Outpatient Specialty Care and Primary Care Clinical Pathway for Evaluation/Treatment of Children with Anaphylaxis

As indicated
Initiate Appropriate
Emergency Response
  • Clinics outside of PHL/KOPH campuses:
    • Activate emergency response
      Call 911
  • Buerger and KOP SCCs:
    • Call code blue — ext. 4-2633 or 4-CODE
Children > 5 kg with Suspected Anaphylaxis
Providers: Use individual clinical decision for infants < 5 kg
Initial Assessment
  • If meets criteria for anaphylaxis:
  • Administer epinephrine IM immediately
  • Repeat epi dose q 5-15 min prn as clinically indicated:
    • Signs of upper airway obstruction
    • Continued respiratory distress/bronchospasm
    • Poor perfusion or hypotension
    • Persistent GI symptoms
Initiate Basic Life Support
Assess, Manage ABCs
Mental status Oxygen
Upper airway obstruction Racemic epinephrine
(should not replace Epi IM)
Lower airway symptoms Albuterol
Circulatory abnormality Trendelenburg position
IV, NS if able
Anaphylaxis is highly likely when one of the following 3 criteria is fulfilled within minutes to 2-3 hours following possible allergen exposure
Criteria 1
  • Acute onset of an illness with involvement of the skin, mucosal tissue, or both
    (e.g., generalized hives, pruritis or flushing, swollen lip-tongue-uvula)
  • And at least one of the following
    • Respiratory compromise
    • Reduced BP or associated symptoms of end-organ dysfunction
    • Persistent gastrointestinal symptoms
    • Significant abdominal pain and/or significant vomiting
Criteria 2
  • Two or more of the following that occur rapidly after exposure to a likely allergen for that child:
    • Involvement of the skin-mucosal tissue
    • Respiratory compromise
    • Reduced BP or associated symptoms
    • Persistent gastrointestinal symptoms
Criteria 3 Reduced BP after exposure to known allergen for that child
  • Epinephrine treats all symptoms of anaphylaxis and can prevent the escalation of symptoms.
  • IM is preferred, being faster and safer.
  • Use of adjunctive medications should not delay epinephrine administration.
Epinephrine Dosing — IM
5-25 kg 0.15 mg EpiPen Jr®
> 25 kg 0.3 mg EpiPen®
  • Risk Factors for Biphasic Reaction
    • History of biphasic or severe reactions
    • Progression of/or persistent symptoms
    • History of severe asthma
    • Hypotension
    • Requires > 1 epinephrine dose
    • Requires fluid bolus
    • Drug trigger
  • Severe Symptoms
    • Upper airway obstruction
    • Lower airway symptoms
    • Circulatory abnormality
  • Consider the use of the following medications:
    • Albuterol
    • Antihistamines
    • Steroids
    • Racemic epi
  • Above medications are available in BLS carts
Posted: August 2017
Revised: July 2023
Editors: Clinical Pathways Team