The Cribsiders podcast

#9: Anaphylaxis: All You Need to Know

September 30, 2020 | By

Or: How I Learned to Stop Worrying and Love Epinephrine

Summary

Wondering about how anaphylaxis presents in kids and how to give an epinephrine auto-injector to an infant? We chat with Dr. Julie Brown, a pediatric emergency medicine attending physician at Seattle Children’s Hospital, about anaphylaxis, a common pediatric condition that can rapidly become dangerous if not quickly recognized and treated. We also discuss food allergy, adjuncts in anaphylaxis therapy, pediatric epinephrine dosing and auto-injectors, and discharge planning.

Credits

  • Producer, Writer, and Infographic: Ann Young MD
  • Cover Art: Chris Chiu MD
  • Hosts: Justin Berk MD, Chris Chiu MD
  • Editor:Justin Berk MD; Clair Morgan of nodderly.com
  • Guest(s): Julie Brown MD

Time Stamps

  • First Case 7:13
  • Diagnosis of anaphylaxis 8:00
  • Epinephrine Mechanism 10:55
  • Anaphylaxis Rash 14:15
  • Anaphylaxis Prognostic Signs 16:00
  • Common Exposures 17:10
  • Dose of Allergen 18:20
  • Adjunctive Therapies 23:35
  • Steroids and Biphasic Reaction 30:20
  • Epinephrine Dosing 33:25
  • Observation Period 38:45
  • Counseling 41:25
  • Presentation in Children vs. Young Adults 51:12
  • Take-Home Points 54:13

Anaphylaxis Pearls

  1. There are 3 ways to diagnose anaphylaxis.
  2. For GI symptoms in the diagnostic criteria of anaphylaxis, remember that these symptoms should be persistent, as many children may vomit when they are upset or coughing.
  3. Diffuse erythroderma is a sign of rapid mast cell release and can be an early sign of skin involvement in anaphylaxis.
  4. Because patients with severe anaphylaxis experience third-spacing, placing patients in supine positioning optimizes both their circulation and epinephrine delivery.
  5. Don’t hesitate to give epinephrine early, even if not meeting all criteria for diagnosis, due to the benefit of treating early to prevent adverse outcomes.
  6. Children tolerate high doses of epinephrine well due to their healthy hearts.
  7. To reduce confusion for parents, refer to autoinjectors by their specific brand name.
  8. When educating parents on when to give an epinephrine auto-injector to their child at home, err on the side of giving the medicine rather than not giving it.
  9. Parents with children who weigh < 15 kg can pinch their child’s thigh to create more needle-to-bone distance to safely administer a 0.15mg epinephrine auto-injector.

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Diagnosis of anaphylaxis

Clinical criteria for the diagnosis of anaphylaxis

Anaphylaxis in a child is highly likely when ONE of the 3 following clinical scenarios are met.

Scenario 1: 

  • No exposure history required
  • Acute onset of skin/mucosal involvement (rash, swelling, angioedema, flushing, pruritis) PLUS ONE of the two: Respiratory compromise (cough, wheeze, stridor, hypoxemia) OR reduced blood pressure or associated symptoms (hypotension, feeling faint, feeling of doom, syncope, collapse)

Scenario 2: 

  • LIKELY allergen exposure for that patient in the preceding minutes to hours

  • At least TWO of FOUR systems involved: skin/mucosa, respiratory, reduced blood pressure, persistent gastrointestinal symptoms (abdominal pain, vomiting)

Scenario 3: 

  • KNOWN allergen exposure for that patient in the preceding minutes to hours

  • Reduced blood pressure or associated symptoms

How does the presentation of anaphylaxis differ between infants and adults?

  • In general, non-verbal patients (infants, toddlers, or medically complex patients) may become inconsolable, irritable, somnolent, or fussy
  • While an older patient may be able to say they “feel faint,”  a younger patient may instead look confused, sleepy, or stumble while walking
  • While an older patient can say their “throat is itchy” or “it’s hard to swallow,” a younger patient may have lip-smacking or drooling

What does the rash look like in anaphylaxis?

