Jay Lieberman, MD, from University of Tennessee

Jay Lieberman, MD

 recognition criteria have not been updated to reflect infant-specific presentations, even as newer international definitions already incorporate them.¹ A recent review found modified age-specific criteria improved detection by 23% in infants and 10% in toddlers compared with standard criteria.² The review also identified drooling, back arching, belly breathing, and tongue-thrusting as additional infant-specific presenting signs worth incorporating into recognition criteria.¹

A companion review found caregiver recognition and confidence gaps, not epinephrine access alone, drive delayed treatment, and 48% of caregivers in a surveyed cohort withheld epinephrine because they did not believe symptoms were severe enough.² Parents who watch a clinician administer epinephrine during a supervised reaction, such as a food challenge, report greater comfort giving it on their own afterward.² Caregivers with a written anaphylaxis action plan were also more likely to use epinephrine.²

In the following Q&A, 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, discusses recognizing anaphylaxis in young children and closing the epinephrine treatment gap.

Q&A: Anaphylaxis Recognition and Epinephrine Use, With Jay Lieberman, MD

What's the single biggest clinical takeaway from these papers for clinicians treating infants and toddlers?

Vomiting (often mistaken for minor illness)

 Infants and toddlers can have different reactions or can look different during severe allergic reactions. We have criteria for symptoms during a reaction that would meet the anaphylaxis definition and…[warrant] epinephrine, [but] infants and toddlers may behave differently, and clinicians need to be aware of [this]. When you see an infant or toddler having a reaction, look for different things to alert you that, wow, this is a multi-systemic allergic reaction or this [is] a more severe allergic reaction.

What behavior patterns signal a severe allergic reaction in nonverbal infants and toddlers?

 Infants can't speak to tell you [what's happening], so they behave differently. They may be more fussy, they may be crying, they may be inconsolable. They can shove a finger in their mouth as a sign they're having an itchy mouth or throat… [or tug] at an ear as a sign of itching inside the ear canal. These are all signs they’re having an allergic reaction.

Which signs and symptoms do clinicians most often overlook as allergic reaction indicators in this age group?

 In older kids, GI symptoms like vomiting. Often, [clinicians] may think the child just ate something bad. When I'm doing a challenge [in an infant and that] infant starts acting funny, my radar goes up, and I start looking a little more into it.

The review found that modified age-specific criteria improved anaphylaxis detection by 23% in infants and 10% in toddlers compared with the standard criteria. What does that mean in practice for an allergist evaluating a nonverbal patient?

 They can use whichever criteria they want. As an allergist in practice, often we're not doing the check boxes of “okay, they meet this, they meet this.” I'm going to go ahead and give them epinephrine. It's more of a clinical feel for a lot of us.

 Your review cites a survey in which 48% of caregivers didn't use epinephrine because they didn't believe symptoms were severe enough. How should clinicians reframe that threshold?

 This is an issue at all ages. Underuse of epinephrine has been shown in every study, whether it's infants, toddlers, or adults, and epinephrine was more often used the older the child is. Infants shouldn't be treated any differently. If we think they're having anaphylaxis, they should get epinephrine.

It's fascinating when a clinician goes through giving epinephrine with a parent during a reaction, such as during a food challenge in [the] clinic…parents feel more comfortable giving epinephrine on their own [afterward]. All these education pieces, showing parents it's not a big deal and it's not harmful, [may contribute to the increase in] epinephrine use.

What should epinephrine training look like for daycare staff, school nurses, and other community caregivers?

 Whatever training we can get helps, [whether] that's a physician or nurse practitioner going to a school district to talk with school nurses…videos that teach [parents and staff] about this…[or] parent volunteers [to] go into schools and give education on food allergy and epinephrine use.

What system-level or policy changes would have the biggest impact on closing this treatment gap?

 The best evidence we have, now incorporated into our allergy anaphylaxis practice parameters, [supports] stock epinephrine. [That] means a school, for example, can have epinephrine available without a prescription that any child can use, whether or not we knew they had a food allergy or a bee sting allergy. It’s the same idea as having defibrillators in stadiums that anyone can use if someone has a heart attack.

