What discharge instructions should be provided for a child who has experienced an allergic reaction?

Pediatric Allergic Reaction Discharge Instructions

Every child discharged after an allergic reaction must receive an epinephrine auto-injector prescription with hands-on training, a written anaphylaxis emergency action plan, and a referral to an allergist—these are non-negotiable, life-saving interventions. 1, 2

Mandatory Discharge Components

1. Epinephrine Auto-Injector Prescription and Training

• Prescribe at discharge: All children with allergic reactions require epinephrine, regardless of reaction severity 1, 2
• Dosing by weight:
  • 10-25 kg: 0.15 mg auto-injector

  • 25 kg: 0.3 mg auto-injector 2

• Provide hands-on training: Use trainer devices and manufacturer materials (DVDs) to demonstrate proper injection technique into the mid-outer thigh 1, 3
• Prescribe TWO auto-injectors: One for home, one for school/daycare 1

2. Adjunctive Medications for Home Use (2-3 days)

Continue these medications after discharge to prevent biphasic reactions 2:

• H1 antihistamine: Diphenhydramine every 6 hours OR a non-sedating second-generation antihistamine
• H2 antihistamine: Ranitidine twice daily
• Corticosteroid: Prednisone daily (1 mg/kg, max 60-80 mg)

Critical caveat: Emphasize that antihistamines and corticosteroids are NOT substitutes for epinephrine and cannot be relied upon to treat severe reactions 2, 4

3. Written Anaphylaxis Emergency Action Plan

Provide a personalized, written plan that includes 1, 2:

• Specific allergen(s) to avoid
• Recognition of anaphylaxis symptoms: Skin (hives, itching), respiratory (cough, wheeze, throat tightness), cardiovascular (dizziness, collapse), GI (vomiting, cramping)
• Clear instructions: "Inject epinephrine immediately for ANY severe symptoms or if allergen was definitely eaten"
• Emergency steps:
  1. Inject epinephrine in outer thigh
  2. Call 911
  3. Second dose may be given 5-15 minutes later if symptoms persist
  4. Position child lying down with legs elevated

Use standardized forms from www.foodallergy.org 1

4. Comprehensive Education Session

Train families on 1:

• Allergen avoidance and label reading
• Symptom recognition: Emphasize that reactions can be progressively more severe with each exposure 1
• When to use epinephrine: Immediately when anaphylaxis criteria are met—do not delay 3, 5
• Proper storage: Away from temperature extremes and direct sunlight
• Expiration date monitoring: Schedule prescription renewals

5. School/Daycare Documentation

Provide 1:

• Copy of emergency action plan
• Section 504 plan or IEP documentation if needed
• Instructions for school nurse and teachers

6. Follow-Up Arrangements

• Primary care follow-up: Within days to weeks
• Allergist referral: Essential for all children with likely food allergy 1
  • Average wait time is 4 months—child remains at risk during this period 1
  • Allergist will perform confirmatory testing, create comprehensive management plan, and assess for oral immunotherapy candidacy

Observation Period Before Discharge

Observe for 4-6 hours minimum after symptom resolution 2. Consider extended observation (up to 6 hours or longer) for 4:

• Severe initial reaction
• Required >1 dose of epinephrine
• Wide pulse pressure
• Unknown trigger
• History of asthma (higher risk for severe reactions) 1, 3
• Poor access to emergency services

Risk of biphasic reactions: Approximately 6-19% of pediatric patients may experience recurrent symptoms hours later 5, 6. However, clinically significant biphasic reactions are rare, and most children without severe risk features can be discharged after 1 hour of asymptomatic observation 4, 6.

Critical Pitfalls to Avoid

1. Never discharge without epinephrine: Even if uncertain about diagnosis, prescribe epinephrine—it's potentially lifesaving 1
2. Don't rely on antihistamines alone: They are adjunctive only and cannot prevent anaphylaxis 2, 4
3. Avoid delayed epinephrine use: Fatal outcomes are associated with delayed or absent epinephrine administration 3, 7
4. Don't assume cross-reactivity: Having IgE to an allergen doesn't confirm clinical allergy; testing by allergist is essential 1
5. Adolescents require special attention: They're at highest risk for fatal reactions due to risk-taking behaviors and failure to carry/use epinephrine 3, 5

Special Considerations

• Asthma comorbidity: Increases risk of severe/fatal anaphylaxis—emphasize strict adherence to asthma control and epinephrine availability 3, 5
• Medical identification: Consider bracelet or wallet card 7
• Yearly follow-up: Recommended for retesting and reassessment of tolerance development 1