This is a 9 month old female (fraternal twin) sent to me by her Pediatrician for evaluation of possible milk and/or soy reaction to various formulas (Similac and Alimentum) which resulted in significant erythematous rash with pruritus. Rast testing revealed a reaction to soy only; patient was eventually begun on Neocate formula with good results. Patient also experienced other food reactions to strawberries and blueberries with reported history of facial swelling at the daycare.

Parents are asking for an EpiPen at the daycare facility; as her current weight is 9.09 kg, the EpiPen Jr would be far too large a dose for her. There are no nurses at the daycare facility to teach giving the appropriate dose of Adrenaline and I am concerned that there are no medical personnel to evaluate this child.

How do I handle this situation regarding Emergency Evaluation and Treatment at this daycare?

Thank you for your time and expertise in dealing with this issue.


Thank you for your inquiry.

There is no “right or wrong” answer to this question, and I can only give you my opinion as to what I would do in this situation, and explain the justification for this strategy.

In a small child, epinephrine is, in the vast majority of instances, a benign drug as far as any serious side effect is concerned. Therefore I would not be overly concerned that using a dose higher than 0.01 mg per kg would produce a serious adverse event. In addition, if one weighs the potential side effects of administration of the “larger” dose versus the potential effect of an untreated anaphylactic event, I believe that the decision favors an act of commission rather than omission.

In addition, in actuality, we really do not know what the proper dose of epinephrine is in any situation. I have not been able to find, with an intensive search of the literature and discussion with peers, where the suggested dose of 0.01 mg per kg arose. To my knowledge, there are no outcome studies and no dose response studies in children of this age. Thus, the suggested dose is, to the best of my knowledge, somewhat arbitrary. Therefore, I do not feel compelled to be restricted to that dose in situations such as the one you described. To further that point, dosage regimens in adults have ranged from as high as 1 mg to as low as 0.3 mg. The standard dose was 0.5 mg until the introduction of the EpiPen. The fact that it exists in a 0.3 mg dose evidently affected the suggested dosing regimen.

Also, as you probably know via Dr. Simons et al’ studies on the accuracy of dosing when epinephrine is drawn into a syringe from a vial, I would be more worried about errors that might occur in trying to administer the dose of 0.01 mg per kg than I would of giving the 0.15 mg dose to your child.

In summary, for all of the reasons noted above, I would furnish your child with a 0.15 mg dose of an automatic epinephrine injector. I will, however, give you the caveat that I am not sure all allergists would agree with this point. Therefore, as mentioned, I can only give it to you as an opinion since there is no consensus to my knowledge regarding this issue.

Thank you again for your inquiry and we hope this response is helpful to you.

Phil Lieberman, M.D.

We received the following letter from a reader of our website and are therefore posting it for an additional reference.

Thank you again.

Phil Lieberman, M.D.

Inquiry containing additional information:
I read your recent Q/A regarding epinephrine dosing in a child under 15kg with great interest. I had recently come across a similar question, and found a resource that was helpful to me. I wanted to share in case it may be helpful to others:

Pediatrics March 2017, VOLUME 139 / ISSUE 3; this policy is a revision of the policy in 119(3):638. From the American Academy of Pediatrics
Clinical Report
Epinephrine for First-aid Management of Anaphylaxis
Scott H. Sicherer, F. Estelle R. Simons, SECTION ON ALLERGY AND IMMUNOLOGY

Thank you.

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