What is the management of a child with anaphylaxis (severe, life-threatening allergic reaction)?

From the Guidelines

Anaphylaxis in a child requires immediate action with epinephrine as the first-line treatment, and it is crucial to administer epinephrine via an auto-injector as soon as possible to reduce morbidity and mortality. For a child experiencing anaphylaxis, administer epinephrine via an auto-injector (such as EpiPen Jr. 0.15mg for children weighing 15-30kg or EpiPen 0.3mg for those over 30kg) into the outer mid-thigh through clothing if necessary, as recommended by the most recent guidelines 1. After administration, call emergency services (911) immediately. Position the child lying flat with legs elevated unless they are having breathing difficulties, in which case allow them to sit up. If symptoms persist after 5-15 minutes and emergency responders haven't arrived, give a second dose of epinephrine.

Some key points to consider when managing anaphylaxis in children include:

• Administering epinephrine as the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis, without delay, as recommended by the guidelines 1
• Keeping the child under observation in a setting capable of managing anaphylaxis until symptoms have fully resolved, to monitor for potential biphasic reactions 1
• Providing education on anaphylaxis, including avoidance of identified triggers, presenting signs and symptoms, biphasic anaphylaxis, treatment with epinephrine, and the use of epinephrine auto-injectors, to improve outcomes and reduce the risk of future episodes 1
• Considering the use of antihistamines and glucocorticoids in anaphylaxis management, although their role is not as well established as epinephrine, and they should not delay the administration of epinephrine 1

Once at the hospital, the child may receive additional treatments including antihistamines, steroids, oxygen, or IV fluids. Following the episode, ensure the child has an anaphylaxis action plan, carries epinephrine auto-injectors at all times, and wears medical identification. Epinephrine works by constricting blood vessels to increase blood pressure, relaxing airway muscles to improve breathing, and reducing hives and swelling. Parents and caregivers should be trained to recognize anaphylaxis symptoms (difficulty breathing, swelling, hives, vomiting, dizziness) and how to use auto-injectors properly, as prompt administration significantly improves outcomes, as highlighted in the guidelines 1.

From the FDA Drug Label

1 INDICATIONS & USAGE Adrenalin® is available as a single-use 1 mL vial and a multiple-use 30 mL vial for intramuscular and subcutaneous use. Emergency treatment of allergic reactions (Type I), including anaphylaxis, which may result from allergic reactions to insect stings, biting insects, foods, drugs, sera, diagnostic testing substances and other allergens, as well as idiopathic anaphylaxis or exercise-induced anaphylaxis.

To manage a child with anaphylaxis, administer epinephrine (IM) as it is indicated for the emergency treatment of allergic reactions, including anaphylaxis.

• The signs and symptoms of anaphylaxis include:
  • Flushing
  • Apprehension
  • Syncope
  • Tachycardia
  • Thready or unobtainable pulse associated with hypotension
  • Convulsions
  • Vomiting
  • Diarrhea and abdominal cramps
  • Involuntary voiding
  • Airway swelling
  • Laryngospasm
  • Bronchospasm
  • Pruritus
  • Urticaria or angioedema
  • Swelling of the eyelids, lips, and tongue 2

From the Research

Managing a Child with Anaphylaxis

To manage a child with anaphylaxis, it is crucial to understand the condition and its treatment. Anaphylaxis is a severe, life-threatening allergic reaction that requires prompt recognition and treatment 3.

First-Line Treatment

The first-line treatment for anaphylaxis is adrenaline (epinephrine), which should be administered intramuscularly 3, 4, 5. There are no contraindications to intramuscular adrenaline in the treatment of anaphylaxis 4.

Administration of Adrenaline

Adrenaline auto-injectors are available in different doses, including 0.15 mg, 0.30 mg, and 0.50 mg, with varying needle lengths to ensure intramuscular delivery in the thigh 5. The correct positioning of the patient is vital, and death can occur within minutes if a patient stands, walks, or sits up suddenly 4.

Key Points to Consider

• Adrenaline is the first-line treatment for anaphylaxis and should be administered early 3, 4, 5.
• Antihistamines and corticosteroids should not be used as first-line treatment, but may be used as second-line or third-line treatment 3, 6.
• The use of corticosteroids in anaphylaxis should be revisited, as they may increase the risk of requiring intravenous fluids and hospital admission 6.
• Education about anaphylaxis and prompt treatment are critical for patients and their caregivers 5.
• Epinephrine auto-injectors should be readily available in schools and other settings where children may be at risk of anaphylaxis 7.

Treatment in Specific Settings

In the school setting, having an undesignated stock of epinephrine auto-injectors can be beneficial in case of an anaphylactic event 7. Nurses and other healthcare professionals play a crucial role in advocating for policy changes to ensure the availability of epinephrine auto-injectors in schools 7.

Additional Considerations

• The Australasian Society of Clinical Immunology and Allergy recommends the use of the 0.15 mg adrenaline injector device for infants and children weighing 7.5-10 kg 4.
• The recommendation to use the 0.3 mg adrenaline injector device for those over 20 kg remains unchanged 4.