FAACT's Roundtable

Ep. 258: Infant and Toddler Anaphylaxis

• Season 5 • Episode 258

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Anaphylaxis can happen to anyone, at any time — but when it comes to infants and toddlers, the signs, symptoms, and response can feel especially overwhelming. Do reactions look the same as in older children or adults? What about emergency steps and epinephrine dosing? To bring clarity and confidence to caregivers and the food allergy community, we’re joined today by renowned allergist, Dr. Michael Pistiner, who will help clear up common questions, confusion, and fears around managing anaphylaxis in our youngest patients. 

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Caroline: Welcome to FAACT's Roundtable, a podcast dedicated to navigating life with food allergies across the lifespan. Presented in a welcoming format with interviews and open discussions,

each episode will explore a specific topic, leaving you with the FAACTS to know or use.

Information presented via this podcast is educational and not intended to provide individual medical advice.

Please consult with your personal board certified allergist or healthcare providers for advice specific to your situation.

Hi everyone, I'm Caroline Moassessi and I am your host for the FAACT Roundtable podcast. I am a food allergy parent and advocate and the founder of the Grateful Foodie Blog.

And I am FAACT's Vice President of Community Relations.

Before we start today's podcast, we would like to say thank you to Kaleo for their kind sponsorship of FAACT's Roundtable podcast and for their support throughout the years.

Also, please note that today's guest was not sponsored by or paid by Kaleo to participate in this specific podcast.

Anaphylaxis can happen to anyone at any time, but when it comes to infant and toddlers, the signs, symptoms and response can feel especially overwhelming. Do reactions look the same as in older children or adults?

What about emergency steps in epinephrine dosing?

To bring clarity and confidence to caregivers and the food allergy community,

we're joined today by renowned allergist Dr. Michael Pistiner, who will help clear up common questions, confusion and fears around managing anaphylaxis in our youngest patients.

Welcome Dr. Pistiner to Facts Roundtable podcast. You are a favorite at our Food Allergy Summits and you are going to be a favorite today because you bring us information in such a simple, pragmatic way that we can all digest.

And so thank you so much for being here.

Dr. Pistiner: Thank you so much for having me.

Caroline: Well, you are very welcome.

So now for listeners who may be new to your work, can you share a bit about your background and then what led you into the food allergy community? Because you go above and beyond the clinic, you are a new level of doctor and advocate.

Dr. Pistiner: I'm a pediatric allergist and I have a deep interest in food allergy. And a lot of that is because while I was training as an allergy fellow, my son, who is now 22,

had his allergic reaction for the first time when he was a little older than three.

And once I started wearing the hat as dad of a child with food allergy, in addition to pediatric allergist, I got really engaged and involved in the food allergy community and really enjoyed working on food allergy advocacy and community education.

And now I Kind of don't know the difference between my hobby and my job.

Caroline: I think that's a good problem to have. Really. Isn't there some kind of saying that if you do the work you love, you don't work again? Isn't there something like that?

I'm probably saying it totally wrong.

Dr. Pistiner: It always feels great, it always feels fresh. And I kind of can't stop.

Caroline: Well, I vote for you not stopping to begin. Can you walk us through what an allergic reaction might look like in an infant or toddler?

What science should parents or caregivers be looking for? Because I know that's a lot different than an adult who can verbalize things.

Dr. Pistiner: Infants and toddlers are not great with their words. They don't yet understand or. And they can't talk. And so how can they tell us signs and symptoms that we're traditionally looking for that might need words like itching, like dizziness,

like confusion,

like shortness of breath? Those are called subjective symptoms. And so those are symptoms that while a bigger kid or a grownup could tell you what they're feeling, a baby or a toddler can't use their words.

So we're going to need to look for signs or symptoms that replace those subjective symptoms.

For example, if a kid's mouth is itchy,

instead of saying, my mouth is itchy, they might scratch their tongue, they might put objects in their mouth, they might lick objects,

they might lick their lips.

If their tummy hurts,

they might, when they're infants, they might draw their knees to their chest, they might arch their back, they might get irritable and cry.

If they are feeling scared or agitated,

then they may cry. A baby may, with mental status changes, get very limp, tired.

So looking for these more subtle signs and symptoms in a younger child that can't tell you what they're feeling is what we need to get used to when we're managing young children.

Caroline: This is really crucial information. I mean, these are things that I would not just naturally have thought of. So I really, really appreciate you sharing this with us.

