ANAPHYLAXIS TREATMENT GUIDELINES (CHILDREN)
All healthcare professionals must exercise their own professional judgement when using guidelines.
However any decision to vary from the guideline should be documented in the patient records to
include the reason for variance and the subsequent action taken.
Tony Kinsey Senior Resuscitation Office
Approved by Clinical Quality Group May 2003
Updated Version Ratified May 2005
Ratified by the Health Care Governance Committee May 2003
Updated Version Noted July 2005
This guideline should not be used after end of: July 2007
THIS DOCUMENT MUST NOT BE
If you require a copy for your department, please contact the Clinical Governance Co-ordinator on
PLEASE NOTE THAT ALL CLINICAL GUIDELINES ARE AVAILABLE ON
Key individuals involved in developing the document
Tony Kinsey Senior Resuscitation Officer, WSSA
Jo Panniers Pharmaceutical Adviser SWPCT
Dr Andy Mills Community Consultant Paediatrician
Circulated to the following individuals for comments
Caron Grainger Director of Public Health
Jane Pugh Director of Nursing and Clinical Services
Dr Jonathan Wells Clinical Governance Lead
Vicky Preece Assistant Director of Nursing /Professional
Adviser District Nursing
Sue Lunec Pharmaceutical Advisor
R&B PCT Clinical Quality Group
ANAPHLYAXIS TREATMENT POLICY - CHILDREN
1. Introduction Page 4
2. Scope of Policy Page 4
3. Treatment guidelines Page 5
4. Cautions Page 5 –6
5. Audit of Policy Page 6
5. References Page 6
Appendix 1 Anaphylactic reactions in children Page 7
Attachment Drug administration Patient Group Direction Page 8 - 9
According to the Resuscitation Council (2002), anaphylaxis is becoming increasingly common, almost
certainly due to the appreciable increase in prevalence of allergic disease over the last two or three decades.
They suggest that anaphylaxis continues to be poorly managed and specifically point to the under use of
intra-muscular adrenaline (epinephrine).
The term anaphylaxis is usually used for hypersensitivity reactions, typically mediated by immunoglobulin E
(IgE). Anaphylactoid reactions are similar, but do not depend upon hypersensitivity. For the purposes of this
policy, the term anaphylaxis will be used for both types of reactions as their manifestations and initial
treatment are the same. Both may present clinically with angio-oedema, urticaria, dyspnoea and
hypotension. But some patients may die from acute irreversible asthma or laryngeal oedema with few more
generalised manifestations. Other symptoms include rhinitis, conjunctivitus, abdominal pain, vomiting,
diarrhoea and a sense of impending doom. There is also usually a colour change: the patient may appear
either flushed or pale. Cardiovascular collapse is a common manifestation, especially in response to
intravenous drugs or stings, and is caused by vasodilatation and loss of plasma from the blood compartment.
Anaphylactic reactions vary in both severity and speed. Reactions may follow exposure to a variety of
agents, with insect stings, drugs or contrast media and some foods being the most common.
Adrenaline (epinephrine) is the most important drug for treating any severe anaphylactic reactions. As an
alpha-receptor agonist, it reverses peripheral vasodilatation and reduces oedema. Its beta-receptor activity
dilates the airways, increases the force of myocardial contraction and suppresses histamine release.
Adrenaline (epinephrine) works best when given early after the onset of the reaction. If given intramuscularly
it is very safe and adverse reactions are very rare.
SCOPE OF POLICY
This policy will apply to all medical staff, dentists, registered nursing staff, state registered podiatrists and
Chartered Physiotherapists working with children (age under 16) within the Redditch and Bromsgrove
Primary Care NHS Trust. Registered nurses, state registered podiatrists and Chartered Physiotherapists, will
be covered by the Patient Group Direction for "Adrenaline (epinephrine) administration in Anaphylaxis
(Children)", Reference number DA/AG/05, after completion of a designated anaphylaxis training session.
Training should be updated annually.
Designated Training sessions can be given by:
(i) Senior Resuscitation Officer/Assistant Resuscitation Officer
(ii) Designated Resuscitation Trainers
1. These treatment guidelines are based on the recommendations of the Resuscitation Council UK
(2002) .The treatment guidelines are summarised in algorithm form in Appendix 1.
