What is the treatment for a pediatric allergic reaction?

Treatment of Pediatric Allergic Reactions

Intramuscular epinephrine into the lateral thigh is the immediate first-line treatment for pediatric anaphylaxis and must be administered without delay—this is the only intervention proven to prevent death from anaphylaxis. 1, 2

Immediate Recognition and First-Line Treatment

Epinephrine Administration

• Administer intramuscular epinephrine immediately into the anterolateral thigh (vastus lateralis) at the first recognition of anaphylaxis symptoms 1, 2, 3
• Dosing by weight:
  • Children 10-25 kg: 0.15 mg epinephrine autoinjector 1, 2
  • Children ≥25 kg: 0.30 mg epinephrine autoinjector 1, 2
  • Alternative dosing: 0.01 mg/kg of 1:1000 solution (maximum 0.3 mg for children, 0.5 mg for adults) 1, 3
• Repeat dosing every 5-15 minutes if symptoms persist or recur 1, 2
• Never delay epinephrine for antihistamines or other medications—delayed epinephrine administration is directly implicated in anaphylaxis fatalities 1, 2

Critical Positioning

• Place the patient supine with legs elevated if cardiovascular symptoms predominate 1
• Avoid sitting or standing positions which can precipitate cardiovascular collapse 1

Adjunctive Treatments (After Epinephrine)

These medications are adjuncts only and should never replace or delay epinephrine administration. 1, 2

Bronchodilators

• Albuterol for respiratory symptoms (wheezing, chest tightness, shortness of breath) 1, 2
  • MDI: 4-8 puffs for children 1, 2
  • Nebulized: 1.5 mL for children, administered every 20 minutes or continuously as needed 1

Antihistamines

• H1-antihistamine (diphenhydramine): 1-2 mg/kg per dose (maximum 50 mg) IV or oral 1, 2
• Oral liquid formulations are absorbed more rapidly than tablets 1
• H1 and H2 antihistamines together may prevent severe cardiac complications 1
• Antihistamines are appropriate for mild isolated symptoms only (few hives, mild nausea) but never for anaphylaxis 1

Supportive Care

• Supplemental oxygen for respiratory distress or patients requiring multiple epinephrine doses 1, 2
• IV fluids (normal saline) in large volumes for orthostasis, hypotension, or incomplete response to epinephrine 1, 2
• Administer IV fluids early with first epinephrine dose if cardiovascular involvement present 1

Corticosteroids

• Limited acute benefit—role is primarily to prevent late-phase biphasic reactions, not to treat acute symptoms 1
• Should never be given before or instead of epinephrine 1
• Not proven to prevent biphasic reactions despite frequent use 1

Post-Treatment Management

Emergency Transport and Observation

• All patients who receive epinephrine must be transported to an emergency facility for observation 1, 2
• Observation period: 4-6 hours minimum for most patients after successful treatment 1, 2
• Extended observation or hospital admission required for:
  • Severe or refractory symptoms 1, 2
  • Patients requiring >1 dose of epinephrine 1
  • Patients with asthma (higher risk for severe reactions) 1, 2

Biphasic Reactions

• Occur in 1-20% of anaphylaxis cases, typically around 8 hours after initial reaction but can occur up to 72 hours later 1, 2
• Risk factors include: severe initial presentation, >1 epinephrine dose required, wide pulse pressure, unknown trigger, and drug triggers in children 1
• Antihistamines and corticosteroids do not reliably prevent biphasic reactions 1

Discharge Requirements

Every patient discharged after anaphylaxis must receive all of the following: 1, 2

1. Two epinephrine autoinjectors (second dose may be needed before emergency services arrive) 1
2. Written anaphylaxis emergency action plan 1, 2
3. Education on autoinjector technique with demonstration using training device 1
4. Plan for monitoring autoinjector expiration dates 1, 2
5. Referral to allergist for further evaluation and testing 1, 2
6. Allergen avoidance education and label-reading instruction 1, 2

Special Populations and Considerations

Infants and Young Children <15 kg

• Clinical dilemma: Current 0.15 mg autoinjector dose may be higher than ideal 0.01 mg/kg dosing 2, 4
• Recommendation: Prescribe 0.15 mg autoinjector given lack of suitable alternative—mild transient adverse effects are preferable to not receiving epinephrine at all 4
• Adverse effects at this dose are expected to be mild and transient 4

High-Risk Patients Requiring Epinephrine Prescription

Prescribe epinephrine autoinjectors for: 1

• Any previous systemic allergic reaction 1
• Food allergy with comorbid asthma 1
• Known allergy to peanut, tree nuts, fish, or crustacean shellfish 1
• Consider for all patients with IgE-mediated food reactions 1

School and Community Settings

• Emergency kits must accompany the child on field trips and off school grounds 1
• Kit should contain at least two epinephrine doses, other prescribed medications, and copy of emergency action plan 1
• Personalized care projects (Section 504 plans, IEP) should be established for school attendance 1
• Studies show epinephrine is underutilized—only 29-54% of children with recurrent anaphylaxis receive epinephrine when indicated 5, 6

Common Pitfalls to Avoid

• Never substitute antihistamines for epinephrine in anaphylaxis—this is a potentially fatal error 1, 2
• Do not inject epinephrine into buttocks, digits, hands, or feet—anterolateral thigh only 3
• Do not delay epinephrine while waiting for IV access or other interventions 1, 2
• Do not discharge without two autoinjectors—second dose frequently needed 1
• Do not rely on corticosteroids to prevent biphasic reactions 1
• Ensure beta-agonists are not forgotten at school, particularly for asthmatic children 7