How to use an EpiPen on a toddler

If your toddler has a diagnosed food, insect, medication, or environmental allergy that could cause anaphylaxis, your allergist has given you epinephrine auto-injectors (EpiPen Jr, Auvi-Q, or Adrenaclick). The auto-injector is the single most important medication in pediatric emergency care. Used quickly, it almost always works. Used hesitantly or skipped, it accounts for most allergy-related deaths.

The catch: most parents never practice with the device. Many freeze when the moment comes. This article fixes both.

What anaphylaxis looks like

Anaphylaxis is a multi-system allergic reaction that can kill within minutes. It's NOT the same as a single mild reaction (just hives, or just a runny nose). It's defined by symptoms in two or more body systems, or one severe symptom.

Symptoms by system:

• Skin: hives, flushing, swelling of lips/face/eyes, severe itching.
• Breathing: wheezing, coughing, tight throat feeling, hoarse voice, trouble breathing, tongue swelling.
• Stomach: vomiting, severe stomach pain, diarrhea.
• Heart/circulation: dizziness, fainting, low blood pressure, pale or bluish skin, weak pulse.
• Other: sense of impending doom (a real symptom), confusion, lethargy, "I don't feel right."

USE THE EPIPEN if you see ANY of these combinations:

• Hives PLUS any breathing symptom.
• Hives PLUS vomiting.
• Swelling of lips or face PLUS any other symptom.
• Any wheeze or trouble breathing after exposure to a known allergen.
• Sudden severe pale, limp, or unresponsive after exposure to a known allergen.
• Throat tightness, change in voice, or trouble swallowing.
• Two or more body systems involved.

When in doubt: use it. Epinephrine is safer than a wait-and-see approach. The risk of using it unnecessarily is small. The risk of waiting too long is death.

How to use an EpiPen (step-by-step)

The standard EpiPen Jr (for kids 33 to 66 lbs) and EpiPen (66+ lbs) use the same technique. The EpiPen Jr is for younger/smaller toddlers; the adult EpiPen is for older kids.

1. Lay or sit your child down. Lay them flat on their back with legs raised. Exception: if they're vomiting, lay them on their side to prevent choking. Don't stand them up; standing can cause blood pressure to drop suddenly.
2. Remove the EpiPen from its tube. Don't remove the blue safety cap yet.
3. Hold the EpiPen with your fist around the middle. Blue end up. Orange end down. Form a fist so the orange tip points at the thigh.
4. Remove the blue safety release cap. Pull it straight off.
5. Place the orange tip against the OUTER thigh. Middle of the thigh, on the side. Through clothing is fine (don't waste time removing pants). Avoid the inner thigh (could hit a vein) and the buttocks (too much fat).
6. Push firmly until you hear a click. The needle is now injecting.
7. Hold for 3 seconds. Count out loud: one Mississippi, two Mississippi, three Mississippi.
8. Pull the EpiPen out. Massage the injection site for 10 seconds (helps absorption).
9. Call 911. Speakerphone. Tell them anaphylaxis and epinephrine has been given.
10. Note the time. EMS needs to know when the dose was given.

Memorization aid: "Blue to the sky, orange to the thigh." That's the orientation. Blue cap up away from the body, orange tip toward the leg.

Auvi-Q has a voice prompt

If you have Auvi-Q (the small rectangular device, not the pen-shape), it talks you through the steps. Listen to the prompts:

1. Pull the device out of the case. Voice prompt begins.
2. Pull off the red safety guard.
3. Place the black end against the outer thigh.
4. Press firmly and hold for 2 seconds.
5. Remove and call 911.

After the injection

The injection takes effect within 1 to 3 minutes. You'll see:

• Breathing easing up.
• Hives starting to fade (slowly).
• Color returning if they were pale.
• Energy returning.

Your child may also feel:

• Racing heart (normal effect of epinephrine).
• Shakiness.
• Pale or flushed face.
• Anxiety or restless feeling.
• Headache.

