Unmet Needs and Challenges in Allergy Management - Episode 3
Recognizing, Managing Anaphylaxis in Infants
In this segment, experts emphasize the importance of giving an infant experiencing anaphylaxis epinephrine at whatever dose may be available rather than delaying treatment.
Part 3 of the special report turns to an increasingly important and nuanced topic: identifying and managing anaphylaxis in infants. As early food introduction becomes standard practice, clinicians are encountering allergic reactions at younger ages, making infant-specific guidance more clinically relevant than ever.
Jay Lieberman, MD, opened the discussion by noting that while most reactions seen during early food introduction are mild and not anaphylaxis, the overall number of reactions has increased. This naturally raises the likelihood of encountering true anaphylaxis in infants. Unlike older children or adults, infants cannot verbalize classic symptoms such as throat tightness or oral itching, which complicates recognition and increases reliance on observable signs and caregiver intuition.
Both Lieberman and David Golden, MD, emphasized that infant anaphylaxis often presents through behavioral and nonspecific symptoms. These can include unusual or inconsolable fussiness, lethargy, persistent crying, tongue thrusting, ear pulling, and changes in appearance that parents frequently recognize before clinicians do. Although the current practice parameters still recommend using standard anaphylaxis criteria, the 2024 update acknowledges that it is reasonable to incorporate these infant-specific behavioral cues when assessing reactions in this age group.
From a management standpoint, the experts stressed that treatment principles in infants are fundamentally the same as in older patients. Epinephrine remains first-line therapy, and hesitation around dosing should not delay treatment. Golden highlighted that although autoinjectors are labeled for children above certain weight thresholds, the guidelines clearly support using whatever epinephrine dose is available, even in very small infants, because treating anaphylaxis takes precedence over concerns about relative dosing.
Lieberman reinforced this point succinctly: if a 0.1 mg device is available, use it; if only a 0.15 mg device is on hand, use that instead. Fear of “overdosing” should never prevent timely epinephrine administration in an infant with a concerning reaction.
The panel also noted emerging efforts to align updated infant recognition criteria, newer epinephrine delivery options, and post-epinephrine observation guidance into revised anaphylaxis action plans. The discussion concluded with a broader reminder that education is central to infant anaphylaxis care. Prescribing epinephrine alone is insufficient; clinicians must also teach caregivers how to recognize visual and auditory signs of systemic allergic reactions and when—and how—to act.
Experts include:
Brian Schroer, MD, of Cleveland Clinic Children’s Hospital
Jay Lieberman, MD, of the University of Tennessee Health Science Center
David Golden, MD, of Johns Hopkins University
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.
References
