This clinical report focuses on practical issues concerning the administration of self-injectable epinephrine for first-aid treatment of anaphylaxis in the community. You will be redirected to aap.org to login or to create your account. Published online February 13, 2017. Both reports were published online February 13 in Pediatrics. Downloadable examples of written plans that can be personalized are available through the Food Allergy & Anaphylaxis Network Web site (www.foodallergy.org/actionplan.pdf [in English] or www.foodallergy.org/spanishaction.pdf [in Spanish]) and from the American Academy of Allergy, Asthma and Immunology Web site (www.aaaai.org/members/resources/anaphylaxis_toolkit/action_plan.pdf).39 The emergency action plan and coaching with regard to use of self-injectable epinephrine should be reviewed with the patient on a regular basis. To comment please, Comments on Medscape are moderated and should be professional in tone and on topic. Nevertheless, pediatricians are advised to prescribe the optimal dose from an autoinjector for each child, even when that dose cannot possibly be precisely 0.01 mg/kg. Everything else, the dose of epinephrine must be less than that. Summary: Epinephrine is the recommended first-line treatment for anaphylaxis and moderate-to-severe croup. So Cohen and colleagues reviewed the charts of 368 children (median age, 5.4 years) who presented with anaphylaxis-like symptoms to a busy tertiary care facility emergency department (ED) in Toronto. Dose: 0.3 mg SC/IM x1; Info: may repeat dose x1 after 5-15min [injectable form] Dose: 0.01 mg/kg/dose (1:1000 solution) SC/IM x1; Info: may repeat dose q5-15min x2; max 0.3 mg/dose in prepubertal pts, max 0.5 mg/dose in teenage pts; if unresponsive to IM, start 0.1 mcg/kg/min IV, titrate to effect up to 10 mcg/min asthma exacerbation, severe epinephrine products are now labelled as 1 mg/mL, while epinephrine 1:10,000 for IV injection is labelled as 0.1 mg/mL. Share cases and questions with Physicians on Medscape Consult. If you log out, you will be required to enter your username and password the next time you visit. Its role in asthma and bronchiolitis is less clear. Our aim was to characterize dosing and timing of epinephrine, diphenhydramine, and albuterol in the pediatric patient with anaphylaxis. Previous guidelines have suggested that epinephrine should be administered promptly at the onset of symptoms after exposure to an allergen that had previously caused anaphylaxis and possibly even in the absence of symptoms if there was a known exposure to an allergen that previously caused anaphylaxis with cardiovascular collapse.28 Generalized acute urticaria itself is not a life-threatening symptom, yet in the context of a known exposure to an allergen that previously triggered anaphylaxis, the recommendation for an exposure outside of a medical setting is to inject epinephrine.28 Whether an individual with generalized acute urticaria has “anaphylaxis” and should be given epinephrine is controversial. When relevant, specific preventive measures should be recommended (eg, for venom anaphylaxis, allergen-specific immunotherapy should be instituted to provide long-lasting protection).44 For exercise-induced anaphylaxis, physicians should recommend appropriate avoidance of food or medication co-triggers, and if no co-trigger has been identified, they should advise individuals to avoid ingestion of anything within 3 to 4 hours of strenuous exercise. The dose of Epinephrine, Clearly Explained. In addition, epinephrine downregulates further mast-cell release of histamine, tryptase, and other mediators of inflammation. Some “high-risk” circumstances that may justify prescription of self-injectable epinephrine in the absence of previous anaphylaxis are summarized in Table 3. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. NB: The ACLS dose of epinephrine is 1mg IV/IO q3-5 min prn. For Severe Allergy and Anaphylaxis What to look for If child has ANY of these severe symptoms after eating the food or having a sting, give epinephrine. Although recurrences were common, epinephrine was injected in only 12% of subsequent reactions. In a prospective, randomized, blinded study of children at risk of anaphylaxis,13 the time to maximum epinephrine concentrations was 8 ± 2 minutes after injection of 0.30 mg of epinephrine from an EpiPen (Dey LP, Napa, CA) intramuscularly in the vastus lateralis. ", Dosing Choices Limited for Small Children. Included in the epinephrine guidance is the recommendation that if anaphylaxis occurs in a healthcare setting, epinephrine … If symptoms recur, then consider a repeat dose or initiation of an IV epinephrine infusion (as below). On the basis of