What are the guidelines for adrenaline (epinephrine) nebulisation in children under 10 years?

Guidelines for Adrenaline (Epinephrine) Nebulization in Children Under 10 Years

Nebulized adrenaline at a dose of 0.5 ml/kg of 1:1000 solution is recommended for children with croup to avoid intubation, stabilize children prior to transfer to intensive care, and manage stridor following intubation. 1

Indications and Dosing

Croup

• Dosage: 0.5 ml/kg of 1:1000 solution 1
• Clinical use: For stabilizing children requiring intensive care and managing post-intubation stridor
• Duration of effect: Short-lived (1-2 hours)
• Important caution: Should not be used in children who are shortly to be discharged or on an outpatient basis 1

Post-extubation Stridor

• Studies show no significant difference in efficacy between doses of 0.5 ml, 2.5 ml, and 5 ml of nebulized L-epinephrine for post-extubation stridor 2
• Higher doses (5 ml) may cause significant increases in systolic and diastolic blood pressure 2

Safety Considerations

• Nebulization with 3-5 ml of adrenaline (1:1000) is generally safe with minor side effects for children with acute inflammatory airway obstruction 3
• Potential cardiovascular effects:
  • Heart rate may increase by 7-21 beats per minute for up to 60 minutes after treatment 3
  • Pallor may occur (reported in up to 47.6% of children receiving 3 ml adrenaline) 3
  • Blood pressure changes are typically not significant with 4-5 ml doses 3

Administration Guidelines

Alternative Routes for Severe Reactions

For anaphylaxis or severe reactions requiring systemic administration:

Intramuscular Administration

• Up to 6 years: 150 μg IM (0.15 ml of 1:1000 solution)
• 6-12 years: 300 μg IM (0.3 ml of 1:1000 solution) 1

Intravenous Administration (for critical situations only)

• For acute settings like operating theaters or intensive care units
• Only by clinicians familiar with its use and if IV access is already available
• Prepare 1 ml of 1:10,000 adrenaline for each 10 kg body weight (0.1 ml/kg)
• Titrate to response, starting with 1 μg/kg (one-tenth of the prepared syringe)
• Children often respond to as little as 1 μg/kg 1

Practical Considerations

• A metered dose inhaler with spacer (with face mask if necessary) is generally preferred over nebulizer for drug delivery in children 1
• However, nebulizers are needed when infants and children cannot tolerate face masks and spacers 1
• Nebulized steroids (e.g., 500 μg budesonide) may also reduce symptoms in croup in the first two hours, but long-term effects are not well established 1

Monitoring and Follow-up

• Monitor vital signs including heart rate and blood pressure during and after administration
• Be alert for pallor, which is a common side effect
• Remember that the effect of nebulized adrenaline is short-lived (1-2 hours), so patients require continued observation 1
• For anaphylaxis cases, observe patients for at least 4-6 hours after symptom resolution 4

Common Pitfalls to Avoid

1. Using nebulized adrenaline for outpatient treatment or in children about to be discharged (contraindicated due to short duration of effect and risk of symptom rebound) 1

2. Failing to prepare for potential cardiovascular side effects, especially with higher doses

3. Not having a clear plan for ongoing management after the short-lived effect of nebulized adrenaline wears off

4. Using nebulized adrenaline in recurrently wheezy infants, as research shows it does not reliably improve lung function in this population 5