What is the recommended dose of epinephrine (adrenaline) for pediatric patients experiencing anaphylaxis?

Pediatric Epinephrine Dosing for Anaphylaxis

Administer intramuscular epinephrine immediately at 0.01 mg/kg (maximum 0.3 mg for children, 0.5 mg for adolescents ≥30 kg) into the anterolateral thigh as soon as anaphylaxis is recognized. 1, 2, 3

Weight-Based Dosing Algorithm

For children <30 kg (66 lbs):

• Dose: 0.01 mg/kg of 1:1000 epinephrine solution (0.01 mL/kg)
• Maximum single dose: 0.3 mg (0.3 mL)
• Route: Intramuscular into lateral thigh (vastus lateralis)
• Repeat every 5-15 minutes if symptoms persist 1, 2, 3

For children ≥30 kg (66 lbs) and adolescents:

• Dose: 0.3-0.5 mg (0.3-0.5 mL) of 1:1000 epinephrine solution
• Maximum single dose: 0.5 mg (0.5 mL)
• Route: Intramuscular into lateral thigh
• Repeat every 5-10 minutes as needed 1, 3

Autoinjector Dosing by Weight

For children 7.5-25 kg:

• Use 0.15 mg epinephrine autoinjector (EpiPen Jr)
• This provides appropriate dosing within the 0.01 mg/kg recommendation 2, 4

For children ≥25 kg:

• Use 0.3 mg epinephrine autoinjector (standard EpiPen)
• The transition at 25 kg prevents underdosing, as the 0.15 mg dose would only provide 0.006 mg/kg at this weight 2, 4

Critical caveat for infants <7.5 kg:

• The 0.15 mg autoinjector exceeds the recommended 0.01 mg/kg dose in this population 2
• Despite this limitation, the 0.15 mg autoinjector is still preferable to ampule/syringe/needle methods, which carry a 40-fold variation in dosing accuracy and significant delays (mean 142 seconds for parents vs. 29 seconds for emergency nurses) 5
• Never prescribe ampule/syringe/needle for home use—the risk of dosing errors and delays outweighs theoretical overdosing concerns 5

Administration Technique

Intramuscular injection into the anterolateral thigh is mandatory:

• Peak plasma concentration achieved at 8±2 minutes (IM) vs. 34±14 minutes (subcutaneous) 1, 4, 6
• Use a needle at least 1/2 to 5/8 inch long to ensure intramuscular delivery 3
• Inject through clothing if necessary—do not delay 1
• Hold the child's leg firmly to minimize movement and injection-related injury 3
• Never inject into buttocks, digits, hands, or feet due to risk of tissue necrosis 3

Repeat Dosing Requirements

Approximately 6-19% of pediatric patients require a second dose: 2

• Administer repeat doses every 5-15 minutes if symptoms persist or recur 1, 2
• Do not inject repeatedly at the same site due to vasoconstriction-induced tissue necrosis risk 3
• Children requiring multiple doses have higher risk of biphasic reactions and should be observed for at least 24 hours 7

Intravenous Epinephrine (Reserved for Refractory Cases)

IV epinephrine should only be used for cardiac arrest or profound hypotension unresponsive to multiple IM doses:

• Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution; maximum 0.3 mg) given slowly over several minutes 1
• Requires continuous cardiac monitoring, ECG, and blood pressure measurement every minute 1
• For continuous infusion: 0.05-0.1 μg/kg/min, escalating as needed 1
• Critical pitfall: IV epinephrine carries significant risk of dilution and dosing errors—reserve for hospital settings only 5, 1

Special Populations Requiring Glucagon

For patients on beta-blockers with refractory symptoms:

• Administer IV glucagon 1-2 mg (20-30 μg/kg, maximum 1 mg for children) over 5 minutes 1
• These patients may be unresponsive to epinephrine due to beta-receptor blockade 1, 3

Critical Pitfalls to Avoid

Delayed epinephrine administration is the leading cause of anaphylaxis fatalities: 1, 8

• Only 54% of pediatric patients meeting anaphylaxis criteria receive epinephrine in prehospital settings 9
• Never substitute antihistamines or corticosteroids for epinephrine—these are adjunctive only and have onset ≥1 hour 1
• Antihistamines do not relieve respiratory symptoms or shock 1

Avoid subcutaneous administration:

• Delayed absorption (34 minutes vs. 8 minutes for IM) may have fatal consequences during anaphylaxis 6
• Only 2 of 9 children achieved peak plasma concentrations by 5 minutes with subcutaneous injection 6

Patients at highest risk for fatal anaphylaxis:

• Adolescents (particularly high-risk group) 1
• Children with severe uncontrolled asthma 1
• Those with comorbid allergic diseases (asthma, allergic rhinitis, atopic dermatitis) are more likely to require multiple epinephrine doses 7

Post-Administration Monitoring

Observe for minimum 6 hours in monitored setting: 1

• Biphasic reactions occur in approximately 3.3% of pediatric cases, with mean onset at 11 hours (range up to 72 hours) 1, 4, 7
• Children experiencing syncope, vomiting, or requiring multiple epinephrine doses are at significantly higher risk for biphasic reactions (p<0.05) 7
• Prescribe epinephrine autoinjector before discharge and provide hands-on training 1