxis. 1

Weight-Based EpiPen Dosing Algorithm

Children <7.5 kg (very small infants)

• Technically, the 0.15 mg dose exceeds the ideal 0.01 mg/kg dose
• However, the American Academy of Pediatrics recommends using the 0.15 mg autoinjector due to the favorable benefit-to-risk ratio compared to the risks of delayed or inaccurate dosing with ampule/syringe/needle 1
• Counsel parents about potential mild transient side effects (pallor, tremor, anxiety)

Children 7.5-25 kg

• Prescribe EpiPen Jr (0.15 mg) autoinjector 1
• This provides the optimal dose for children weighing 15 kg (0.01 mg/kg) 2
• For children closer to 7.5 kg, the dose is higher than ideal but benefits outweigh risks 3
• For children closer to 25 kg, the dose is slightly lower than ideal but still effective 2

Children 25-30 kg

• Prescribe EpiPen (0.3 mg) autoinjector 1
• At 25 kg, this provides a slight overdose (0.012 mg/kg) which is preferable to underdosing during anaphylaxis 2
• The American Academy of Pediatrics recommends switching from 0.15 mg to 0.3 mg at approximately 25 kg 2, 1

Children ≥30 kg

• Prescribe EpiPen (0.3 mg) autoinjector 1, 4
• This provides the optimal dose for children weighing 30 kg (0.01 mg/kg) 2

Important Clinical Considerations

Administration Technique

• Instruct on proper intramuscular injection into the mid-outer aspect (anterolateral) of the thigh 2, 4
• Hold the leg firmly in place for young children to minimize risk of injection-related injury 4
• Maintain the autoinjector in place for 3 seconds after triggering 1
• Intramuscular injection is strongly preferred over subcutaneous due to faster absorption (8 minutes vs. 34 minutes) 1

Potential Complications

• Risk of intraosseous injection in very small children:

  • Children <15 kg using high-pressure EAIs (like EpiPen Jr) have up to 29% risk of injection into bone 5
  • This risk increases to 60% in children <10 kg 5
  • The 12.7 mm needle length of standard autoinjectors may exceed the skin-to-bone distance in small children 5

• Risk of subcutaneous (rather than intramuscular) injection:

  • Up to 9% risk in children >30 kg using high-pressure autoinjectors 6
  • This can lead to delayed absorption and suboptimal treatment 1

Repeat Dosing

• 6-19% of pediatric patients require a second dose of epinephrine 2
• If needed, administer a second dose 5-15 minutes after the first 2, 4
• Do not administer repeated injections at the same site to avoid tissue necrosis 4

Side Effects

• Expect transient side effects including pallor, tremor, anxiety, and palpitations 2
• More significant side effects (headache, nausea) are more common with the 0.3 mg dose 7
• Serious adverse effects are rare with appropriate IM administration 1

Post-Administration Care

• All patients must be transported to an emergency department after epinephrine administration for monitoring 1
• Typical observation period is 4-6 hours 1
• Additional treatments may be needed (oxygen, IV fluids, antihistamines) 2

Remember that delayed administration of epinephrine is associated with increased mortality in anaphylaxis, so having the appropriate autoinjector readily available and properly administered is critical for pediatric patients at risk.