Jay Lieberman, MD, from University of Tennessee

Jay Lieberman, MD

Two newly published reviews outline barriers to timely epinephrine use in 

among infants and toddlers and support incorporating age-specific signs into recognition criteria.

Current National Institutes of Health anaphylaxis criteria have not been updated to include infant-specific presentations for frontline clinicians, even as newer international definitions already incorporate them.

"Children, specifically infants and toddlers, can have different reactions or can look different during severe allergic reactions," said Jay Lieberman, MD, professor at the University of Tennessee Health Science Center and program director of the Allergy/Immunology Fellowship Program at Le Bonheur Children's Hospital, in an interview with 

Age-Specific Criteria Improve Anaphylaxis Detection in Infants

Recognizing Atypical Anaphylaxis Signs in Infants and Toddlers

Infants and toddlers cannot verbalize early symptoms such as oral or throat itching the way older children and adults can, which often delays recognition, Lieberman said. Because of this, clinicians and caregivers need to watch for nonverbal cues signaling a systemic allergic reaction. These cues include increased fussiness, inconsolable crying, clinging to a caregiver, placing a finger in the mouth to indicate oral or throat itching, and tugging at an ear to indicate itching inside the ear canal, according to Lieberman.

The plain language review by Pistiner et al, published in Expert Review of Clinical Immunology, identifies additional age-specific signs worth incorporating into recognition criteria, including drooling, back arching, belly breathing, and tongue-thrusting or licking behaviors.¹ Gastrointestinal symptoms such as vomiting are also commonly overlooked in this age group, as clinicians and caregivers may attribute them to a minor illness rather than an allergic reaction, Lieberman said.

Impact of Age-Specific Criteria on Anaphylaxis Detection

Why is anaphylaxis harder to recognize in infants and toddlers?

Infants and toddlers cannot verbalize symptoms and instead show nonverbal behavioral cues such as fussiness, ear tugging, and finger-in-mouth behavior.

How much do age-specific criteria improve anaphylaxis detection?


A plain language review found modified criteria improved detection by 23% in infants and 10% in toddlers compared with standard criteria.

What is the biggest barrier to epinephrine use in young children?


According to Leeds et al, gaps in caregiver recognition and confidence, not epinephrine access alone, are key drivers of underuse.²

The review by Leeds et al. found modified age-specific anaphylaxis criteria improved detection by 23% in infants and 10% in toddlers compared with standard criteria.2 In practice, Lieberman said allergists and emergency physicians often rely on clinical judgment rather than a strict checklist when deciding to give epinephrine. Awareness of these additional presenting signs makes clinicians more likely to identify a reaction as anaphylaxis and to use epinephrine sooner, he said.

Leeds and colleagues analyzed more than a decade of literature to identify barriers behind delayed or missed epinephrine use in this age group.² Investigators point to gaps in caregiver recognition and confidence, rather than epinephrine access alone, as key drivers of delayed or missed treatment among infants and toddlers.

“If you're doing a food challenge or you have a patient with a food allergic reaction in the community, if it's an older kid or an adult, they can usually tell you, ‘Oh, I'm starting to have some itching in my mouth, or my throat feels a little funny,’ whereas an infant or toddler may not be able to tell you that,” Lieberman said, “and so, they're doing other things or behaving differently as that first sign.”

Pistiner et al. Recognizing and Treating Serious Allergic Reactions (Anaphylaxis) in Infants and Toddlers: A Plain Language Review of Four Studies. 

Leeds et al. Epinephrine Underuse for Anaphylaxis in Infants and Toddlers: A Practical Review for Pediatricians. 

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New reviews outline barriers to epinephrine use and support age-specific anaphylaxis recognition criteria in infants and toddlers, says Jay Lieberman, MD.

What is the Role of Immunology in Atopic Dermatitis Care? With Jay Lieberman, MD

Jay A. Lieberman, MD, a professor at the University of Tennessee Health Science Center, highlighted the increasingly collaborative nature of atopic dermatitis care during a discussion at the 

2026 Revolutionizing Atopic Dermatitis (RAD) Conference

, with the ways in which advances in immunology and systemic therapies are reshaping the relationship between dermatology and allergy/immunology being notable takeaways.

In discussion with the editorial team at 

, Lieberman described the historic divide between the 2 specialties as having narrowed considerably as the understanding of atopic dermatitis has shifted over time. With the emergence of biologics and targeted systemic medications for patients, both dermatologists and allergists are now approaching the disease through an immunologic lens. Lieberman explained while dermatologists have traditionally focused on cutaneous manifestations, the increasing emphasis on immune pathways and systemic disease has brought the specialties closer together.