current, albeit limited, data, it seems reasonable to recommend autoinjectors with 0.15 mg of epinephrine for otherwise healthy young children who weigh 10 to 25 kg (22–55 lb) and autoinjectors with 0.30 mg of epinephrine for those who weigh approximately 25 kg (55 lb) and more. The mean ± SEM times for drawing up doses were 142 ± 13 seconds (range: 83–248 seconds) for parents, 52 ± 3 seconds (range: 30–83 seconds) for physicians, 40 ± 2 seconds (range: 26–71 seconds) for general duty nurses, and 29 ± 0.09 seconds (range: 27–33 seconds) for emergency department nurses. An intramuscular (IM) dose of 0.3 to 0.5 mg of EPINEPHrine is recommended for anaphylaxis in adults, but no comparative trials have been conducted to determine which dose is most clinically effective. Anaphylaxis is an acute, life-threatening reaction, usually mediated by an immunologic mechanism involving immunoglobulin E, that results in sudden systemic release of mast-cell and basophil mediators such as histamine and tryptase.1 Anaphylaxis has many clinical presentations, but respiratory compromise and cardiovascular collapse cause the greatest concern, because they can potentially lead to fatalities. Intramuscular injection in the anterolateral thigh is the preferred route regardless of age, as faster and higher plasma concentrations are obtained. Patients and families should be reminded to check expiration dates on their EAs and to keep them in proper storage. "All other medications, including H1-antihistamines and bronchodilators such as albuterol, provide adjunctive treatment but do not replace epinephrine," write lead authors Scott H. Sicherer, MD, professor of pediatrics at the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai in New York City, and Estelle R. Simons, MD, professor of pediatrics and child health in the College of Medicine at the University of Manitoba, Winnipeg, Canada, and colleagues from the Section on Allergy and Immunology Executive Committee. The dose may be repeated two or three times at 10 to 15 minutes intervals. It is not ethical to perform randomized, double-blind, placebo-controlled comparative studies on route of administration of epinephrine in children who are experiencing anaphylaxis, so definitive evidence-based recommendations on route of dosing cannot be made. Please use this form to submit your questions or comments on how to make this article more useful to clinicians. In some circumstances, epinephrine for self-injection should be prescribed for persons who have not experienced anaphylaxis but are at increased risk of anaphylaxis on the basis of their specific comorbid medical conditions and medical-social evaluation. The epinephrine dose for anaphylaxis in pediatrics must be calculated according to the patient’s weight Recommended dose is 0.01 mg/kg of a 1:1000 [1 mg/mL] solution to a maximum of 0.5 mg in adults and 0.3 mg in children. In the case of schools, the authors suggest a new plan should be provided at the beginning of the school year to reflect changes in medication doses, allergic triggers, or comorbid conditions. The Physician's Desk Reference20 and product inserts provide ambiguous advice and place the responsibility of dose selection entirely on the prescribing physician. Physicians face a particularly difficult dilemma in prescribing epinephrine doses for infants and children who weigh less than 15 kg (33 lb). Traditional beta2-agonists are seen as first-line therapies for moderate bronchiolitis and asthma exacerbations. Clearly, specific clinical circumstances must be considered in this decision. Clinical use data support weight-based dosing for treatment of anaphylaxis in pediatric patients, and other reported clinical experience with the use of epinephrine suggests that the adverse reactions seen in children are similar in nature and extent to those both expected and reported in adults. Epinephrine is the critical intervention for anaphylaxis. An example for the need for epinephrine before symptoms might be that a child has a history of cardiovascular collapse after exposure to an allergen, the authors write. The lack of additional autoinjector doses is a serious concern. For infants who weigh less than 10 kg (22 lb), dosing with 0.15-mg autoinjectors would exceed 1.5-fold overdosage, and although this situation is unacceptable from the standpoint of autoinjector availability, it is apparent that many pediatricians opt for the certainty of an autoinjector dose compared with the uncertainty of an ideal dose when the epinephrine ampule/syringe/needle technique is used.21 Still, physicians and families should consider and discuss the benefits and risks of choosing between an autoinjector or epinephrine ampule/syringe/needle