What is the treatment protocol for children experiencing anaphylaxis after epinephrine (adrenaline) administration?

Steroids After Epinephrine for Pediatric Anaphylaxis

Corticosteroids are adjunctive medications that may be considered after epinephrine administration in children with anaphylaxis, but they are not mandatory and provide no acute benefit—they serve only to potentially prevent biphasic or protracted reactions, which remain unpredictable. 1

Epinephrine Remains the Only Essential Treatment

• Intramuscular epinephrine 0.01 mg/kg (maximum 0.3 mg in prepubertal children, 0.5 mg in adolescents) injected into the mid-outer thigh is the only first-line, life-saving treatment for anaphylaxis and must be given immediately upon recognition. 2, 3
• Epinephrine can be repeated every 5-15 minutes as needed if symptoms persist or recur. 2, 1
• No other medication—including steroids, antihistamines, or bronchodilators—should ever delay or replace epinephrine administration. 1, 3

Role and Limitations of Corticosteroids

• Corticosteroids have a slow onset of action (≥1 hour) and do not treat the acute, life-threatening manifestations of anaphylaxis such as airway obstruction, bronchospasm, or hypotension. 1
• The theoretical benefit is prevention of biphasic reactions (which occur in up to 20% of cases) or protracted anaphylaxis, though evidence supporting this is limited and biphasic reactions remain unpredictable despite steroid administration. 1, 4
• Glucocorticoids may reduce prolonged hospitalizations for anaphylaxis, but clinically important biphasic reactions are rare. 4

When to Consider Steroids

Consider administering corticosteroids particularly for children with:

• History of asthma (especially if severe or poorly controlled). 2, 1
• Severe or prolonged anaphylaxis requiring multiple epinephrine doses. 1
• History of idiopathic anaphylaxis. 1
• Significant generalized urticaria or angioedema. 1

Specific Dosing Regimens

For hospitalized children:

• Methylprednisolone 1-2 mg/kg IV divided every 6 hours (maximum 60-80 mg/day). 1
• Alternative: Hydrocortisone 25 mg IM/IV for infants <6 months, 50 mg for children 6 months to 6 years, 100 mg for children 6-12 years. 1

For children being discharged:

• Prednisone 0.5-1 mg/kg orally daily (maximum 60 mg) for 2-3 days. 1
• No tapering is required for this short course. 1

Critical Pitfalls to Avoid

• Never prescribe corticosteroids alone without also providing two epinephrine auto-injectors with hands-on training. 1
• Do not extend the corticosteroid course unnecessarily beyond 2-3 days. 1
• Do not rely on steroids to prevent biphasic reactions—observation for 4-6 hours (or longer for severe reactions) remains essential regardless of steroid administration. 1, 3
• Fatal anaphylaxis is often associated with delayed epinephrine administration, concomitant poorly controlled asthma, and adolescence. 2

Complete Discharge Bundle

Every child discharged after anaphylaxis treatment should receive:

• Two epinephrine auto-injectors (0.15 mg for children 10-25 kg; 0.3 mg for children ≥25 kg) with demonstration of proper use. 2, 1
• Written personalized anaphylaxis emergency action plan. 2, 3
• H1-antihistamine (diphenhydramine) for home use. 1
• Optional: H2-antihistamine (ranitidine or famotidine) twice daily for 2-3 days. 1
• Prednisone 0.5-1 mg/kg daily for 2-3 days if steroids are deemed appropriate. 1
• Follow-up appointment within 1-2 weeks, preferably with an allergist for trigger identification. 1, 3