Is there anything else clinicians should know about anaphylaxis in young children?

 Newer [food allergy] guidelines suggest early introduction of allergenic foods, even something like peanut, which we used to say don’t feed kids and now say to feed as early as 6 months. Greater education and awareness will be very helpful.

Age-Specific Criteria Improve Anaphylaxis Detection in Infants

Stock Epinephrine Could Close Anaphylaxis Care Gap, With Jay Lieberman, MD

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

Leeds S, Anagnostou A, Pistiner M, et al. Epinephrine Underuse for Anaphylaxis in Infants and Toddlers: A Practical Review for Pediatricians. 

Articles

Infants and toddlers frequently manifest anaphylaxis with age-specific, nonverbal behaviors that are not fully captured by traditional recognition criteria. Incorporating modified pediatric criteria and infant-predominant signs—such as drooling, back arching, belly breathing, and tongue-thrusting—can meaningfully improve detection. Delayed epinephrine use is driven more by caregiver misperception of severity and lack of confidence than by access alone. Supervised epinephrine administration, written action plans, and structured community training improve readiness, while stock epinephrine policies can reduce system-level barriers.

Lieberman discusses atypical anaphylaxis signs in infants and toddlers and why epinephrine remains underused.

Reframing when caregivers reach for epinephrine and expanding stock epinephrine access could meaningfully reduce delayed treatment in infants and toddlers with 

, according to 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.

Underuse spans every age group, but infants and toddlers are treated less often than older children during confirmed reactions.

A recent review by Leeds and colleagues found 48% of caregivers withheld epinephrine because they did not believe symptoms were severe enough.²

"Infants shouldn't be treated any differently," Lieberman told 

 "If we think they're having anaphylaxis, they should get epinephrine."

Building Caregiver Confidence in Administering Epinephrine

Hands-on exposure appears to move the needle more than instruction alone, Lieberman said. Parents who watch a clinician administer epinephrine during a supervised food challenge report greater comfort using an autoinjector on their own later.

Education emphasizing that standard auto-injector doses are not harmful, paired with a written anaphylaxis action plan, was also associated with higher caregiver willingness to treat. However, Lieberman noted randomized evidence directly testing action plans remains limited.

Why do caregivers delay giving epinephrine?


Many underestimate symptom severities, and a review found 48% of caregivers withheld treatment for this reason.


Undesignated epinephrine kept on-site, at a school for example, that can be administered to any child during a suspected reaction regardless of a known allergy diagnosis.

Lieberman said community caregivers, including daycare staff, school nurses, and camp staff, represent a persistent education gap, with no single delivery method proven superior among clinician-led sessions, video training, and parent-volunteer programs. The intervention Lieberman flagged as highest yield is stock epinephrine, now reflected in allergy practice parameters, which allows a dose to be given to any child regardless of known allergy history.

“It's the same idea as having defibrillators in stadiums that anyone can use if someone has a heart attack,” Lieberman said.

Lieberman added that awareness should keep pace with early allergen introduction guidance, since earlier peanut and other allergenic food exposure may increase reaction frequency in the populations reviewed.

Reported disclosures for Lieberman include AQUESTIVE THERAPEUTICS, Genentech USA, kaleo, Bayer Healthcare, ABBVIE, BioCryst US Sales Co, and Amgen.

Gabryszewski S, Gupta R, and Hernandez-Trujillo V. Peanut Allergy Rates Plummet 10 Years After AAP Early Introduction Guidelines. HCPLive. Published October 30, 2025. Accessed August 13, 2026. 

https://www.hcplive.com/view/peanut-allergy-rates-plummet-10-years-aap-early-introduction-guidelines

Videos

In part 2, Lieberman discusses why caregivers hesitate to use epinephrine and what system-level changes could close the gap in infants and toddlers.

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 

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. 

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.
