How to manage a child with a wasp sting?

Management of Wasp Sting in a Child

Immediately remove any visible stinger within the first 10-20 seconds by scraping or flicking it away with a fingernail—never grasp and pull the venom sac as this injects additional venom—then treat based on reaction severity: local reactions with cold compresses and oral antihistamines, large local reactions with prompt oral corticosteroids, and anaphylaxis with immediate intramuscular epinephrine 0.01 mg/kg (up to 0.3 mg) in the anterolateral thigh. 1, 2, 3

Immediate Stinger Management

• Remove the stinger within 10-20 seconds if present by scraping or flicking it away with a fingernail to prevent additional venom injection 1, 2
• Never grasp the venom sac and pull it out, as this forces more venom into the tissue 1
• Wash the area with soap and water after removal 2

Note: Wasps typically do not leave stingers (unlike honeybees), but if one is present, speed of removal matters more than technique 1, 2

Treatment Algorithm Based on Reaction Type

For Simple Local Reactions (Most Common)

Local reactions present with pain, swelling, and redness at the sting site lasting hours to days 1

• Apply cold compresses or ice packs to reduce local pain and swelling 1, 2
• Give oral antihistamines to reduce itching and discomfort 1, 2
• Provide oral analgesics (acetaminophen or ibuprofen) for pain relief 2
• Do NOT prescribe antibiotics—the swelling is allergic inflammation, not infection 1, 2

For Large Local Reactions

Large local reactions show extensive swelling extending from the sting site, peaking at 24-48 hours, and lasting up to a week or more 1

• Initiate a short course of oral corticosteroids promptly (within the first 24-48 hours) to limit progression of swelling 1, 2
• Continue cold compresses and oral antihistamines 1
• Antibiotics are NOT indicated—this is allergic inflammation caused by IgE-mediated response, not bacterial infection 1, 2

For Systemic Reactions/Anaphylaxis (LIFE-THREATENING)

Systemic reactions range from cutaneous manifestations (urticaria, angioedema) to life-threatening anaphylaxis with bronchospasm, upper airway edema, and shock 1

Immediate Management:

• Administer intramuscular epinephrine 0.01 mg/kg (maximum 0.3 mg in children) into the anterolateral thigh immediately 1, 2, 3
• Epinephrine is the ONLY first-line treatment for anaphylaxis—antihistamines and corticosteroids are NOT substitutes and should never delay epinephrine administration 1, 2
• Intramuscular injection in the anterolateral thigh achieves more rapid and higher plasma concentrations than subcutaneous or arm injection 1
• Activate emergency medical services immediately 2
• Be prepared to repeat epinephrine dosing if symptoms persist or recur 1
• Delayed epinephrine use is associated with fatal outcomes—prompt administration is critical 1, 2

Important Distinction for Children:

• Systemic reactions in children limited to skin only (urticaria/angioedema without respiratory or cardiovascular symptoms) are NOT considered anaphylactic reactions 1
• However, these children still require epinephrine if symptoms are widespread or progressive 1

Critical Pitfalls to Avoid

• Never delay epinephrine in anaphylaxis to give antihistamines or corticosteroids first—this delay can be fatal 1, 2
• Do not prescribe antibiotics for swelling—this is allergic inflammation, not infection 1, 2
• The slower the onset of anaphylaxis symptoms, the less likely progression to life-threatening events, but still treat aggressively 1
• Reactions can be biphasic or protracted—observe for recurrence even after initial improvement 1
• There is NO contraindication to epinephrine in life-threatening anaphylaxis, even in children with cardiovascular conditions 1

Post-Treatment Management

For All Systemic Reactions:

• Prescribe an epinephrine autoinjector and train the child's caregivers on proper use and indications 1, 2
• Refer to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy (VIT) 1, 2
• Educate on insect avoidance measures: avoid brightly colored clothing, flowery prints, walking barefoot outdoors, and areas near nests 1
• Consider medical identification bracelet 1

Special Considerations for Children:

• VIT is generally NOT necessary in children ≤16 years who experienced only cutaneous systemic reactions (urticaria/angioedema alone) without respiratory or cardiovascular symptoms 1
• VIT IS recommended for children who experienced anaphylaxis with respiratory compromise, cardiovascular symptoms, or shock 1
• Children with only large local reactions do NOT typically need VIT unless they have frequent unavoidable exposure 1

Rare but Serious Complications

• Multiple stings (typically >100) can cause toxic reactions from massive envenomation even in non-allergic individuals, potentially causing multi-organ dysfunction 1, 2, 4
• Upper airway stings (to uvula, tongue, or throat) can cause rapid, life-threatening airway obstruction requiring immediate epinephrine and emergency airway management 5
• Rare delayed reactions (serum sickness, vasculitis, neuritis) have been reported but are uncommon 1