2. As soon as a severe allergic-type reaction is suspected (compatible history, respiratory difficulty
and/or hypotension and especially if skin changes are present) the first priority is a 999 call for
transfer to Accident and Emergency.
3. As soon as it is available, oxygen should be administered at high flow rates (10-15 litres/minute).
4. All victims should recline in a position of comfort. Lying flat with leg elevation may be helpful for
hypotension but unhelpful for breathing difficulties.
5. If there is a cardiac arrest, cardiopulmonary resuscitation (CPR) should be performed according to
6. Adrenaline (epinephrine) should be administered intra-muscularly to all patients with clinical signs of
shock, airway swelling or definite breathing difficulty, and will be absorbed rapidly. Manifestations
such as inspiratory stridor, wheeze, cyanosis, pronounced tachycardia and decreased capillary filling
will alert staff to the likelihood of a severe reaction.
7. The following dose of Adrenaline (epinephrine) 1:1000 solution should be administered.
Over 12 years: 500 micrograms intramuscularly (0.5ml)
250 micrograms if child is small or prepubertal
6 years - 12 years: 250 micrograms intramuscularly (0.25ml)
6 months – under 6 years: 120 micrograms intramuscularly (0.12ml)
Under 6 months: 50 micrograms intramuscularly (0.05ml)
This can be repeated after 5 minutes in the absence of clinical improvement or if deterioration
9. Absolute accuracy of the 50 micrograms dose of Adrenaline (epinephrine) is “not essential” –
Resuscitation Council (2002).
10. The above doses are now compatible with the advice given by the Resuscitation Council (UK), the
British National Formulary and the Department of Health Immunisation and Vaccination "Green
11. For children who have been prescribed Epipen, and one is available, 150 micrograms can be given
instead of 120 micrograms, and 300 micrograms can be given instead of 250 or 500 micrograms. An
Epipen that has already been prescribed to a patient may be administered without a Patient Group
12. Remember the urgency of transfer to Accident and Emergency, because of the danger of further
collapse and the need for further treatment.
1. The use of Adrenaline (epinephrine) by the intravenous route is potentially very hazardous. It must
only be given by the intra-muscular route in the emergency treatment of anaphylactic reactions in
2. Attention should be drawn to the fact that Adrenaline (epinephrine) is available in two strengths. For
anaphylaxis, Adrenaline (epinephrine) is used in a dilution of 1:1000 intra-muscularly. Whereas a
dilution of 1:10000 is used intravenously principally for cardiac arrest.
3. All who treat anaphylaxis should be aware of the potential for confusion between anaphylaxis and
panic attacks. Victims of previous anaphylaxis may be particularly prone to panic attacks if they think
they have been re-exposed to the allergen that caused a previous problem. The sense of anxiety
and breathlessness, leading to hyper-ventilation are symptoms that resemble anaphylaxis in some
ways. While there is no hypotension, pallor, wheeze or urticarial rash/swelling, there may sometimes
be an erythematous rash associated with anxiety which adds to the diagnostic difficulty. A mild
anaphylactic reaction that triggers panic causes particular diagnostic difficulty.
Problems can also arise with vasovagal attacks after immunisation procedures, but the absence of
rash, breathing difficulties, and swelling is a useful distinguishing feature as is the slow pulse of a
vasovagal attack compared with the rapid pulse of a severe anaphylactic episode.
AUDIT OF POLICY
Adherence to this policy will be monitored via the review of Critical Incident Reports received by the PCT
relating to the management of anaphylaxis.
Resuscitation Council (UK) (2002). The Emergency Medical Treatment of Anaphylactic Reactions For
Medical Responses and for Community Nurses.