  • Teach parents to look for ANY skin changes
  • Clinicians should look for signs of mast-cell release: urticaria, hives, angioedema, flushing.
  • Erythroderma, which appears as a diffuse sunburn, indicates rapid mast cell release prior to edema onset, and can signal early onset of anaphylaxis.

Are there any signals of progression to anaphylactic shock?

  • History is essential: kids with prior episodes of anaphylactic shock, biphasic reaction, or admission for anaphylaxis are at higher risk for progression.
  • Otherwise, there are no definitive signs/symptoms to indicate progression to shock.

Food allergies and anaphylaxis

Food allergies are a common cause of anaphylaxis in children, so it’s important to review the connection between the two.

What are the most common food allergies in children?

  • Top 8 food allergies in children: Milk, eggs, wheat, soy, peanuts, tree nuts, fish, shellfish
  • Former four (milk, eggs, wheat, soy) usually present and resolve in early childhood
  • Latter four (peanuts, tree nuts, fish, shellfish) usually present in later childhood and become lifelong allergies

What route of exposure to a food allergen leads to anaphylaxis?

  • Ingestion is the most important route: while higher ingested amounts increase the risk of a severe reaction, severe reactions can occur with minuscule amounts of ingested allergen.
  • Intradermal and aerosolized routes are incredibly rare sources of food allergen anaphylaxis.

When should we be introducing peanuts to children?

  • Recent RCT data shows that introducing high-risk patients to peanuts earlier (during the first year of life), rather than later leads to decreased frequency of developing a peanut allergy

How young is “too young” to consider food allergy-induced anaphylaxis?

  • No known age cutoff for “too young” to consider anaphylaxis as a diagnosis.
  • Expert opinion: Dr. Brown has found infants as young as 3 month-olds in her research that have had allergic reactions severe enough to require epinephrine. 

Treatment of anaphylaxis

Epinephrine is your friend.

  • Give IM epinephrine ASAP when anaphylaxis is recognized as epinephrine reverses all the symptoms of anaphylaxis
  • It is the only definitive treatment for anaphylaxis so sign your order for epinephrine first, then consider adjuncts
  • The earlier you give epinephrine, the better the outcomes for patients.

Is there a role for adjunctive therapies in anaphylaxis treatment?

  • No randomized control trials have been performed in children to show benefit in anaphylaxis for either antihistamines or corticosteroids
  • H1-blockers & H2-blockers treat rash but do not change course or outcomes, so are usually prescribed if patients have skin symptoms or if meeting clinical criteria for anaphylaxis
  • There is a theoretical benefit to steroids, but data is mixed and scant (may reduce length of stay in admitted patients and reduce need for additional doses of epinephrine)
  • Albuterol, IV fluids, and oxygen are all helpful and should be administered as needed

Does patient positioning make a difference?

What is the biphasic reaction of anaphylaxis?

  • Definition: Complete resolution of anaphylaxis symptoms with return of symptoms within 72 hours of initial onset. Occurs in about 15% of pediatric anaphylaxis cases.
  • Cohort studies have NOT demonstrated either antihistamines or steroids as effective in reducing the incidence of biphasic reactions in children

What epinephrine dosing is appropriate for anaphylaxis in kids?

  • Dosing recommendations are historical, not based on evidence or pharmacokinetics
  • Epinephrine anaphylaxis dosing is 0.01 mg/kg/dose in children, to a max of 0.3mg/dose.
  • “Little, middle, big” rule: Little kids get 0.1 mg/dose, Middle-sized kids get 0.2 mg/dose, Big kids get 0.3 mg/dose

Are there contraindications to epinephrine in kids?

  • There are NO absolute contraindications to epinephrine in children
  • Children tolerate high doses of epinephrine much better than adults due to their healthier cardiovascular systems

When should you re-dose epinephrine?

