What is the management of an allergic reaction in pediatric patients?

Management of Allergic Reactions in Pediatric Patients

Prompt administration of intramuscular epinephrine into the lateral thigh is the first-line treatment for anaphylaxis in pediatric patients and must be given immediately upon recognition of symptoms to reduce mortality and morbidity. 1

Recognition of Anaphylaxis

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 1
• Two or more of the following occurring rapidly after allergen exposure:
  • Skin-mucosal involvement (hives, swelling of lips/tongue/uvula) 1
  • Respiratory compromise (dyspnea, wheezing, stridor) 1
  • Reduced blood pressure or associated symptoms 1
  • Persistent gastrointestinal symptoms (cramping, vomiting) 1
• Reduced blood pressure after exposure to known allergen 1

First-Line Treatment

• Epinephrine administration:
  • Intramuscular injection into lateral thigh (vastus lateralis) is preferred route 1
  • Dosing:
    • Children weighing 10-25 kg: 0.15 mg epinephrine autoinjector 1
    • Children weighing ≥25 kg: 0.30 mg epinephrine autoinjector 1
    • Weight-based dosing: 0.01 mg/kg up to 0.30 mg maximum 1, 2
  • May repeat every 5-15 minutes if symptoms persist 1

Adjunctive Treatments

• Position patient supine with legs elevated; do not place in upright position 3
• Bronchodilator (albuterol):
  • MDI: 4-8 puffs for children 1
  • Nebulized solution: 1.5 mL for children 1
• H1 antihistamine (diphenhydramine):
  • 1-2 mg/kg per dose (maximum 50 mg) 1
• Supplemental oxygen as needed 1
• IV fluids for hypotension 1

Post-Treatment Management

• All patients who receive epinephrine should be transported to an emergency facility for observation 1
• Observation period:
  • 4-6 hours for most patients 1
  • Longer observation or hospital admission for severe or refractory symptoms 1
  • Patients requiring multiple doses of epinephrine should be observed for 24 hours due to increased risk of biphasic reactions 4

Discharge Planning

All patients who have experienced anaphylaxis should be discharged with:

1. Anaphylaxis emergency action plan 1
2. Two doses of epinephrine autoinjector 1
3. Plan for monitoring autoinjector expiration dates 1
4. Referral for further evaluation 1
5. Education on allergen avoidance 1

Special Considerations

• Infants and young children <15 kg: Current autoinjector doses may be too high; this presents a clinical dilemma as the lowest available dose (0.15 mg) may be excessive for very small children, especially those ≤7.5 kg 1
• Patients with asthma: Higher risk for severe reactions; require close monitoring 1
• Biphasic reactions: Can occur in 1-20% of cases, typically around 8 hours after initial reaction but may occur up to 72 hours later 1

Common Pitfalls to Avoid

• Delayed epinephrine administration: Associated with increased mortality and poor outcomes 1, 3
• Relying on antihistamines alone: H1 antihistamines are not appropriate first-line therapy for anaphylaxis as they have slow onset (>1 hour) and primarily relieve only cutaneous symptoms 1
• Upright positioning: Can worsen hypotension and should be avoided 3
• Inadequate observation time: Patients requiring multiple doses of epinephrine are at higher risk for biphasic reactions 4
• Underestimating severity: Food allergies, especially to peanuts and tree nuts, can cause fatal reactions 1

Prevention Strategies

• Confirmation of trigger allergen 1
• Education on strict allergen avoidance 1
• Written individualized emergency action plan 1
• Education of supervising adults on recognition and treatment 1
• Comprehensive management approach involving families, schools, and other organizations 1