So now let's talk about the actual emergency respons response. So if a parent or caregiver suspects that a reaction's happening, they've seen these signs and symptoms,

how does the approach differ or if it does differ for infants and toddlers? And how should parents and caregivers respond?

So let's say they've already been diagnosed, now what? And if they haven't been diagnosed,

now what? So you suspect the reaction, what happens next?

Dr. Pistiner: All right, so in the case of if I am the parent of a young child with a newly diagnosed food allergy.

Then I kind of have like a big responsibility.

And if I'm new to it, and so this is for all those out there who have an infant or a toddler who recently got a diagnosis.

Well, welcome to the club.

And that in this club we have many hats to wear. And so as the parent of a kid with a food allergy,

we're going to be coordinating and we're going to be working with other grownups who are going to be taking care of our kid when we're not. So it might be our partner, it might be their other parent, it might be a grandparent, it might be a cousin, it might be a babysitter.

But we're now going to have to get comfortable enough in managing an allergic reaction to train these other people who weren't necessarily there at the doctor's appointment and who weren't there to be trained directly from them.

So as parents of kids, infants, toddlers with food allergies, now we need to train the other people who are going to care for our kids.

Caroline: And so then with that training, I know a lot of us use action plans. Can you talk about that?

Dr. Pistiner: Yeah. So the action plan that currently I'm using when I'm training parents in my clinic and that I use for the parents of infants and toddlers and, and actually use to train everyone is the American Academy of Pediatrics, their allergy and anaphylaxis emergency care plan.

What I like about it is that it can be used universally.

So primary care pediatricians, the American Academy of Pediatrics, they support that plan.

And national association of School Nurses also supports that plan.

And so when I put one of these action plans together,

it's nice to know that it can be accepted not only by the pediatrician who's managing the family that I'm co managing. And by the way, I'm an allergist. And so we co manage.

And so I'm working with families and families are working with their primaries,

but then they also are going to need to work with school health. And so in the older kids, it becomes very important that their school health, school health services accept the action plan that I put together.

And that's kind of why I like to use the American Academy of Pediatrics to fill out from the specific patient that I take care of.

So this way the school nurses and the schools can then use it for their students.

Now I like using the same plan for infants and toddlers, but then I like to teach families that there's going to be some things they need to think about differently when they're looking for some of the signs and symptoms on this action plan.

And this is the very signs and symptoms that I was mentioning earlier. Some of the subjective ones that the infant or toddler can't tell you, but then also some other nuanced things that we might see in a younger kid.

Caroline: Thank you for that explanation. And now can we dive a little deeper into that action plan and what the American Academy of Pediatrics is saying?

Dr. Pistiner: Yeah. All right. So then on that plan.

So the plan has certain severe signs and symptoms that you would just go ahead and treat a child with epinephrine for. So epinephrine is the first line treatment for and a severe, potentially life threatening allergic reaction, anaphylaxis.

Epinephrine works everywhere we need it to,

it works quickly and it's safe.

And so epinephrine, and we'll talk more about that later.

But ultimately, epinephrine is what you're going to want to use for potentially severe symptoms. And so the American Academy of Pediatrics action plan highlights some of the severe signs and symptoms that if after potential exposure to the allergen,

if after a kid eats their food allergen, they have any of these potential severe signs and symptoms, then the next step is to treat with epinephrine. And so some of the severe signs and symptoms that the American Academy of Pediatrics action plan highlights are shortness of breath,

wheezing or coughing,

tight or hoarse throat,

trouble breathing or swallowing,

swelling of the lips or tongue that bothers breathing. Now, things then that you would want to think about and look for in a younger child are going to be possibly belly breathing, fast breathing, nasal flaring, tugging of the chest.

You might see hoarseness of the voice or hormone, horse cry in a younger baby.

And drooling is something that you could see. So these would be things that people should be thinking above and beyond just what's highlighted in the American Academy of Pediatrics action plan.

Another thing that they highlight in the action plan is when the skin is pale or blue,

if the kid has a weak pulse, if there's fainting or dizziness.

And babies can have skin modeling, they can have what's called cyanosis, which is blueness. You could see that around their lips. You could see it around their hands.

You can also,

instead of having low blood pressure, which some people doctors or a doctor's office can identify in older patients, in a baby, they could have a very fast heartbeat or a Toddler, they can have a fast heartbeat.

And then where a bigger kid can say that I'm busy, or we might see some obvious fainting in somebody. In a baby you could see floppiness, poor head control and like lethargy, being very, very sleepy and unable to wake up and unresponsive.