(Available on the Resuscitation Council website: www.resus.org.uk )
ANAPHYLACTIC REACTIONS IN CHILDREN
Treatment by First Responders
Consider diagnosis of anaphylaxis when compatible history of
severe allergic-type reaction with respiratory difficulty and/or
hypotension especially if skin changes present
Oxygen treatment as
soon as available
Stridor, wheeze, respiratory distress
or clinical signs of shock 1
For hypotension lie patient flat with legs raised
(unless respiratory distress increased)
Adrenaline (epinephrine) 1:1000 solution
Over 12 yrs: 500 micrograms IM (0.5ml)
250 micrograms if child is small or prepubertal (2)
6 years -12 yrs: 250 micrograms IM (0.25ml)
6 months – under 6 years: 120 micrograms IM (0.12ml) (2)
Under 6 months: 50 micrograms IM (0.05 ml)
Repeat in 5 minutes if no clinical improvement
1. If profound shock judged immediately life threatening start CPR
2. For children who have been prescribed Epipen, and one is available, 150
micrograms can be given instead of 120 micrograms, and 300 micrograms can
be given instead of 250 micrograms or 500 micrograms.
3. Absolute accuracy of this small dose is not essential
Drug Administration Patient Group Direction for:
Adrenaline (Epinephrine) 1mg in 1ml (1:1000) Injection DA/ / D
to Children under 16 DA/AG/05
Subject to all the conditions and criteria below, this Patient Group Direction allows the designated authorised staff to
administer the named drug to patients of the Trust either on Trust premises or in the community in the course of Trust
healthcare provision, without the need for a prescription from a doctor/dentist.
Staff Applies to:- Registered nurses, State Registered Podiatrists and Chartered Physiotherapists who have
attended designated anaphylaxis training every 12 months
1st April 2005
Implementation date:- This Patient Group Direction is valid from
Expiry date:- This Patient Group Direction is invalid after 1st April 2007
Standard treatment regimen.
Drug/form/strength/route Adrenaline (epinephrine) Injection 1mg in 1ml (1:1000)
No variation Intra-muscular injection
Dose/frequency Over 12 years: 500micrograms (0.5ml) IM stat
250 micrograms (0.25ml) IM stat
if child is small or prepubertal
Over 6 years -12 years: 250 micrograms (0.25ml) IM stat
6 months - under 6 years: 120 micrograms (0.12ml) IM stat
Under 6 months: 50 micrograms (0.05ml) IM stat
Duration/quantity Repeat ONCE after 5 minutes if no clinical improvement or
the patient further deteriorates. Maximum of TWO doses
Legal status of drug POM
Description: Used in the emergency management of acute anaphylaxis/ anaphylactoid allergic reaction
Clinical conditions/situation under which the drug may be administered without a prescription AND the criteria for
confirming that the condition/situation exists.
Collapse, hypotension, angioedema (swelling of the lips, face, neck or tongue), dyspnoea (difficulty in
breathing, stridor, wheeze), tachycardia following exposure to an allergen such as drugs, food, insect bite,
substance or vaccine.
Clinical criteria that must exist for a patient to be eligible for the administration of the drug.
Patients under 16 years old who present with the clinical signs of an anaphylactic reaction as listed above.
Where appropriate, previous history and known sensitivities should be established.
If any of the following apply, the Patient Group Direction CANNOT be used and the patient MUST BE REFERRED
TO A DOCTOR.
THERE ARE NO EXCLUSION CRITERIA
Circumstances where special care is needed.
Personnel/facilities/supplies which must be immediately available.
Ambulance must be called (999)
Emergency Drug box (in hospital)
Anaphylaxis shock pack (in community)
Information/advice to be given to the patient, including possible adverse effects and what the patient should do if
If able, nursing staff should explain why the injection is being given to the patient. However, this may not be
practical in managing the anaphylactic situation.
Administration details to be recorded.
Drug, dose, route, time and site of administration
Patient’s attendance number/ registration number (where applicable)
Name of nurse providing treatment.
If known, also record what precipitated the anaphylaxis
Direction Ratified by: -
Name and Signature Signature Date
Senior doctor Dr John Dow Original document 13.04.05
Senior Practitioner: Tony Kinsey, Resuscitation Original document 13.04.05
Senior Pharmacist (s) Sue Lunec, Pharmaceutical Original document 13.04.05
Adviser, R&BPCT signed
Authorised on behalf of Dr Caron Grainger, Director Original document 13.04.05
Redditch and of Public Health, R&BPCT signed
For use in the Clinical All clinical and community
Area(s) listed opposite. areas