for this age group on a case-by-case basis. The authors of both papers have disclosed no relevant financial relationships. Currently, self-injectable epinephrine is available in only two doses: 0.15 mg (EpiPen Jr) and 0.3 mg (EpiPen). Vander Leek et al34 showed that among 24 young children with peanut allergy whose first reaction was isolated to the skin after ingestion or skin contact, 18 (75%) experienced symptoms beyond the skin in a subsequent reaction. Epinephrine can save lives in cases of anaphylaxis, but it can be confusing to prescribe, prepare and administer. Epinephrine may have a role for subse … American College of Allergy, Asthma, and Immunology, American Academy of Allergy, Asthma, and Immunology. The AAP's universal Allergy and Anaphylaxis Emergency Plan offered in this report is available on the AAP website. Patients and caregivers must also be instructed in the techniques of autoinjector use or epinephrine ampule/syringe/needle use. It seems that adolescents are at particular risk of fatal anaphylaxis, possibly because they are more likely to engage in risky behaviors, fail to recognize triggers, deny symptoms, and not carry or use emergency medications.8,9 Additional efforts to provide anaphylaxis education for adolescents and their friends and peers are needed. Cite this: AAP Updates Guidance on Epinephrine Use for Anaphylaxis - Medscape - Feb 13, 2017. Fatal anaphylaxis in the pediatric population has particularly been associated with known preexisting asthma, failure to administer epinephrine promptly, and the adolescent age group.8,9, Clinical Criteria for Diagnosing Anaphylaxis (Fulfilling Any 1 Criterion Indicates That Anaphylaxis Is Highly Likely)7. Individual plans should be updated regularly as conditions change. Included in the epinephrine guidance is the recommendation that if anaphylaxis occurs in a healthcare setting, epinephrine should be given in these doses: 0.01 mg/kg (maximum dose, 0.3 mg) in a prepubescent child, and up to 0.5 mg in a teenager. Send comments and news tips to news@medscape.net. Emergency Department Anaphylaxis Pathway The following information is intended as a guideline for the management of children with anaphylaxis. Ischemic Stroke May Hint at Underlying Cancer, Topol: US Betrays Healthcare Workers in Coronavirus Disaster, The 6 Dietary Tips Patients Need to Hear From Their Clinicians. The American Academy of Pediatrics (AAP) recommends a lateral thigh epinephrine injection of 0.01 mg per kg, but no more than 0.30 mg, for children with anaphylaxis. Protection of children at risk of anaphylaxis while in school, child care, or camp requires a concerted effort.28 Several organizations have developed thoughtful summaries of shared responsibilities concerning food allergies for use by schools, children, adolescents, and parents (a list is available online at www.foodallergy.org/school/SchoolGuidelines.pdf). Epinephrine is the medication of choice for first-aid treatment of an episode of anaphylaxis. Included in the epinephrine guidance is the recommendation that if anaphylaxis occurs in a healthcare setting, epinephrine should be given in these doses: 0.01 mg/kg (maximum dose, 0.3 mg) in a prepubescent child, and up to 0.5 mg in a teenager. If more symptoms then develop, or if more than one organ system is involved, epinephrine is indicated, the authors write. Because of the acute, life-threatening nature of anaphylaxis, there are no contraindications to epinephrine administration. Pediatric Anaphylaxis 2.1 Pharmacology epiNEPHine Generic Name: epiNEPHrine Trade Name: Adrenalin ... *Note: Epinephrine dose is based on body weight. Anaphylaxis is a potentially life-threating, severe allergic reaction. In a survey of 29 pediatricians, 80% responded that they would prescribe the 0.15-mg autoinjector dose for a child who weighs 10 kg (22 lb); 100% responded that they would prescribe it for a child who weighs 15 kg (33 lb); and 70% responded that they would prescribe it for a child who weighs 20 kg (44 lb).25 In a study of epinephrine-dispensing patterns,21 72% of prescriptions for infants younger than 6 months (weighing less than approximately 7 kg [15 lb]) were for a 0.15-mg autoinjector, and 20% were for ampule/syringe/needle; 95% of prescriptions for infants 6 to 12 months of age (likely weighing up to approximately 10 kg [22 lb]) were for a 0.15-mg autoinjector. Regardless of whether epinephrine is administered, parents should urgently seek medical attention at the nearest ED if they are concerned about anaphylaxis. This is well established to be effective and life-saving. There are only two EA doses currently available: 0.15 and 0.3 mg. Among 32 food-anaphylaxis fatalities recorded in a