Where the action plan then also highlights having hives,

many hives of redness all over the body.

Then in babies you can see swelling around their eyes, around their lips, you could even see, but more rarely swelling in their extremities. But then in addition to the hives that, that you'd be able to see now,

not necessarily considered severe, is that scratching that somebody else might say they're itchy. A baby, you'd actually see them scratching or rubbing up against things.

And then the American Academy of Pediatrics plan also talks about vomiting or diarrhea if it's severe or combined with other symptoms. And in a baby this might be not just effortless spit up, but intense retching, vomiting that's more than once,

or recurrent with other symptoms or diarrhea that isn't just like a little squirts, but like a full out blowout and then like continuous.

Those are all things. And that can be caused by an allergic reaction, especially in the setting of the allergen being eaten and other signs and symptoms.

The action plan also talks about how bigger kids can have that feeling of pending doom or confusion or, or altered consciousness.

And so that's where you could see lethargy in the baby. Very difficult to wake up,

limp, floppy,

non interactive, not happy, go lucky. These are things that all of a sudden can change in the kid's behavior. Now some of the mild symptoms that are highlighted in the action plan are going to be sneezing, itchy mouth, itchy nose,

also a few hives, especially local in the area where the food was touched, or some mild stomach discomfort or nausea.

And in the case of a baby, they're not going to be able to tell you it's itchy. You're going to be looking for the places that they scratch it. You're going to be looking at them mouthing objects, licking objects.

You're going to see them as far as the skin stuff, you're going to see them rubbing or scratching. And as far as the belly stuff, as I mentioned earlier when we were talking, pulling up their knees to their chest because of some mild abdominal pain,

arching their backs. And then here we might see an increase in spitting up.

Caroline: This information is so critical, I can't tell you how much I appreciate it, but I really appreciate how you're taking the information from that action plan and then giving us more detail and giving us more description that we can visualize.

That is so helpful because as you're speaking, I'm thinking back to when my son, who's now 27,

who was 2, having his first reaction and how he was exhibiting so many of the things you just described. And I didn't realize what was going on. So this is just amazing and incredible.

And thank you just for listeners to know,

this is the same action plan that FACT uses. So I will have that link in the show notes so you can find it very easily.

So now let's turn our attention over to practical tips that you can share with our listeners today for preparing for the reaction. You talked about the action plan, which is very huge.

But how many epinephrine devices should they carry?

What's the best way to carry it? And then dealing with an infant or toddler, what's the best way to hold them, to give them the medication?

Dr. Pistiner: All right, so as I was mentioning before,

our role as parents of a kid with food allergy is also as trainer of others when we pass off responsibility of our infant or toddler. And then remember, you need a break, too.

So you're gonna have to sometimes relinquish control and let your kid hang out with someone else. And to get comfortable takes training. And so in the case of these of different epinephrine, at this point,

the only available epinephrine for infants and toddlers is intramuscular.

And there's multiple versions. Now, intranasal has been recently approved for older children.

And so intranasal is now approved for 15 kilos and up and age 4 and up.

And so right now, the infant toddler population is all under age 4. So right now the intramuscular devices are what's available.

Any intramuscular device that you have, any form of epinephrine that you have,

is going to work great as long as you're comfortable with it and you're trained.

And the same is going to be the case of any of the secondary caregivers who you're going to have taking care of your kid. So the first thing you're going to want to do is have a training device and be trained.

If you're not comfortable, you're not going to make someone else comfortable. So get comfortable.

Make sure that when your prescriber gives you the prescription and ultimately puts in the epinephrine device to your pharmacy, that you get trained and you get a trainer. And so this might be working with your primary care or your allergy team to make sure that they have available training and trainers.

And if not, then you can go on the Internet, find training videos for it. And also in some of the cases,

reaching out to the company and asking for trainers may be necessary.

Where most of the devices, when you get the prescription and you get your epinephrine,

in addition to actual epinephrine, the training device can come within the packaging.

Caroline: And again, listeners, I'll make sure I put links for you to find training videos. Fact has some information and I can put other information up there so you can quickly find it.

And so now how about holding the child? How do we do that?

Dr. Pistiner: Actually, it's seems a lot scarier, I think, than people anticipate. So first off, in the case of all of the auto injector devices, this is a short, skinny needle.

Prior to the availability of the RBQ, 0.1 milligram dose only existed the 0.15 milligram doses,

the needle length of those is about a half an inch.

Where the needle length of the bigger person dose, the 0.3, which would be appropriate for adults and bigger kids,

is about three quarters of an inch.

