What is the recommended treatment and dosage for an 8-year-old patient with erythema and swelling following a local bee sting?

Treatment for 8-Year-Old with Local Bee Sting Reaction (Erythema and Swelling on Next Day)

For this large local reaction in an 8-year-old, administer oral diphenhydramine 10 mL (25 mg) every 4-6 hours, apply topical corticosteroid cream to the sting site, use cold compresses, and give ibuprofen or acetaminophen for pain—antibiotics are not needed as this is allergic inflammation, not infection. 1, 2, 3

Treatment Algorithm

Immediate Assessment

• Confirm this is a local reaction only (confined to the sting site with erythema and swelling), not systemic symptoms like difficulty breathing, throat swelling, widespread hives, or lightheadedness, which would require immediate epinephrine. 1, 4
• The next-day presentation with persistent erythema and swelling indicates a large local reaction, which typically develops within 24-48 hours and can persist for several days. 1

First-Line Medications (All Should Be Given Together)

Oral Antihistamine:

• Diphenhydramine 10 mL (25 mg) every 4-6 hours for children 6 to under 12 years of age, not exceeding 6 doses in 24 hours. 5
• This reduces itching and helps control the allergic inflammatory response. 1, 2

Topical Corticosteroid:

• Apply topical corticosteroid cream or ointment directly to the sting site 2-3 times daily to reduce local inflammation and itching. 1, 2, 3
• This is the preferred steroid formulation for local reactions. 3

Cold Therapy:

• Apply ice packs or cold compresses to the affected area for 15-20 minutes several times daily to reduce pain and swelling. 1, 2

Pain Management:

• Ibuprofen (10 mg/kg per dose every 6-8 hours) or acetaminophen (15 mg/kg per dose every 4-6 hours) for pain relief. 1, 2

When to Escalate to Oral Corticosteroids

If the swelling is severe or extensive (involving a large area or causing significant functional impairment), consider a short course of oral prednisone 1-2 mg/kg/day (maximum 60 mg) for 3-5 days. 1, 3

• Oral corticosteroids are most effective when started within the first 24-48 hours of symptom onset to limit progression of swelling. 1, 3
• The evidence supporting oral corticosteroids comes from clinical experience rather than controlled trials, but they are effective for limiting severe local reactions. 1, 3

Critical Management Points

What NOT to Do

• Do not prescribe antibiotics—the swelling is caused by allergic inflammation, not bacterial infection, and antibiotics are not indicated unless there are clear signs of secondary infection (increasing warmth, purulent drainage, fever). 1, 2
• Do not delay treatment if any systemic symptoms develop—epinephrine must be given immediately for anaphylaxis. 1, 4

Stinger Removal (If Not Already Done)

• If a stinger is still visible, remove it immediately by scraping or plucking—the method doesn't matter, but speed does, as venom delivery continues for up to 60 seconds. 1, 2
• Wash the area with soap and water after stinger removal. 1, 2

Expected Course

• Large local reactions typically peak within 24-48 hours and gradually resolve over 3-7 days with appropriate treatment. 1
• The swelling is caused by allergic inflammation developing over hours, not immediate venom toxicity. 1

Red Flags Requiring Immediate Emergency Care

Activate emergency services immediately if the child develops:

• Difficulty breathing, wheezing, or chest tightness 4
• Throat tightness, hoarseness, or difficulty swallowing 4
• Widespread hives beyond the sting site 4
• Facial swelling extending beyond the local area 4
• Lightheadedness, dizziness, or fainting 4
• Vomiting or abdominal cramping 4

These symptoms indicate anaphylaxis and require intramuscular epinephrine 0.01 mg/kg (maximum 0.3 mg in prepubertal children) into the anterolateral thigh, not antihistamines or corticosteroids. 1, 4

Follow-Up Considerations

• No routine follow-up is needed for uncomplicated large local reactions that respond to treatment. 1
• Referral to an allergist is not necessary for isolated large local reactions, as these do not predict future anaphylaxis risk in the same way systemic reactions do. 1
• Educate parents that large local reactions can recur with future stings but do not require an epinephrine autoinjector prescription unless systemic symptoms develop. 1