registry maintained through the Food Allergy & Anaphylaxis Network,8 all but 1 individual had a known allergy to the food, only 10% had self-injectable epinephrine available, peanut or tree nut caused 94% of the reactions (milk and fish caused the others), most of those who died were adolescents or young adults, and 96% had asthma. It may be mild and resolve spontaneously due to end… Click the topic below to receive emails when new articles are available. Nevertheless, caregivers should be advised that individuals with severe anaphylaxis who may benefit from being in a supine position with legs raised should remain in that position and be transported that way by emergency personnel until advanced care can be accessed (eg, additional medications and intravenous fluids). Risk reduction entails confirmation of the trigger, discussion of avoidance of the relevant allergen, a written individualized emergency anaphylaxis action plan, and education of supervising adults with regard to recognition and treatment of anaphylaxis. Asthma puffers and/or antihistamines cannot be depended on in anaphylaxis.39. These criteria, as well as various signs and symptoms that may occur during anaphylaxis, are listed in Table 1. Physicians should carefully instruct patients and families on the indications for, and the technique for using, self-injectable epinephrine. Children are at increased risk for medication errors because the correct dose varies based on the child’s weight. This may partly be due to failure to appreciate that anaphylaxis is a much broader syndrome than \"anaphylactic shock,\" and the goal of therapy should be early recognition and treatment with epinephrine to prevent progression to life-threatening respiratory and/or cardiovascular symptoms and signs, including shock. Epinephrine should be given in the muscle of the mid-outer thigh because that helps achieve peak efficacy and is safer than injecting a bolus intravenously. Plans should be dated to show when the care provider created the plan, and the child's weight should be recorded and updated to confirm the correct medication dose. Effective care for individuals at risk of anaphylaxis requires a comprehensive management approach. The recommendation for epinephrine dosing in children with anaphylaxis, based primarily on anecdotal evidence, is to inject 0.01 mg/kg, up to 0.30 mg.17–19 Epinephrine autoinjectors are currently available in 2 fixed doses: 0.15 and 0.30 mg. Physicians, therefore, face a quandary with regard to dosing children who do not weigh approximately 15 kg (33 lbs [for whom the 0.15-mg dose is ideal]) or 30 kg (66 pounds or more [for whom the 0.30-mg dose is recommended]). as a child dose for the treatment of anaphylaxis in a pediatric population. Traditional beta2-agonists are seen as first-line therapies for moderate bronchiolitis and asthma exacerbations. For children who weigh less than 10 kg (22 lb), the physician and family should weigh the risks of delay in dosing and dosing errors when an ampule/syringe/needle is used against accepting nonideal autoinjector doses, taking into consideration the specific health needs of the individual child and abilities of the caregivers. Accidental injection of epinephrine into a digit can cause vasoconstriction and necrosis and should be promptly evaluated and treated, if necessary, with warming, topical nitroglycerin cream, or locally injected phentolamine or other vasodilator.42 Review and practice of injection technique using “trainers” and review of manufacturer's educational materials (eg, DVDs) are strongly recommended. Anecdotal evidence generally suggests that in the absence of a response to epinephrine, the epinephrine injection may be repeated at 5- to 20-minute intervals.1,28 Retrospective studies have suggested that a second dose may be required in 18% to 35% of cases, although data in this regard are limited.29,30 As stated previously, some of the effects of epinephrine (pallor, tremor, anxiety, and palpitations) and even severe adverse effects (such as cough from pulmonary edema) can mimic some of the symptoms of anaphylaxis. Please confirm that you would like to log out of Medscape. Freelance writer, MedscapeDisclosure: Marcia Frellick has disclosed no relevant financial relationships. For children who have asthma or other additional risk factors for fatality from anaphylaxis, switching to the higher dose at a lower weight might be considered.19 There are no data at this time to support specific recommendations for children who weigh less than 15 kg (33 lb). Commenting is limited to medical professionals. Gold and Sainsbury41 surveyed families of children for whom self-injectable epinephrine was prescribed for a previous