So we're talking about shorter than the width of a dime for the length of even like the 0.15 auto injector. And again, the 0.1 is even smaller.

You want the medicine, the epinephrine, to go into the muscle of the person who needs their epi.

It's called intramuscular because it goes into the muscle and the muscle of the thigh, the outer meaty part of the thigh, it's pretty vascular, it's got a lot of blood that's going and coming around it.

And that's the point. You put the medicine in there and it gets around the body quickly gets around the body of the infant or the toddler, right to where it needs to go.

So when you're giving epinephrine to the baby, and currently now the only form of epinephrine available for that in the younger ones is the intramuscular, you're going to want to hold them so you can put the device right where you want it to be, in that outer thigh.

And so we're not always with backup.

So if we're alone as a grown up and we have the baby and no one else who can hold the baby's hands and give them kisses, then what I like to teach the families that I take care of is to lay the child down on a firm surface so we're not talking like tabletops.

The floor is always available so you could always put the kid on the floor.

And then I'm a righty. So I would hold the device in my right hand. Now I'm realizing this is only audio,

so I think that we'll be able to maybe have some visuals to come along with this in handout or something. So I'm going to rely to you, Caroline, to come up with something that makes this easier.

Caroline: Okay, I'll do my homework.

Dr. Pistiner: All right, very good. But I'm a righty. So I would hold the device in my right hand.

With my left hand, my non dominant hand, I would take the safety off of the device.

I would take off. It depends on the device we could actually go through in addition each of the devices, but for the sake of time,

then I'd be holding the device after the safeties are off in my dominant hand.

Now with my non dominant hand, that's the one that I'm going to use to get control of the child.

And so if I'm a righty and the device is held in my right hand,

then I would lay the child down on the floor and their head would be away from the my right hand, their head would be towards my left.

So now what I would be doing is going across their waist with my non dominant armpit like a seat belt.

And then I could use my left hand to immobilize their thigh and make sure that the epinephrine device is going in the meaty part of the thigh.

And now their hands are behind my back and the best they could do is punch me in the back of the head.

But they can't get their little hand to grab the auto injector while I have it placed in their thigh. For in the case of RV Q A count of two.

And in the case of the myelin, generic in the case of the EpiPen, in the case of the TevaGeneric 3 second hold.

And in the case of the impacts, generic up to 10 second hold, but only as long as you can hold the child without them breaking loose.

Caroline: That was a perfect visual.

Seriously, I am following along and I can see it.

That makes complete sense to not have their arms all over the place. You're right. Disrupting you,

providing the epinephrine.

Dr. Pistiner: Right. So then imagine that your view when you're doing that is that you're actually like looking at their feet.

So you're looking at their feet, their knees are right up near your nose and your armpit is on their waist.

And then you can just take your non dominant hand and bunch up that thigh and make sure that you have the thigh muscle right there.

Caroline: This is such critical information.

I just can't thank you enough. This is so important because it's an area that's kind of gray and I'm hoping listeners, you will use this podcast as a teaching tool when you are training others.

It's not long Share it with people.

Dr. Pistiner: Now if you got more than one grownup available now, you could imagine that one person can have the child's hands in their hands,

holding their hands, gently giving them kisses,

your face. The other parent can be right up there while the other person is immobilizing the leg, immobilizing the thigh and giving the dose.

So this way you're insured again that the hands aren't coming down and grabbing. But that two person hold is kind of nice because it might be less scary for the kid and especially if the other parent is right up there in their face.

Caroline: Again, this is really important information.

So thank you and well, our time is actually up. So before we say goodbye, is there anything else you want our listeners to hear from you?

Dr. Pistiner: Yeah,

I think we're going to be talking about it in our next clip, but that if ever you feel like things are getting out of control,

then using epinephrine is actually going to get you control.

And so the sooner you treat a kid who is experiencing a severe allergic reaction with epinephrine, the faster they're going to feel better and the more control you're going to get.

Caroline: Absolute brilliant words of wisdom. Thank you so much. We truly appreciate the time you spent with us today and look forward to seeing you in the next podcast about epinephrine.

Dr. Pistiner: Thanks for having me.

Caroline: You're welcome.

Before we say goodbye today, we just want to pause for one more minute to say thank you to Kaleo for being a kind sponsor of FAACT's Roundtable Podcast and for their support throughout the years.

And also please note that today's guest was not sponsored by or paid by Kaleo to participate in this specific podcast.

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Have a great day and always be kind to one another. Another.