Suspected anaphylaxis in a child
Acute allergic reaction with breathing or circulation problems. If in doubt, give adrenaline. Stop any IV drug infusion now.
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PediatricsEmergency
Pediatric Anaphylaxis (ASCIA 2026 / EAACI 2021 / GA²LEN 2024)
Pediatric Anaphylaxis (ASCIA 2026 / EAACI 2021 / GA²LEN 2024): Suspected anaphylaxis in a child → Recognise anaphylaxis (GA²LEN 2024 criteria) → Give IM...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Recognise anaphylaxis (GA²LEN 2024 criteria)
Acute onset over minutes to hours. Life-threatening anaphylaxis can occur without skin signs. After an insect sting, abdominal pain or vomiting alone is a sign of anaphylaxis: give adrenaline. In children, low BP is a late sign.
- No known allergen: skin or mucosa signs PLUS breathing or circulation problems
- Likely or known allergen: 2 or more systems (skin or mucosa, breathing, circulation, severe gut symptoms)
- Known allergen: breathing or circulation problems alone are enough
- Infants: hoarse cry, drooling, repeated lip licking, sudden irritability, floppy, pale or mottled
- Children: persistent tachycardia is the first circulation sign. Alone it is not diagnostic (crying, fever, pain, adrenaline). A beta-blocker (for example propranolol for haemangioma) can blunt it
- Low SBP: age 1-12 months <70 mmHg; 1-10 years <70 + (2 x age in years) mmHg; over 10 years <90 mmHg; or fall >30% from baseline
03Action Give IM adrenaline now: 0.01 mg/kg (max 0.5 mg)
Child: adrenaline 1 mg/mL (1:1000) 0.01 mL/kg, max 0.5 mL, into the outer mid-thigh. Do not delay. Repeat every 5 min if no or poor response. Call for help; not in hospital, phone ambulance 000.
- 10 kg or less: 0.1 mL of 1 mg/mL (ASCIA and RCH tables). Volumes under 0.1 mL risk a 10-fold error
- Child over 50 kg or adult: 0.5 mg (0.5 mL of 1 mg/mL)
- No ampoule ready (AU devices): 150 microgram for 7.5-20 kg; 300 microgram for 20 kg or more; 300 or 500 microgram for 50 kg or more
- Intranasal device (AU, neffy): 1 mg for 15-30 kg (age 4 years or more); 2 mg for 30 kg or more
04Action Lay flat. Do NOT let the child stand or walk
Standing or walking can cause sudden fatal collapse, even when the child looks better. Keep flat for at least 1 h after 1 dose and 4 h after more than 1 dose.
- Hold infants and young children flat, not upright or over a shoulder
- Unresponsive and not breathing normally: start CPR
- Poor circulation: consider raising the legs. Breathing hard: sit with legs out straight, not on a chair
- Unconscious or vomiting: recovery position. Pregnant: left side
05Action Remove the trigger. Oxygen, monitoring and IV access
Hypotension: 0.9% sodium chloride 10-20 mL/kg IV or IO, rapid bolus.
- Stop an IV drug infusion; flick out a sting; stop food. Tick: freeze it and let it drop off; do not pull it out
- Oxygen. Monitor SpO2, BP and ECG
- IV access (IO if IV fails)
- Take blood for mast cell tryptase when feasible; do not delay treatment
06Action Adjuncts only after adrenaline, never instead of it
Choose by symptom. Give adrenaline first, also in children with asthma.
- Do NOT give injectable promethazine or sedating antihistamines
- Stridor or upper airway swelling: nebulised adrenaline 5 mL of 1 mg/mL (1:1000), plus IM adrenaline
- Persistent wheeze: salbutamol, dose as for acute asthma; then treat as acute severe asthma
- Persistent wheeze: consider prednisolone 1 mg/kg oral (max 50 mg) or hydrocortisone 5 mg/kg IV (max 200 mg); benefit unproven
- Skin symptoms only, after anaphylaxis is treated: oral non-sedating antihistamine
07Decision Improving 5 min after adrenaline?
Check airway, breathing, BP, perfusion and conscious state.
- If Yes
- Improving
08Action Once improving: observe at least 4 h after the last dose; overnight if high risk
Biphasic reactions occur in 3-20%, within 48 h.
- Overnight if: severe or refractory reaction (repeat doses, fluids or infusion); past severe, refractory or biphasic reaction; severe asthma, arrhythmia or mastocytosis; remote from care; late-evening presentation
09Outcome Discharge: adrenaline device, ASCIA Action Plan and allergy referral
Before discharge, prescribe and, if possible, dispense an adrenaline device. Teach use with a trainer device.
- Give an ASCIA Action Plan for Anaphylaxis
- Refer every child to a clinical immunology or allergy specialist
- Review asthma control
If No- Not improving
10Action Not improving: repeat IM adrenaline every 5 min
Same dose, 0.01 mg/kg (max 0.5 mg). Call ED senior, ICU or anaesthetics now.