  • If the patient has not improved or is worsening 5-10 minutes after the initial epinephrine dose, you should give a second IM epinephrine 0.01 mg/kg dose (to a max of 0.3 mg/dose).
  • The Anaphylaxis Score Assisting Providers (ASAP): Dr. Brown developed a time-based tool used in the Seattle Children’s Anaphylaxis Pathway to help emergency department clinicians determine whether or not to re-dose epinephrine based on current symptoms and previously administered treatments. 

Discharge planning

How do you know when it’s safe to send a patient home and how do you prepare families?

The observation period for anaphylaxis is not clear

  • Current standard of care is to observe for 4 hours post-epinephrine administration as long as the patient continues to look well.
  • Expert opinion: Dr. Brown says that patients with food-allergen induced anaphylaxis may be observed for only 3 hours as long as they meet strict discharge criteria (page 5 of the  Seattle Children’s Anaphylaxis Pathway describes these criteria in detail).

Epinephrine auto-injectors: More than just EpiPens

  • Refer to the auto-injector by its correct brand name (Mylan EpiPen, Mylan Generic, AuviQ, Adrenaclick, Emerade, etc) since the administration of each autoinjector is different (check out Dr. Brown’s YouTube channel, where she demos the ballistics of each autoinjector!).
  • Most auto-injectors come in two doses: 0.15 mg (15-30 kg child) or 0.3 mg (>30kg child)
  • Do NOT prescribe a syringe/vial as there is a high risk of administration error.
  • Even if your patient is < 15kg, you can still prescribe the 0.15 mg auto-injector, because young children tolerate high doses of epinephrine well.
  • Parents with children who weigh < 15 kg can pinch their child’s thigh to create a longer needle-to-bone distance to safely administer a 0.15mg epinephrine auto-injector.

Educating families on anaphylaxis home care

  • Families should leave with the autoinjector in hand prior to discharge
  • Auto-injector training done with the patient’s specific auto-injector brand
  • Provide resources from Food Allergy Research and Education (FARE)
  • Print and review their Anaphylaxis action plan
  • Remember that diagnostic criteria clinicians use are more strict when compared with the criteria parents use to give epinephrine to their child at home. Teach parents that when they’re in doubt, they should give the epinephrine.

Future directions

What research does Dr. Brown look forward to in the area of anaphylaxis?

  • RCTs for antihistamines and steroids
  • Alternatives to IM epinephrine administration: no-needle, sublingual or intranasal
  • Curing food allergies

Goal

Listeners will explain the pathophysiology, diagnosis, and management of anaphylaxis to improve both inpatient emergent care and outpatient counseling. 

Learning objectives

After listening to this episode listeners will…  

  1. Learn the diagnostic criteria for anaphylaxis in children
  2. Learn the most common causes of food allergy in children
  3. Compare the presentations of anaphylaxis in infants, children, and adults
  4. Discuss adjunct therapies in the management of anaphylaxis
  5. Learn about epinephrine administration and dosing in children
  6. Prepare families for anaphylaxis home care

Disclosures

Dr. Julie Brown reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Brown J, Young AL, Chiu C, Berk J. “Dr. Julie Brown and Anaphylaxis; Or: How I Learned to Stop Worrying and Love Epinephrine”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com. 9/30/20.

Comments

  1. October 1, 2020, 9:56am Jamie Fox, MD writes:

    I am PEM physician and long-time fan of The Curbisders. SO happy you've created this Pediatrics-focused podcast and absolutely loved this episode with Dr. Brown. In particular, I was really impressed by her comments regarding congratulating parents when they give their child IM epi for anaphylaxis prior to coming to the ED even when the ED physician believes the child may not have absolutely needed it. I teach my learners all the time that IM epi is one of 3 meds that families are extremely reluctant to give their child for fear of causing pain when not necessary. So when families give it, YES - please do congratulate them and tell them it was right call. Also, in my experience (as a PEM doc and father of teenage daughter with peanut allergy [dx'd at 22mos] who needed IM epi for first time a few months back), the injection from the auto-injectors (I've learned correct language from Dr. Brown ;-)) causes very little pain when I've ask my patients (and my needle-phobic daughter). Even more reason to empower parents and reassure them.

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