Indian Academy of Pediatrics (IAP)

STANDARD
TREATMENT
GUIDELINES 2022

Anaphylaxis
Under the Auspices of the
IAP Action Plan 2022
Remesh Kumar R
IAP President 2022
Upendra Kinjawadekar Lead Author
IAP President-Elect 2022 Neeraj Gupta
Piyush Gupta Co-authors
IAP President 2021
Akash Bang, Nihar Ranjan Mishra
Vineet Saxena
IAP HSG 2022–2023
© Indian Academy of Pediatrics

IAP Standard Treatment Guidelines Committee

Chairperson
Remesh Kumar R
IAP Coordinator
Vineet Saxena
National Coordinators
SS Kamath, Vinod H Ratageri
Member Secretaries
Krishna Mohan R, Vishnu Mohan PT
Members
Santanu Deb, Surender Singh Bisht, Prashant Kariya,
Narmada Ashok, Pawan Kalyan
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Anaphylaxis
Definition

An acute clinical syndrome characterized by severe, life threatening, generalized type 1 hyper­
sensitivity reaction, usually caused by exposure to a foreign substance leading to mast cell
degranulation and release of chemical mediators.

Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled:

1. 
Acute onseta of an illness 2. 
Two or more of the Acutely after
3. 
with involvement of the following that occur exposure to
skin, mucosal tissue, or acutelya after exposure to known allergen
bothb AND AT LEAST ONE a likely allergen for that for that patient,
OF THE FOLLOWING: patient: a. Involvement of reduced BP-

Diagnostic Criteria
a. Respiratory compromisec the skin-mucosal tissueb defined as low
b. Circulatory compromised b. Respiratory compromise c
SBP for agef or >
c. Circulatory compromise d
30% decrease in
d. Persistent gastrointestinal SBP
(GI) symptomse

a
Acute onset: Onset within minutes to hours
b
Involvement of the skin, mucosal tissue: Includes generalized hives or urticaria, pruritus, flushing,
swollen lips-tongue-uvula
c
Respiratory compromise: Includes dyspnea, wheeze-bronchospasm, low PEFR, stridor, hypoxemia
d
Circulatory compromise: Includes low BP or associated symptoms of end-organ dysfunction like
hypotonia, collapse, syncope, incontinence
e
GI symptoms: Crampy abdominal pain, vomiting
Low systolic blood pressure (SBP) for children is defined as: < 60 mm Hg from birth to 1 month, < 70 mm Hg
f

from 1 month to 1 year, < (70 mm Hg + [2 × age]) from 1 to 10 years, < 90 mm Hg for 11 years and above

Modified from National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network
(NIAID/FAAN) criteria for diagnosis of anaphylaxis in the emergency department (ED).
Precipitating Anaphylaxis

;; Enteral ingestion: Drugs (Antibiotics, NSAIDs, Aspirin), Food

;; Parenteral administration: Drugs (Antibiotics, Paralytic agents, Opioids, Propofol),
Factors

Insect bites and stings, Contrast media, Vaccines, Blood products

;; Physical contact: Latex
;; Others: Exercise in cases of FDEIA (Food-dependent exercise-induced anaphylaxis)

Lab Parameters
Anaphylaxis is a clinical diagnosis and no lab parameters are required for diagnosis. However,
serial measurements of serum tryptase done at the acute stage and later can help to rule
out systemic mastocytosis or pseudo anaphylaxis.

Features Anaphylaxis Vaso Vagal Attack

Differential Diagnosis

Onset In Minutes In Seconds

Common Triggers Medications, Insect Bite, Pregnancy, Dehydration, Extreme
Exercise, Milk, Shellfish Pain/Fear/Stress/Heart Block
Skin Red, Hot and Wheals with Pale and Cold
Itchy Rashes
Respiratory System Adventitious Sounds Like Normal
Wheeze/Stridor
Cardiovascular Tachycardia with Bradycardia with Hypotension
System Hypotension
GI System Nausea/Vomiting Non-Specific
Prone Position No Improvement Good Response
Treatment IM Adrenaline Inj Treat the Cause

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 Anaphylaxis

Management Algorithm

Clinical Suspect 5 to 10 min

Patient satisfying any of the 3 criterias (as mentioned If No Improvement give 2nd Dose of IM
above) in presence of a known trigger or precipitating Epinephrine
factor ;; IV/IO Assess to be Established (If not
done earlier
;; Prepare for Difficult Intubation