- Hypotension: repeat 0.9% sodium chloride 10-20 mL/kg IV or IO
- Infants: pallor can persist after adrenaline. More than 2 doses can cause hypertension and tachycardia. Check BP before more doses
- No routine IV adrenaline bolus (peri-arrest exception: see refractory step)
- Taking a beta-blocker (for example propranolol): response may be blunted; get critical care advice early
11Decision Still not improving after 2 IM doses?
Persisting breathing or circulation problems after 2 doses = refractory anaphylaxis. Count doses given before arrival.
- If Yes
- Refractory
12Warning Refractory: IV adrenaline infusion with ED senior or ICU. No routine IV bolus
Keep giving IM adrenaline every 5 min until the infusion runs. IV boluses can cause arrhythmia and pulmonary oedema. Only exception: school-age child peri-arrest, experienced acute care clinician: 1 microgram/kg IV (max 50 microgram) over 1-2 min while the infusion is set up.
- Infusion: 1 mL of 1 mg/mL adrenaline in 100 mL 0.9% sodium chloride; start 0.5 mL/kg/h (about 0.1 microgram/kg/min); titrate to response
- Pump, dedicated IV or IO line, not on the BP cuff arm. Continuous ECG and SpO2, frequent BP
- Hypotension: 0.9% sodium chloride 10-20 mL/kg IV or IO; repeat as needed
13Action Refractory: airway, breathing and circulation support
Critical care support is essential. Seek expert help early. Cardiac arrest: follow ANZCOR paediatric advanced life support.
- Stridor: nebulised adrenaline 5 mL of 1 mg/mL; early intubation by an expert
- Severe bronchospasm: nebulised salbutamol and ipratropium; follow life-threatening asthma protocol
- Low BP despite adrenaline infusion and fluids: ICU to add a second vasopressor, per expert advice and local protocol
- Non-tertiary site: 1 mL of 1 mg/mL in 1000 mL 0.9% sodium chloride at 5 mL/kg/h, with senior and retrieval advice; arrange transfer
- Taking a beta-blocker, still refractory after infusion and fluids: with critical care advice, consider glucagon 20-30 microgram/kg IV (max 1 mg)
- Path rejoins step 08Shared downstream outcome
If No- Improving
- Path rejoins step 08Shared downstream outcome
Guideline Source
ASCIA Guidelines: Acute Management of Anaphylaxis (July 2026) + EAACI Guidelines: Anaphylaxis (2021 update)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Not for anaphylaxis under general anaesthesia (IV adrenaline by an anaesthetist); use the perioperative anaphylaxis pathway
- Device weight bands are Australian (ASCIA 2026); other countries' labels differ. The ampoule dose 0.01 mg/kg (max 0.5 mg) applies everywhere
- For clinicians in a medical setting; community first aid follows the ASCIA Action Plan
- Beta-blockers may blunt the response to adrenaline
- Low SBP thresholds do not cover infants under 1 month
Contraindicated Populations
Anaphylaxis during general anaesthesia (use the perioperative anaphylaxis pathway)
Applicable Regions
AUEUUS
AU: Follows ASCIA 2026. TGA-registered and PBS-listed devices: EpiPen Jr and Jext Jr 150 microgram, EpiPen and Jext 300 microgram, Anapen 500 500 microgram, neffy 1 mg and 2 mg nasal spray.
EU: Autoinjector weight bands follow EAACI 2021 and local product labels; they differ from the ASCIA bands.
US: Autoinjector weight bands follow US product labels and AAP/AAAAI guidance; they differ from the ASCIA bands.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Pediatric Anaphylaxis (ASCIA 2026 / EAACI 2021 / GA²LEN 2024)?
The Pediatric Anaphylaxis (ASCIA 2026 / EAACI 2021 / GA²LEN 2024) is a emergency clinical algorithm for Pediatrics. It provides a structured decision tree to guide clinical decision-making, based on ASCIA Guidelines: Acute Management of Anaphylaxis (July 2026) + EAACI Guidelines: Anaphylaxis (2021 update).
What guideline is the Pediatric Anaphylaxis (ASCIA 2026 / EAACI 2021 / GA²LEN 2024) based on?
This algorithm is based on ASCIA Guidelines: Acute Management of Anaphylaxis (July 2026) + EAACI Guidelines: Anaphylaxis (2021 update) (DOI: 10.1111/all.15032).
What are the limitations of the Pediatric Anaphylaxis (ASCIA 2026 / EAACI 2021 / GA²LEN 2024)?
Known limitations include: Not for anaphylaxis under general anaesthesia (IV adrenaline by an anaesthetist); use the perioperative anaphylaxis pathway; Device weight bands are Australian (ASCIA 2026); other countries' labels differ. The ampoule dose 0.01 mg/kg (max 0.5 mg) applies everywhere; For clinicians in a medical setting; community first aid follows the ASCIA Action Plan; Beta-blockers may blunt the response to adrenaline; Low SBP thresholds do not cover infants under 1 month. Individual patient factors may require deviation from these recommendations.
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