“I think as we get these newer therapies and these systemic agents, and we learn about all these immunologic aspects of atopic dermatitis, dermatologists are at the forefront of this now,” Lieberman said. “And I think that difference in allergy and dermatology is really decreasing over time.”

A key theme of Lieberman’s discussion was the importance of considering the broader spectrum of comorbidities known to commonaly accompany atopic dermatitis. He encouraged clinicians to think beyond the skin and evaluate patients for conditions linked to the disease impacting treatment decisions. As more drugs demonstrate efficacy across multiple atopic and inflammatory diseases, Lieberman stated, understanding a patient’s complete disease burden has become increasingly necessary.

In his interview, Lieberman also reflected on how dramatically the therapeutic landscape has shifted over the course of his career. When he began training, treatment options for moderate-to-severe atopic dermatitis were described as limited, with few systemic treatments being accessible. Today, clinicians have access to a growing number of targeted agents designed to address the underlying immunologic mechanisms of disease, fundamentally changing how atopic dermatitis is managed.

From an allergy and immunology perspective, Lieberman described immune system biology as having long been central to specialty training and clinical practice. However, Lieberman highlighted the evolution of modern dermatology in a similarly manner, with today's dermatologists increasingly functioning as “immunodermatologists” as they incorporate complex immunologic concepts into patient care. In other words, Lieberman sees fewer differences between the specialties than in the past.

Disclosures: Lieberman has previously been associated with Novartis Pharmaceuticals, ABBVIE, Genentech, Aquestive Therapeutics.

Lieberman J, Hawkes J. Connecting AD to Other Dermatologic Disorders and Related Comorbidities. Session presented at: 2026 Revolutionizing Atopic Dermatitis Conference; June 17-19, 2026; Nashville, TN.

Lieberman J. How Should Clinicians Address the Link Between Atopic Dermatitis and Allergy? HCPLive. June 18, 2026. 

https://www.hcplive.com/view/how-clinicians-address-link-between-atopic-dermatitis-allergy-

At RAD2026, Lieberman notes advances in immunology and systemic therapies that are reshaping the link between dermatology and allergy/immunology.


How Should Clinicians Address the Link Between Atopic Dermatitis and Allergy? With Jay Lieberman, MD

Jay A. Lieberman, MD, professor at the University of Tennessee Health Science Center, noted the value of viewing atopic dermatitis within the broader context of allergic disease during his presentation, ‘Connecting AD to Other Dermatologic Disorders and Related Comorbidities,’ at the 

team, Lieberman emphasized that while dermatologists and allergists share the same goal of improving patient outcomes and quality of life, those working in allergy often look at atopic dermatitis through a wider lens. Instead of aiming only toward the skin manifestations of disease, Lieberman noted many of those with atopic dermatitis also report other atopic conditions, including asthma, allergic rhinitis, and food allergies.

As a result, treatment decisions are often guided by a patient's broader allergic disease profile and the opportunity to address multiple conditions simultaneously. A major theme of Lieberman’s discussion centered on the growing evidence supporting early intervention in atopic disease. He pointed to ongoing research evaluating whether aggressive management of eczema early in life, including the use of emollients and low-dose topical corticosteroids, may help restore skin barrier function and alter the trajectory of disease development.

Investigators are increasingly examining whether such strategies could reduce not only the long-term burden of atopic dermatitis but also the risk of developing additional allergic conditions. Lieberman also pointed to advances in food allergy prevention as another example of how early intervention is reshaping clinical practice. The growing amount of literature supporting early introduction of allergenic foods has demonstrated that proactive management can reduce food allergy risk, he noted, reinforcing the broader concept that early action may influence the progression of atopic disease.

The discussion additionally highlighted the rapidly evolving therapeutic landscape in atopic dermatitis. With an expanding number of biologics and systemic therapies now available, clinicians are faced with more opportunities to personalize treatment than ever before. Lieberman noted that evaluating a patient’s comorbid conditions has become increasingly important when selecting therapy, as certain treatments may provide benefits across multiple atopic diseases.

Overall, Lieberman underscored the need for a comprehensive, patient-centered approach to disease management. As understanding of the connections between eczema, food allergy, asthma, and other allergic conditions continues to grow, clinicians may be better positioned to intervene earlier and to tailor their treatment strategies more effectively.

Lieberman, spoke at RAD 2026 about highlights from his session, ‘Connecting AD to Other Dermatologic Disorders and Related Comorbidities.'

How Should Clinicians Address the Link Between Atopic Dermatitis and Allergy?

