Dr. John James, a board-certified allergist, answers some common questions people have about food allergies, anaphylaxis, and epinephrine.

Question: My child has food allergies. How can I tell if they are having a severe allergic reaction (anaphylaxis)?

Dr: James: Anaphylaxis [anna-fih-LACK-sis] is a serious allergic reaction that happens fast and can be life-threatening. Signs and symptoms usually start within 5 to 30 minutes after exposure to the relevant food allergen (such as, but not limited to, peanut, tree nuts, egg, and cow’s milk). Some of the most common symptoms that should raise your suspicion are:

• Generalized hives and/or swelling of the face, throat, and body
• Repeated vomiting with or without diarrhea
• Trouble swallowing or talking (hoarseness, changes in voice), trouble breathing, shortness of breath, repeated coughing, wheezing
• Dizziness, fainting
• Feeling or sensation that something very bad is happening

Note that these symptoms can occur alone or several at the same time.

An Anaphylaxis Action Plan can help you identify symptoms.

Question: I’m afraid to give my child epinephrine. Will epinephrine hurt my child if I give it to them if they aren’t having an allergic reaction or I give it too soon?

Dr. James: This is an excellent and common question that parents often ask when they have an infant or child with food allergies. Epinephrine is used to treat severe allergic reactions, including those triggered by food allergies. It is the only medicine that can stop severe allergic reactions.

You give epinephrine by injection. It comes in devices that help you do the injection. The most common options are auto-injectors. These devices are pre-filled with the medicine, and upon pressing them against the outer thigh, they will inject the medicine for you. For two of the epinephrine auto-injector options available in the U.S., you never see the needle. The needle pulls back into the device instantly when you are done injecting.

If you need to use epinephrine, have your child lie down. Hold their leg firmly, but not roughly, just to help them hold still. Inject the medicine into the middle of the outer thigh.

If you are feeling nervous or afraid, be sure to practice before an emergency occurs. When or if an emergency does happen, keep yourself calm as you give the epinephrine so you can help your child feel as comfortable as possible.

An epinephrine auto-injector is always safe and appropriate to give to your infant or child if they are having a severe allergic reaction. This is the most effective, rapid, and life-saving treatment for these reactions. Even if you give epinephrine too soon or if you are not sure if they are having anaphylaxis, you should still give them this medicine because it will help stop an allergic reaction and it will not do any harm or cause any major side effects.

Epinephrine may cause some noticeable symptoms including shakiness, dizziness, increased heart rate, headache, anxiety, and sweating. These are not severe and typically go away quickly and on their own. The benefit of injecting epinephrine always outweighs potential risks. In summary, this medicine can be lifesaving. If you suspect your child is having anaphylaxis, give epinephrine immediately and as directed.

Question: If my child has an allergic reaction to a food, when should I give them epinephrine? Should I give BENADRYL® first?

Dr. James: If you suspect your child is having a serious allergic reaction after they eat their food allergen, your first step should always be to give epinephrine immediately. Then call 911. Only epinephrine can stop anaphylaxis. This is your child’s first line of defense when this type of reaction occurs.

Antihistamines like BENADRYL® and ZYRTEC® cannot stop anaphylaxis, so you should never use these medicines in place of epinephrine. Antihistamines are not appropriate for treating anaphylaxis and are not proper substitutes for epinephrine during a severe allergic reaction. Antihistamines do not reverse swelling of the airways or raise low blood pressure. They can help relieve some allergy symptoms but work slowly and do not adequately manage anaphylaxis symptoms. You certainly can give antihistamines after giving epinephrine to help in the overall management of allergy symptoms. There are no adverse interactions between these two medicines.

Question: Should I give my child epinephrine if they accidently ate their food allergen but aren't having symptoms of an allergic reaction?

Dr. James: This is an excellent question that should be decided on for your child between you and your doctor. Your child’s history of prior serious allergic reactions to foods, such as peanuts, tree nuts, eggs, and cow’s milk, is critical here. In some instances, it may be very helpful to treat with epinephrine even if anaphylaxis is not yet occurring, such as when anaphylaxis is likely to develop after an exposure or when it may be hard to tell by the observer (such as a school nurse, health aide, etc.).

A food allergy Anaphylaxis Action Plan has options that your doctor can choose to address these possibilities. There may be times when your doctor may recommend that you give epinephrine immediately after a definite food allergen ingestion before symptoms occur because severe reactions can occur suddenly without major warning signs.

For example, if your child has a history of a very severe anaphylaxis, such as respiratory distress, hypoxia (low oxygen in the blood), low blood pressure, or neurologic compromise after exposure to specific food allergens, your doctor may recommend that you give epinephrine immediately after your child accidentally eats their food allergen before symptoms develop because severe reactions can progress rapidly.

Other examples would include a child who has a history of repeated anaphylaxis with exposure to a specific food allergen or a child with a history of major reactions to very small amounts to a food allergen. All these issues need to be considered when writing an Anaphylaxis Action Plan for family, other caregivers, school personnel, and others.

Question: What is the best way to inject epinephrine? Do I inject it into the arm or thigh?

Dr. James: Below are instructions for using most epinephrine auto-injector devices. Instructions may vary depending on the brand.

1. Take the epinephrine auto-injector out of its package/carrier.
   
   
2. Remove the safety cap.
   
   
3. Hold the auto-injector in your fist. Do not hold your hand or thumb over the ends of the device. This could lead to an accidental needle stick.
   
   
4. Hold the leg of a young child firmly in place before and during the injection.
   
   
5. Push the end with the needle firmly against the outer side of your child's thigh, about halfway between the hip and knee. After you feel or hear a click from the auto-injector, hold it in place for 3 seconds.
   
   
6. You can give the injection through clothes or on bare skin.
   
   
7. A protective shield will cover the needle when it is pulled out of the thigh.
   
   
8. Call 911. The child treated with epinephrine should be taken to a hospital emergency room for further observation and treatment.
   
   
9. Give the used auto-injector to the EMS or hospital staff for disposal.
   
   

Question: Do I need to take my child to the emergency room after I give them epinephrine? Why? Is it because of the epinephrine or the allergic reaction?

Dr. James: Severe allergic reactions (anaphylaxis) should receive emergency medical treatment. This starts with using your epinephrine immediately and then getting medical care (e.g., call 911). It is generally recommended that if someone experiences anaphylaxis, they go to a hospital emergency room for observation and treatment for several hours. This is not because of the epinephrine, but because the allergic reaction requires further monitoring. Many people need more than one dose of epinephrine or other emergency treatments.

There can be delayed allergic reactions (a second wave of serious symptoms called a “biphasic reaction”) several hours after the first symptoms. These symptoms can be appropriately managed in an emergency room.

John M. James, MD, is a board-certified allergist. He is a medical specialist and spokesperson for the Asthma and Allergy Foundation of America. He is also President of Food Allergy Consulting and Education Services, LLC. He has worked as a medical specialist in the field of allergy, asthma, and immunology for over 30 years. Dr. James received his bachelor’s degree from the University of Arkansas and his Doctor of Medicine degree from the University of Tennessee. Dr. James completed his allergy and immunology fellowship at Johns Hopkins Hospital in Baltimore, Maryland, and he is board certified by the American Board of Allergy and Immunology.