What is the management of anaphylaxis in a pediatric patient?

From the Guidelines

Immediate management of anaphylaxis in a child requires prompt administration of intramuscular epinephrine as the first-line treatment, with a dose of 0.01 mg/kg (maximum 0.3 mg) of 1:1000 (1 mg/mL) solution via intramuscular injection into the mid-outer thigh, as recommended by the most recent guidelines 1. This dose can be repeated every 5-15 minutes if symptoms persist. For children who weigh less than 30 kg, the dose is 0.15 mg, while those weighing 30 kg or more should receive 0.3 mg. After administering epinephrine, the child should be placed in a supine position with legs elevated unless respiratory distress is present, in which case they should sit upright. The trigger should be removed if possible, and emergency services should be called immediately. Supplemental oxygen should be provided if available, and intravenous access established for fluid resuscitation with normal saline (20 mL/kg boluses) if hypotension is present. Second-line medications include H1-antihistamines such as diphenhydramine (1 mg/kg, maximum 50 mg) for cutaneous symptoms, H2-blockers like ranitidine (1 mg/kg, maximum 50 mg), and corticosteroids such as methylprednisolone (1 mg/kg, maximum 60-80 mg) to prevent biphasic reactions. Epinephrine works by causing vasoconstriction, reducing mucosal edema, increasing cardiac output, and bronchodilation, making it the most effective medication for reversing the life-threatening cardiovascular and respiratory effects of anaphylaxis, as supported by recent studies 1. All children with anaphylaxis should be observed for at least 4-6 hours after resolution of symptoms due to the risk of biphasic reactions, and those with severe reactions should be monitored for 24 hours. It is essential to note that there is no absolute contraindication to epinephrine use in the treatment of anaphylaxis, and providers should be aware of the need to appropriately counsel patients when using epinephrine, as highlighted in recent guidelines 1. The importance of prompt epinephrine administration is further emphasized by the fact that delay in treatment is widely presumed to be associated with increased mortality, although the mortality from anaphylaxis is remarkably low at <0.5% per episode of anaphylaxis 1. Key points to consider in the management of anaphylaxis in children include:

• Prompt administration of intramuscular epinephrine as the first-line treatment
• Removal of the trigger if possible
• Calling emergency services immediately
• Providing supplemental oxygen if available
• Establishing intravenous access for fluid resuscitation if hypotension is present
• Using second-line medications such as H1-antihistamines, H2-blockers, and corticosteroids as needed
• Observing the child for at least 4-6 hours after resolution of symptoms due to the risk of biphasic reactions.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Anaphylaxis: ... Children 30 kg (66 lbs) or less: 0.01 mg/kg (0.01 mL/kg), up to 0.3 mg (0. 3 mL), intramuscularly or subcutaneously into anterolateral aspect of the thigh every 5 to 10 minutes as necessary ( 2)

The management of anaphylaxis in a pediatric patient involves administering epinephrine intramuscularly or subcutaneously. The recommended dose is:

• 0.01 mg/kg (up to 0.3 mg) for children weighing 30 kg (66 lbs) or less. The dose should be administered into the anterolateral aspect of the thigh and may be repeated every 5 to 10 minutes as necessary 2.

From the Research

Management of Anaphylaxis in Pediatric Patients

The management of anaphylaxis in pediatric patients involves prompt recognition and treatment with epinephrine, as well as long-term management strategies to prevent recurrences. Key aspects of management include:

• Immediate administration of intramuscular epinephrine as the first-line treatment for anaphylaxis 3, 4, 5
• Use of an auto-injector for epinephrine administration, with a dose of 10 µg/kg for children 3, 4
• Administration of epinephrine in the lateral portion of the thigh, which can be repeated every 10-15 minutes until there is a response 3
• Consideration of other treatments, such as β2-adrenergic agonists and glucagon, as second-line options, and glucocorticoids and antihistamines as third-line options 6

Diagnostic Challenges in Pediatric Anaphylaxis

Diagnosing anaphylaxis in pediatric patients, particularly infants, can be challenging due to:

• Variable presentation of symptoms, which can include skin, respiratory, gastrointestinal, and cardiovascular manifestations 7, 5
• Lack of specific diagnostic criteria for anaphylaxis in infants 5
• Difficulty in ascertaining potential exposure to common allergens in infants 5
• Similarity of anaphylaxis symptoms to those of less serious illnesses or normal findings in infants, such as drooling, loose stools, and irritability 5

Long-term Management of Pediatric Anaphylaxis

Long-term management of pediatric anaphylaxis involves a patient-centered, multidimensional approach that focuses on:

• Recognition of anaphylaxis and its symptoms 7
• Use of epinephrine auto-injectors and education on their proper use 7, 4
• Prevention of recurrences through avoidance of known allergens and other triggers 7
• Close communication and collaboration between the child, caregivers, healthcare professionals, and schools 7