reaction with respiratory or cardiovascular involvement. In many circumstances, astute clinical judgment is required to differentiate symptoms that may mimic aspects of an episode of anaphylaxis (eg, viral syndrome with acute urticaria, asthma, choking, a panic episode) or represent a mild allergic reaction that does not require epinephrine. A second potential factor contributing to incorrect dosing is the need for a dose calculation in the pediatric age group. Its role in asthma and bronchiolitis is less clear. The “allergy epi” 1:1000 concentration is 10 times more concentrated than the “cardiac epi”. Antihistamines and, for those with asthma, inhaled selective β2-adrenergic agonists such as albuterol provide adjunctive therapy but cannot replace epinephrine. In addition, several quandaries in management will be identified and possible solutions described. The Epinephrine Injection, USP Auto-Injector is indicated in the emergency treatment of allergic reactions (TYPE I) including anaphylaxis to stinging and biting insects, food, drugs, allergen immunotherapy, diagnostic testing substances, and other allergens, as well as idiopathic or exercise-induced anaphylaxis. Optimally, evaluation by an allergy/immunology specialist with American Board of Allergy and Immunology or international equivalent certification should be obtained to confirm allergic triggers, to provide education on trigger avoidance, and to initiate specific preventivetreatment (eg, venom-injection immunotherapy for insect-sting anaphylaxis). At-risk patients include "those with a history of anaphylaxis who can re-encounter their triggers, such as foods or stinging insects, those with idiopathic anaphylaxis, and those at increased risk of anaphylaxis who might not yet have experienced it...including patients living in remote areas with minimal or no access to emergency medical services. Instructions on allergen avoidance are key. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. If epinephrine is ineffective in treating anaphylaxis in patients taking beta- blockers, then glucagon administration may be necessary. You've successfully added to your alerts. In summary, epinephrine should be prescribed for children who have experienced anaphylaxis and may re-encounter the trigger outside of a hospital setting. This route of administration should be reserved for those with severe anaphylaxis that does not respond to intramuscular epinephrine and/or individuals with anaphylaxis who are being treated in hospital settings. The recommended epinephrine dose for anaphylaxis in children, based primarily on anecdotal evidence, is 0.01 mg/kg, up to 0.30 mg. On the basis of the available data at this time, intramuscular injection of epinephrine into the lateral thigh (vastus lateralis) seems to be the preferred route for therapy in first-aid treatment, assuming that an early peak epinephrine concentration is important to effective management. Prompt injection of epinephrine is nearly always effective in the treatment of anaphylaxis, and delayed injection of epinephrine is associated with poor outcomes including fatality. Omission of these preventive strategies may contribute to poor outcomes.9,11, In summary, epinephrine is the drug of choice for first-aid treatment of anaphylaxis and should be injected promptly in the event of an anaphylactic reaction or when progression to anaphylaxis is likely and advanced care is not promptly available. Multiple medication errors involving epinephrine have been reported, including the potential for significant cardiovascular side effects. -Since the lowest dose of the auto-injector is 0.1 mg, consider using other injectable forms of this drug if doses lower than 0.1 mg are necessary. The EpiPen ™ auto-injector (0.3mg) is for patients weighing more than 66 lbs/30 kg while the EpiPen ™ Jr (0.15 mg) is for patients weighing between 33 lbs/15 kg and 66 lbs/30 kg. The number and timing of epinephrine doses should be recorded and communicated to EMS. For more news, join us on Facebook and Twitter. Date: February 2019 Health Professions Act Leads (Nursing) Committee Page 6 of 13 6.0 Anaphylaxis Response Kit Contents Copy of this Decision Support Tool 4 ampoules of EPINEPHrine 1mg/mL 4 – 1 mL syringes Needles (25 to 27 gauge) o 4 - 1 inch o 4 - 1½ inch … Epinephrine is the recommended first-line treatment for anaphylaxis and moderate-to-severe croup. 18,37,38 Definitive evaluations of such children by an allergy/immunology specialist with American Board of Allergy and Immunology certification or international equivalent should be encouraged.39, Examples of Factors That May Indicate the Need to Prescribe Epinephrine for Persons “at Risk” of Anaphylaxis18,37,38.