Initial Management (First 1 min) For Respiratory Distress

;; 2nd nebulized epinephrine @
;; Keep Supine Position (Sitting Position If 0.5 mL/kg for Stridor; 2nd nebulized
respiratory distress/nausea/vomiting) salbutamol @ 0.15 mg/kg for Wheeze
;; Assess Airway, Breathing, Circulation, heart rate,
Hypotension/Poor Perfusion/Loss of
BP & SpO2
Consciousness
;; Provide O2 @ 10-15 L/min by NRBM (If respiratory
;; 2nd Bolus of NS @ 20ml/kg by IV/IO
distress/shock)
Rapid Push Technique
;; Identify and Remove the Allergic Trigger if
;; Prepare for IV Epinephrine
possible (e.g., insect sting)
;; Administer 1st Dose of IM Epinephrine @ Alert Pediatric ICU/ Tertiary Care Centre
0.01mg/kg/dose (1mg/ml of 1:1000 dilution) at
anterolateral aspect of thigh
;; Can be repeated at 5 to 10 mins interval as needed 10 to 20 min
If no Improvement give 3rd Dose of IM
Epinephrine
1 to 5 min
For Respiratory Distress
Respiratory Distress ;; 3rd nebulized epinephrine @ 0.5 mL/kg
;; Sitting Position for Stridor; 3rd nebulized salbutamol @
;; Provide High Flow O2 by HFNC and plan for 0.15 mg/kg for Wheeze
intubation ;; Proceed for Intubation
;; If Stridor, 1st nebulized epinephrine @ 0.5 mL/kg
Hypotension/Poor Perfusion/Loss of
;; If Wheeze, 1st nebulized salbutamol @ 0.15 mg/kg
Consciousness
Hypotension/Poor Perfusion/Loss of Consciousness ;; Start giving IV Epinephrine @ 0.05 mcg/
;; Supine Position kg/min with titrate by 0.02 mcg/kg/min
;; IV/IO Assess to be established up to effect
;; 1st Bolus of NS @ 20 mL/kg by IV/IO Rapid Push
Transfer to Pediatric ICU/ Tertiary Care
Technique
Centre

If still no Improvement Suspect Refractory Anaphylaxis

;; Start IV Norepinephrine Infusion (persistent hypotension) @ 0.05 mcg/kg/min with titrate by
0.02mcg/kg/min up to effect (Max: 2 mcg/kg/min)
;; IV Glucagon Bolus (persistent anaphylaxis/patients on beta blockers) @ 20 – 30 mcg/kg/dose
(Max: 1 mg) over 5 mins followed by 5 to15 mcg/min titrated till achievement of clinical effects
Manage as per Pediatric ICU protocols
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Monitoring & Follow Up Anaphylaxis

;; Delayed Anaphylaxis may be due to biphasic reaction (1 to 20% cases) which generally occurs
within 1 to 72 hours (mostly within 10 hours) after initial improvement or protracted variety
which is the severe persistent anaphylactic symptoms for 24 to 36 hours despite aggressive
treatment.
;; Monitoring of vitals (BP, SpO2) along with Respiratory Symptoms (stridor or wheeze) should
be done over minutes during first 30 mins and then hourly for next 24 hour and then 2 hourly
for next 48 hour.
;; Follow up of patients should be done for at least 4 hours after last IM Epinephrine injection
and in severe hospitalized cases for minimum 3 days.

Indication of Hospitalization
;; Tachycardia, Hypotension (SBP in mm Hg: < 70 + Age in Years × 2)
;; Stridor, Wheeze, Tachypnoea (1 to 5 Year - ≥ 40 / min; > 5 Year - ≥ 30 / min; >10 Year - ≥ 20 /min)
;; SpO2 < 95% in Room Air
;; History of Severe Protracted Anaphylaxis
;; Comorbidities (asthma, arrhythmia, systemic mastocytosis)
;; Live in remote area or present late in the evening
Home Action Plan

;; Hives with Itching is the earliest (most common) sign though it may not happen in few
cases
;; EpiPen (Green colour - 0.15mg / inject; Yellow colour - 0.3mg / inject) is ideal but due its
limited resources in India, home prepared IM Epinephrine Inj (0.01mg / kg of 1:1000
dilution) in 1ml Syringe over anterolateral aspect of thigh may be a practical option.
;; It can be kept for 3 months at room temperature with protection from light. (expiry date
should be written for future reference)
;; Call Your State Emergency Number (National Emergency No – 112)

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Key Learning Points Anaphylaxis

;; Anaphylaxis is a sudden, severe, life-threatening allergic reaction to an allergen with multi

system involvement.
;; Early identification and management are the corner stone in good outcome.
;; IM Epinephrine is the Drug of Choice.
;; Follow up of patients for minimum of 3 days due to biphasic nature of anaphylaxis.
;; Education of Parents about its early recognition and appropriate management is the need
of hour.

1. Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, et al. Second
symposium on the definition and management of anaphylaxis: summary report--Second National
Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J

References
Allergy Clin Immunol. 2006;117(2):391-7.
2. Campbell RL, Hagan JB, Manivannan V, Decker WW, Kanthala AR, Bellolio MF, et al. Evaluation of
national institute of allergy and infectious diseases/food allergy and anaphylaxis network criteria
for the diagnosis of anaphylaxis in emergency department patients. J Allergy Clin Immunol.
2012;129(3):748-52.
3. Anagnostou K. Anaphylaxis in Children: Epidemiology, Risk Factors and Management. Curr Pediatr
Rev. 2018;14(3):180-6.
4. Poowuttikul P, Seth D. Anaphylaxis in Children and Adolescents. Pediatr Clin North Am. 2019;66(5):
995-1105.