Pediatric Anaphylaxis (EAACI/GA²LEN 2024)

Algorithm Steps

1. ▶

   Start

   Suspected Pediatric Anaphylaxis

   Acute onset multisystem allergic reaction

   1. ●

      Action

      Recognize Anaphylaxis

      Clinical criteria

      • ACUTE ONSET (minutes to hours) with:
      • • Skin/mucosal involvement (hives, swelling, pruritus, flushing)
      • + Respiratory compromise (dyspnea, wheeze, stridor, hypoxia)
      • OR + Cardiovascular (hypotension, syncope, incontinence)
      • OR exposure to known allergen with rapid onset of:
      • • Hypotension (SBP <70 + [2×age] or >30% decrease)
      1. ●

         Action

         EPINEPHRINE IM - First Line

         Give immediately - do not delay

         • DOSE: 0.01 mg/kg IM (1:1000) - max 0.5 mg
         • AUTOINJECTOR DOSES:
         • • <15 kg: 0.15 mg (Epipen Jr or equivalent)
         • • 15-25 kg: 0.15 mg or consider 0.3 mg
         • • ≥25 kg: 0.3 mg
         • SITE: Anterolateral thigh (through clothing if needed)
         • May repeat every 5-15 minutes if no response
         • Up to 3 doses usually sufficient
         1. ◆

            Decision

            Response to Epinephrine?

            Reassess after 5-15 minutes

            1. ✓

               Outcome

               Observation Period

               Monitor for biphasic reaction

               • Observe 4-6 hours minimum
               • High-risk (severe, refractory): observe 12-24 hours
               • Prescribe epinephrine autoinjector
               • Provide anaphylaxis action plan
               • Refer to allergist for testing
            2. ●

               Action

               Repeat Epinephrine

               Same dose IM if persistent symptoms

               • Repeat 0.01 mg/kg IM (max 0.5 mg)
               • Consider IV epinephrine if refractory:
               • • 0.01 mg/kg (1:10,000) slow IV
               • • Or infusion: 0.1-1 mcg/kg/min
               1. ●

                  Action

                  Adjunctive Therapies

                  Secondary treatments (do NOT delay epinephrine)

                  • FLUIDS: NS 20 mL/kg bolus if hypotensive
                  • ANTIHISTAMINES (do not replace epi):
                  • • Diphenhydramine 1-1.25 mg/kg IV/IM (max 50 mg)
                  • • Cetirizine 2.5-10 mg PO if tolerated
                  • CORTICOSTEROIDS (prevent biphasic):
                  • • Methylprednisolone 1-2 mg/kg IV (max 125 mg)
                  • • Or Prednisone 1-2 mg/kg PO (max 60 mg)
                  • BRONCHODILATORS: Albuterol neb for wheeze
                  1. ⚠

                     Warning

                     Refractory Anaphylaxis

                     Persistent hypotension despite epinephrine

                     • Continue IV fluid boluses
                     • Epinephrine infusion: 0.1-1 mcg/kg/min
                     • Consider glucagon if on beta-blocker:
                     • • 20-30 mcg/kg (max 1 mg) IV over 5 min
                     • Vasopressin may be considered
                     • Prepare for intubation if airway compromise
      2. ●

         Action

         Position + Monitoring

         Supportive measures

         • Position supine with legs elevated (if tolerated)
         • If respiratory distress: allow to sit up
         • If vomiting/unconscious: recovery position
         • Apply high-flow O2
         • Monitor vitals continuously
         • Obtain IV access