A child presents with periorbital edema, swollen lips, and a rash—what is the appropriate immediate management?

Immediate Management of Suspected Anaphylaxis in a Child

Administer intramuscular epinephrine immediately—this child is presenting with classic signs of anaphylaxis (periorbital edema, lip swelling, and rash involving multiple organ systems), and epinephrine is the first-line, life-saving treatment that must not be delayed. 1

Recognition of Anaphylaxis

• Anaphylaxis involves 2 or more body systems and presents with respiratory difficulty (wheezing), cutaneous manifestations (hives, swelling of lips and eyes), cardiovascular effects (hypotension, shock), or gastrointestinal symptoms (cramping, diarrhea). 1

• The combination of periorbital edema (puffy eyes), swollen lips, and rash in this child represents multi-system involvement characteristic of anaphylaxis. 2, 3

• Approximately 50% of patients with angioedema also have urticaria (rash), typically representing a type I allergic reaction to food allergens, drugs, or insect stings. 2

Immediate Treatment Algorithm

First-Line: Epinephrine

• Administer epinephrine 0.3 mg intramuscularly for children >30 kg, or 0.15 mg intramuscularly for children 15-30 kg (or as prescribed by physician). 1

• Epinephrine should be given intramuscularly in the lateral thigh and can be repeated every 5-15 minutes if symptoms are not responding. 1, 4

• Call 9-1-1 immediately when caring for a child with suspected anaphylaxis or severe allergic reaction—do not delay emergency services activation. 1

• Antihistamines should NOT be used in place of epinephrine for anaphylaxis—they are adjunctive only and do not treat the life-threatening cardiovascular and respiratory components. 1

Critical Pitfall to Avoid

• The main risk of angioedema is swelling of the tongue, larynx, and trachea, which can lead to airway obstruction and death—this is why epinephrine must be given immediately, not antihistamines alone. 2

• Antihistamines should only be used for mild symptoms (a few hives, mild nausea) but never for symptoms involving respiratory difficulty, obstructive swelling of tongue/lips that interferes with breathing, or circulatory symptoms. 1

Adjunctive Treatment

• After epinephrine administration, adjunctive treatments include:
  • H1 and H2 antihistamines (both types are important to prevent severe cardiac deficit) 1
  • Bronchodilators if wheezing is present 1, 5
  • Corticosteroids (limited immediate benefit but prevent biphasic reactions) 1, 5
  • Intravenous fluids if hypotension develops 5

Assessment During Resuscitation

• Assess ABCs (airway, breathing, circulation) rapidly at onset and reassess at frequent intervals during the emergency. 1

• Monitor for biphasic reactions—corticosteroids help prevent late-onset activation of immune mediators (such as leukotrienes) that can cause symptom recurrence hours later. 1

Post-Emergency Management

• All children who experience anaphylaxis require:
  • Prescription of two epinephrine autoinjectors (in case a second dose is needed before EMS arrives) 1
  • Referral to an allergist for evaluation of possible triggers 3
  • Written anaphylaxis action plan 3
  • Education that symptoms can recur and proper medical attention must be obtained if symptoms return 4

Common Triggers in Children

• The most common causes of allergic angioedema and anaphylaxis in children are:

  • Foods (especially eggs, shellfish, peanuts, tree nuts) 2, 3
  • Insect stings (bee and wasp stings) 1, 2
  • Medications 2, 6

• Foods are the most common cause of anaphylaxis in the pediatric population. 3