Epinephrine Underuse for Anaphylaxis in Infants and Toddlers: A Practical Review for Pediatricians

A recent consensus report defined anaphylaxis as a serious allergic reaction that may involve the skin/mucosa, respiratory, cardiovascular, and/or gastrointestinal systems that can progress rapidly and may cause death. Epinephrine treatment is recommended in suspected anaphylaxis cases; however, numerous barriers exist to consistent, widespread epinephrine use, including difficulty identifying anaphylaxis signs and symptoms; challenges recognizing when to use epinephrine; low propensity of prescribing and filling prescriptions; low epinephrine carrying rates; knowledge gaps in epinephrine administration techniques; fears of contacting emergency medical services; use of antihistamines, inhaled bronchodilators, and other medications as first-line agents over epinephrine; and limited epinephrine device availability in community settings (e.g., schools, daycares, and restaurants). To address these challenges, healthcare providers should provide training and educational resources to caregivers on signs and symptoms of anaphylaxis that warrant epinephrine use, how to use epinephrine devices, and the importance of having epinephrine readily available at all times. System-level strategies, including measures to improve access, legislative efforts to stock epinephrine in childcare centers, and scalable digital education approaches, are also needed. Furthermore, healthcare providers should implement shared decision-making with caregivers to prepare and empower caregivers to make informed decisions when managing anaphylactic events. Understanding barriers to consistent, widespread epinephrine use when infants and toddlers experience anaphylaxis and providing actionable educational tools to caregivers alongside system-level strategies can improve outcomes in this vulnerable population.