What are the next steps in managing a 14-month-old child with a history of milk allergy, who accidentally ingested milk, was given an EpiPen (epinephrine) by the mother, and presents with tachycardia, normal oxygen saturation, and tachypnea?

Management of Milk-Induced Anaphylaxis in a 14-Month-Old Child

The 14-month-old child with milk-induced anaphylaxis who has already received epinephrine requires continued observation, a second dose of epinephrine if symptoms persist or worsen, supplemental oxygen if needed, and IV fluid administration for tachycardia. 1

Initial Assessment and Management

• Evaluate the child's airway, breathing, and circulation with particular attention to the vital signs (tachycardia at 156, respiratory rate of 36, oxygen saturation 97%) 1
• Place the child in a recumbent position with legs elevated if tolerated to prevent orthostatic hypotension and improve circulation 1
• Establish IV access for fluid administration with normal saline (crystalloid) at 20-30 mL/kg in the first hour to address tachycardia 1
• Monitor vital signs continuously, particularly heart rate, respiratory rate, and oxygen saturation 1, 2
• Administer a second dose of epinephrine (0.15 mg via autoinjector or 0.01 mg/kg of 1:1000 solution IM in the anterolateral thigh) if symptoms persist or worsen after 5-15 minutes 1

Adjunctive Treatments

• Provide supplemental oxygen if respiratory distress worsens or oxygen saturation drops below 92% 1, 3
• Consider nebulized albuterol (1.5 mL) if wheezing or bronchospasm is present 1
• Administer H1-antihistamine such as diphenhydramine (1-2 mg/kg, maximum 50 mg) as adjunctive therapy, not as a replacement for epinephrine 1
• Consider corticosteroids (e.g., methylprednisolone 1 mg/kg IV) to potentially reduce the risk of prolonged or biphasic reactions, although evidence for this is limited 1, 4

Observation Period

• Observe the child for at least 4-6 hours after the initial reaction, as biphasic reactions can occur in 1-20% of anaphylaxis cases 1, 5
• Monitor closely for signs of deterioration including increased respiratory distress, declining oxygen saturation, worsening tachycardia, or hypotension 1, 2
• Be prepared to administer additional epinephrine if symptoms recur during the observation period 1

Discharge Planning

• Prescribe two doses of epinephrine autoinjector (0.15 mg for a child weighing less than 25 kg) 1, 3
• Create a written anaphylaxis emergency action plan that includes recognition of symptoms and instructions for epinephrine administration 1, 3
• Provide education to parents about proper technique for epinephrine autoinjector use, including demonstration and practice with a trainer device 1, 3
• Arrange follow-up with an allergist for comprehensive evaluation and management of milk allergy 1, 3
• Educate parents about strict milk avoidance, including hidden sources of milk in foods 1

Important Considerations and Pitfalls

• Do not delay administering a second dose of epinephrine if symptoms persist or worsen, as delayed administration is associated with increased mortality 1, 3
• Be aware that epinephrine can cause transient pallor, tremor, anxiety, and palpitations, which are expected pharmacologic effects and not reasons to withhold treatment 1
• Avoid administering epinephrine in incorrect locations (e.g., digits, hands, feet, or buttocks) as this can lead to tissue necrosis or infections 6
• Remember that antihistamines and corticosteroids should not delay epinephrine administration and do not prevent respiratory or cardiovascular compromise 4, 7
• Consider that infants and young children may have atypical presentations of anaphylaxis, with respiratory symptoms often predominating over cutaneous manifestations 1, 2