These side effects are normal and not dangerous. The medication is working.

WHILE WAITING FOR 911:

• Keep your child lying flat with legs raised (or on side if vomiting).
• Don't let them stand up. Even if they seem better.
• Stay calm and speak to them.
• Don't give them anything to eat or drink.
• If they had vomited the allergen, do NOT try to make them vomit more.
• If breathing stops, start CPR. See infant CPR for under 1, or use the adult/child CPR sequence for older toddlers.

When to use a second dose

About 20 to 30% of anaphylactic reactions need a second epinephrine dose. Reasons:

• Symptoms not improving after 5 minutes.
• Symptoms initially improving then getting worse again.
• New symptoms appearing.
• Breathing trouble persisting or worsening.

Wait 5 to 15 minutes after the first dose. If you're still seeing trouble, use the second auto-injector (this is why prescriptions are usually for TWO injectors). Same technique, other thigh.

If still no improvement, EMS should be very close. Continue CPR if needed.

Always go to the ER

Even if your child seems completely better after the EpiPen, you MUST go to the ER. Reasons:

• Biphasic reactions: symptoms can return 4 to 8 hours later. The ER monitors for this.
• Additional treatment (steroids, antihistamines, IV fluids) is sometimes needed.
• Observation for at least 4 to 6 hours is standard.
• If symptoms recur, you're already in a hospital.

Don't skip the ER because the EpiPen "worked." The EpiPen bought time. The ER finishes the job.

EpiPen storage and care

• Room temperature. Don't refrigerate. Don't freeze. Don't leave in a hot car.
• Check the expiration date monthly. Replace when expired (insurance covers replacement).
• Inspect through the window for cloudy or discolored liquid. Should be clear.
• Keep two doses at all times: one at home, one with the child (school bag, daycare, with sitter).
• Add a third for travel.
• Practice with a trainer device (every auto-injector comes with a needle-free trainer). Use it monthly so your hands know what to do.

Teach everyone

Anyone who watches your toddler should know how to use an EpiPen. That includes:

• Partner / co-parent.
• Grandparents.
• Daycare provider (file a written action plan with them).
• Nanny / regular babysitter.
• Older siblings (age-appropriate; school-age and up).
• Frequent visiting family.

Show them the trainer device. Walk through the steps. Don't assume they remember from a YouTube video; muscle memory takes practice.

Things people get wrong

• Waiting to "see if it gets worse." By the time it's clearly bad, you've lost critical minutes.
• Trying antihistamines (Benadryl) first. Antihistamines treat symptoms but DON'T stop anaphylaxis. They have a place after the EpiPen, not before.
• Asthma inhaler instead of EpiPen. An asthma inhaler doesn't treat the systemic reaction. Use the EpiPen.
• Standing the child up. Can cause sudden blood pressure drop. Keep them lying down.
• Not calling 911 because "they seem fine now." Biphasic reactions can kill 4 to 8 hours later. Always 911.
• Removing pants before injection. Wastes time. EpiPen works through clothing.
• Holding the device incorrectly. Some parents hit themselves with the needle when checking which end is which. The orange tip is the needle end. The blue cap is the safety. Practice with the trainer.

The "preventive" question

Some parents ask whether to give epinephrine "just in case" if their kid accidentally ate the allergen but isn't reacting yet. The answer from most pediatric allergists is no; the medication has side effects and shouldn't be used without symptoms. But if you see ANY symptoms (even mild ones) plus a known accidental ingestion, use it.

The general principle: when in doubt, use it. Erring on the side of injecting is safer than erring on the side of waiting.

A complete written action plan

Your allergist should provide a written Anaphylaxis Action Plan with these sections:

• Your child's name, photo, age, weight.
• Specific allergies.
• List of mild symptoms (give antihistamine, observe).
• List of severe symptoms (give EpiPen, call 911).
• Medication doses and brand names.
• Emergency contacts.
• Pediatrician and allergist contact info.

File copies with daycare, school, sitters, and grandparents. Update annually.