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epinephrine injection in the mid-outer thigh reduces hospitalizations, This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have
morbidity, and mortality; (3) prescribing EAs facilitates timely epinephrine filed conflict of interest statements with the American Academy
injection in community settings for patients with a history of anaphylaxis of Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
and, if specific circumstances warrant, for some high-risk patients who Pediatrics has neither solicited nor accepted any commercial
involvement in the development of the content of this publication.
have not previously experienced anaphylaxis; (4) prescribing epinephrine
for infants and young children weighing <15 kg, especially those who Clinical reports from the American Academy of Pediatrics benefit from
expertise and resources of liaisons and internal (AAP) and external
weigh 7.5 kg and under, currently presents a dilemma, because the lowest reviewers. However, clinical reports from the American Academy of
Pediatrics may not reflect the views of the liaisons or the organizations
dose available in EAs, 0.15 mg, is a high dose for many infants and some or government agencies that they represent.
young children; (5) effective management of anaphylaxis in the community The guidance in this report does not indicate an exclusive course of
requires a comprehensive approach involving children, families, preschools, treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
schools, camps, and sports organizations; and (6) prevention of anaphylaxis
recurrences involves confirmation of the trigger, discussion of specific All clinical reports from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
allergen avoidance, allergen immunotherapy (eg, with stinging insect venom, revised, or retired at or before that time.
if relevant), and a written, personalized anaphylaxis emergency action DOI: 10.1542/peds.2016-4006
plan; and (7) the management of anaphylaxis also involves education of Address correspondence to Scott H. Sicherer, MD. E-mail: scott.
children and supervising adults about anaphylaxis recognition and first-aid sicherer@mssm.edu
autoinjectors (EAs) can be used in biphasic anaphylaxis, defined as effects cannot be dissociated from the
health care settings to deliver a recurrence of symptoms hours beneficial effects of epinephrine.23
0.15-mg dose in a young child and a after resolution of initial symptoms
Epinephrine given by IM injection
0.3-mg dose in a child or teenager. despite no further exposure to the
achieves peak concentrations faster
trigger, which is reported in up to
If the response to the first than that given by subcutaneous
11% of pediatric patients. Food-
epinephrine injection is inadequate, injection.20 Epinephrine, 0.3 mg IM,
induced anaphylaxis is associated
it can be repeated once or twice at is 10 times safer than epinephrine
with biphasic anaphylaxis less often
5- to 15-minute intervals.1,2,8 From given as an intravenous bolus.34
than is venom- or drug-induced
6% to 19% of pediatric patients Serious adverse effects of IM
anaphylaxis.32,33
treated with a first epinephrine epinephrine are rare in children.
injection in anaphylaxis require a Reluctance to inject epinephrine There is no absolute contraindication
second dose.29–31 A third dose is promptly at the onset of anaphylaxis to epinephrine treatment in
needed infrequently. Subsequent symptoms is best overcome by anaphylaxis.1,2,8,23
doses are typically given by a awareness that the severity of an
health care professional along anaphylactic episode can differ from
with other interventions.1,2,4,8 In a 1 patient to another and in the same DILEMMAS IN EPINEPHRINE DOSING
retrospective chart review study in patient from 1 episode to another.21 Only 2 premeasured, fixed doses
emergency department patients with At the onset, it is impossible to of epinephrine, 0.15 mg and 0.3 mg,
anaphylaxis, most of whom were predict whether the patient will are currently available in EA
children, 17% of those who received respond promptly to treatment, formulations in the United States and
1 epinephrine injection required 1 die within minutes, or recover Canada.35 EA manufacturers advise
or more additional doses. The need spontaneously because of secretion prescribing the 0.15-mg dose for
for subsequent injections did not of endogenous epinephrine. patients weighing 15 to 30 kg and the
correlate with obesity or overweight 0.3-mg dose for those weighing 30 kg
status.31 and over. These doses are optimal for
SAFETY OF EPINEPHRINE many children but not necessarily for
Subsequent epinephrine doses
all children.
are needed for severe or rapidly Pharmacologic effects of epinephrine
progressive anaphylaxis and for include transient pallor, tremor, The 0.15-mg dose is high for infants
failure to respond to the initial anxiety, and palpitations, which, (a twofold dose for those weighing
injection because of delayed injection although perceived as adverse ≤7.5 kg) and for some young
of the initial dose, inadequate initial effects, are similar to the symptoms children.6,21 Some EA manufacturers
dose, or administration through caused by increased endogenous have suggested that an alternative
a suboptimal route.23 Subsequent epinephrine levels produced in the approach for infants is to have
doses also might be needed in “fight or flight” response. These caregivers draw up the dose from
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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