AAP Updates Guidance on Epinephrine Use for Anaphylaxis

Marcia Frellick

February 13, 2017

The American Academy of Pediatrics (AAP) confirms in a new report that epinephrine is the medication of choice for the first-aid treatment of anaphylaxis and updates a 2007 report on how it should be used most effectively.

"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.

Published alongside the clinical report on epinephrine use is a clinical report on the preparation and value of allergy action plans. Both reports were published online February 13 in Pediatrics.

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.

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.

Outside healthcare settings, epinephrine autoinjectors (EAs) are preferred because they are relatively easy to use and have more reliable accuracy of dosing than laypeople filling a syringe or using a prefilled syringe, the report says.

However, some physicians fail to prescribe EAs for their at-risk patients, the authors note.

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."

Dosing Choices Limited for Small Children

There are only two EA doses currently available: 0.15 and 0.3 mg. However, even the low dose can be high for many infants, especially those weighing 16.5 pounds or less.

The authors note that international guidelines suggest that patients who weigh between 16.5 and 55 pounds should receive the 0.15-mg dose. They acknowledge that dose is not ideal for patients who weigh less than 33 pounds, but note the alternatives may mean delayed or inaccurate doses.

They recommend EAs containing a 0.3-mg epinephrine dose for those weighing at least 55 pounds.

Patients and families should be reminded to check expiration dates on their EAs and to keep them in proper storage.

Report Details Universal Action Plan

In the accompanying clinical report, the AAP lays out an action plan for patients and their families, schools, and communities to respond quickly to life-threatening allergic reactions.

Julie Wang, MD, associate professor of pediatric allergy at the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai, and Dr Sicherer are coauthors on the report.

They note that several versions of emergency plans are in use, which can lead to confusion. The AAP's universal Allergy and Anaphylaxis Emergency Plan offered in this report is available on the AAP website.

Individual plans should be updated regularly as conditions change. 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.

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.

The forms should also document whether a child is allowed to carry emergency medications and/or self-administer them.

However, the authors write, even if a child is allowed to self-medicate, adults who can administer the medication should be listed on the form in case the child panics or the symptoms are severe.

The plan also notes that two EAs should be accessible at all times because a second injection may be needed if the first does not work.

For mild symptoms, the plan suggests an oral antihistamine first. If more symptoms then develop, or if more than one organ system is involved, epinephrine is indicated, the authors write.

The forms include space for the healthcare provider to recommend, depending on a patient's history, that epinephrine be given even though only mild symptoms occur or, controversially, when there are no symptoms, but a definite ingestion or sting has occurred.

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 authors of both papers have disclosed no relevant financial relationships.

Pediatrics. Published online February 13, 2017.

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