Expanding Epinephrine Options to Reduce Barriers, Improve Early Use

Part 4 of the special report explores one of the most rapidly evolving areas in 

 care: the expanding range of epinephrine delivery options and their potential to overcome long-standing barriers to timely treatment. Panelists reviewed both currently available products and emerging alternatives that may reshape how patients carry and use epinephrine.

The discussion began with a review of injectable options. In the United States, epinephrine autoinjectors are available in 0.1 mg, 0.15 mg, and 0.3 mg doses, while a 0.5 mg autoinjector is available in Europe but not yet in the US. Golden noted that this raises concerns about underdosing in larger adults and underscores the importance of promptly administering a second 0.3 mg dose if symptoms do not improve. Using weight-based dosing (0.01 mg/kg), a 0.3 mg dose is theoretically appropriate for a patient weighing approximately 30 kg (66 pounds), highlighting the need for repeat dosing in adolescents and adults with severe reactions.

Both experts emphasized that syringe-and-needle intramuscular epinephrine remains appropriate in healthcare settings, where dosing can be precisely tailored, even though autoinjectors achieve faster absorption in pharmacokinetic studies. However, many of the persistent gaps in anaphylaxis outcomes stem not from pharmacology but from human factors, including fear of needles, reluctance to carry devices, uncertainty about diagnosis, and hesitation to use epinephrine early.

The panel highlighted the significance of newly approved and emerging non-injectable options. Golden described the first FDA-approved intranasal epinephrine spray (neffy), which has been on the market for over a year.1 Because placebo-controlled anaphylaxis trials are not feasible, approval relied on pharmacokinetic data demonstrating plasma epinephrine levels comparable to existing intramuscular products.2 The nasal spray falls within the therapeutic range between manual intramuscular injection and autoinjectors, and early real-world experience has been encouraging.

The experts discussed additional products in development, including other nasal formulations and a sublingual oral film (Anaphylm) using a prodrug approach to overcome epinephrine’s absorption challenges.3 Lieberman noted that many patients strongly prefer oral medications, making a sublingual option particularly appealing if efficacy is maintained. Newer formulations may also offer practical benefits such as longer shelf life and greater temperature stability.

In closing, Golden and Lieberman returned to the core message of the entire series. Improving anaphylaxis outcomes requires earlier epinephrine use, fewer barriers to administration, and abandoning outdated reliance on antihistamines and corticosteroids in acute care. As Lieberman summarized succinctly: “Epinephrine, epinephrine. Let's stop using steroids for anaphylaxis, and let's use epinephrine early on and get rid of barriers to use.”

, a board certified allergist/immunologist from Cleveland Clinic Children’s Hospital.

, an associate professor from the College of Medicine - Memphis, department of pediatrics, and division of peds pulmonology at the University of Tennessee Health Science Center. He is also a practicing physician at LeBonheur Children’s Hospital, current chair of the food allergy committee for the American College of Allergy, Asthma, and Immunology, and is co-chair of the Joint Task Force for Practice Parameters.

, associate professor of medicine (part-time) at Johns Hopkins, co-chair of the Joint Task Force on Practice Parameters for allergy, and division chief for allergy-immunology at Sinai Hospital of Baltimore and Franklin Square Hospital in Baltimore.

Disclosures include Novartis Pharmaceuticals, Regeneron Pharmaceuticals, BioCryst, GlaxoSmithKline, Amgen, GENZYME Corporation, AstraZeneca Pharmaceuticals, and LEO Pharma for Schroer; Novartis Pharmaceuticals, ABBVIE, Genentech, Aquestive Therapeutics for Lieberman; and Phadia US and Genentech USA for Golden.

Greenhawt M, Schroer B, Kraft C, et al. One Year Later: How Intranasal Epinephrine Is Changing Emergency Allergy Treatment. HCPLive. Published on August 8, 2025. Accessed on February 10, 2026. 

https://join.hcplive.com/view/one-year-later-how-intranasal-epinephrine-is-changing-emergency-allergy-treatment

Smith T. FDA Approves Epinephrine Nasal Spray for Emergency Treatment of Allergic Reactions. HCPLive. Published on August 9, 2024. Accessed on February 10, 2026. 

https://www.hcplive.com/view/fda-approves-epinephrine-nasal-spray-for-emergency-treatment-of-allergic-reactions

Golden D. Anaphylm Remains Promising for Anaphylaxis Despite FDA CRL, With David Golden, MD. HCPLive. Published on February 3, 2026. Accessed on February 10, 2026. 

https://www.hcplive.com/view/anaphylm-remains-promising-anaphylaxis-despite-fda-crl-david-golden-md

Part 4 highlights how expanding epinephrine delivery options can reduce barriers, support earlier administration, and improve real-world anaphylaxis outcomes.

Jay Lieberman, MD

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