What is the first step in managing a child with acute stridor, tachypnea, pallor, and hypotension due to a suspected food allergy?

Management of Anaphylaxis in a 7-Year-Old with Food Allergy

The correct answer is C: Adrenaline (epinephrine) must be administered immediately as the first-line treatment for this child presenting with anaphylaxis. 1

Clinical Recognition

This child meets diagnostic criteria for anaphylaxis with:

• Acute onset after allergen exposure (food at school party) 1
• Multi-system involvement: respiratory compromise (stridor, tachypnea), cardiovascular compromise (hypotension), and skin manifestations (pallor) 1
• Life-threatening presentation requiring immediate intervention 1

First-Line Treatment: Epinephrine

Epinephrine is the only first-line medication for anaphylaxis and must be administered immediately upon recognition. 1, 2

Why Epinephrine First?

• Prevents or reverses upper airway edema (addressing the stridor) 1
• Reverses hypotension and shock through vasoconstrictor effects 1
• Provides bronchodilation for respiratory symptoms 1
• Stabilizes mast cells to prevent further mediator release 3
• Delayed administration increases risk of death and poor outcomes including hypoxic-ischemic encephalopathy 1, 4

Dosing for This Patient

For a 7-year-old child:

• Intramuscular injection in the mid-outer thigh (vastus lateralis) 1
• Dose: 0.01 mg/kg of 1:1000 solution, maximum 0.3 mg for prepubertal children 1
• If weight >25 kg: 0.3 mg epinephrine autoinjector 1
• If weight 10-25 kg: 0.15 mg epinephrine autoinjector 1
• May repeat every 5-15 minutes if symptoms persist or recur 1

Why Other Options Are Incorrect

Steroids (Option A)

• Not first-line treatment for anaphylaxis 1
• Slow onset of action - do not address immediate life-threatening symptoms 5
• Used as adjunctive therapy only to potentially prevent biphasic reactions, though evidence is limited 1
• Should be given after epinephrine, not instead of it 1, 5

Antibiotics (Option B)

• No role in acute anaphylaxis management - this is an allergic reaction, not an infection 1
• Completely inappropriate for this clinical scenario

Fluid Bolus (Option D)

• Adjunctive therapy only, not first-line 1
• Should be given after epinephrine for hypotension unresponsive to initial epinephrine dose 1
• Dose: 10-20 mL/kg IV bolus if needed for persistent hypotension 1
• Patient should be placed recumbent with legs elevated while fluids are administered 1

Complete Management Algorithm

Immediate Actions (First 5 Minutes)

1. Administer epinephrine IM immediately 1
2. Call for emergency assistance/activate EMS 1
3. Position patient supine with legs elevated (if tolerated and no vomiting) 1
4. Assess airway, breathing, circulation 1

Adjunctive Therapies (After Epinephrine)

• Supplemental oxygen for hypoxia 1
• IV fluid bolus (10-20 mL/kg) for persistent hypotension 1
• Albuterol nebulizer (1.5 mL for child) for bronchospasm 1
• H1 antihistamine (diphenhydramine 1-2 mg/kg, max 50 mg) for urticaria/pruritus 1, 5
• H2 antihistamine (ranitidine 1-2 mg/kg) in combination with H1 blocker 1, 5
• Corticosteroids (prednisone 1 mg/kg, max 60-80 mg or methylprednisolone IV) for potential biphasic reaction 1

Critical Pitfalls to Avoid

Never delay epinephrine to give antihistamines or other medications - this is the most common error and significantly increases mortality risk. 1, 5, 4

Do not rely on antihistamines or bronchodilators alone - they cannot reverse the life-threatening cardiovascular and airway manifestations of anaphylaxis. 1, 5

Do not administer epinephrine subcutaneously - intramuscular route in the thigh provides faster, more reliable absorption. 1

Do not use epinephrine inhalers - they cannot achieve plasma concentrations needed for hemodynamic stabilization. 6

Observation and Disposition

• Minimum 4-6 hours observation after symptom resolution 1
• Monitor for biphasic reactions (occur in 1-20% of cases, typically ~8 hours later but can occur up to 72 hours) 1
• Discharge with two epinephrine autoinjectors, emergency action plan, and allergy referral 1