ASCIA Guidelines - Adrenaline (Epinephrine) Injector Prescription

Children less than 7.5kg

Adrenaline injectors are not usually recommended for children less than 7.5kg as the risk of fatal anaphylaxis in children this age is very low. While the ‘optimal’ dose of adrenaline is unknown there is a risk that the lower dose adrenaline injector could provide a significant overdose.

ASCIA does not recommend the use of adrenaline ampoules and syringes for children less than 7.5kg as they are inappropriate for non-medical settings, such as childcare centres. Even if ampoules are administered by ‘trained’ non-medical personnel, such as parents, there may be a risk of a serious dosing error.

If there is a concern regarding an infant under 7.5kg requiring adrenaline, they should be referred to a clinical immunology/allergy specialist for assessment. The issues should be discussed with the parents based on a risk assessment. Where it is felt that it is essential for emergency adrenaline to be prescribed for a child less than 7.5kg, the risk of administering a ‘fixed’ overdose via a 150 microgram device is considered to be lower than the risk of a dose error with an adrenaline ampoule and syringe.

Adrenaline injector prescription is recommended for patients with:

• History of anaphylaxis - If the patient is considered to be at continuing risk from allergic reactions to identified triggers (confirmed allergen/s) or unidentified triggers (idiopathic anaphylaxis).
• Food allergy (excluding oral allergy syndrome) and co-existing unstable or moderate to severe, persistent asthma. Rationale: Most food allergy related fatalities occur in those with unstable asthma.
• Underlying mast cell disorders (e.g. systemic mastocytosis or elevated baseline serum tryptase concentrations) together with any previous systemic allergic reactions to insect stings, including patients undergoing venom immunotherapy.

Adrenaline injector prescription is sometimes recommended for patients with a history of a generalised allergic reaction, with one or more of the following additional risk factors:  

• Age
  • Teenagers and young adults with food allergy. While food allergy is most common in young children aged five years or less, the majority of recorded fatal reactions to foods (~90%) occur in teenagers and young adults. This may in part relate to greater risk taking behaviour in this age group, but may also reflect greater likelihood of accidental exposure to food allergens when eating away from home, or while not under parental supervision.
• Specific allergic triggers
  • Peanut, tree nuts and seafood. Fatal anaphylaxis may arise from any food, but most fatalities arise from food allergy that persists into adolescence and adult life (e.g. peanut, tree nut, sesame seed and seafood allergies). Allergic reactions to these foods may occur following ingestion of relatively small amounts, and the risk of reaction is unlikely to be reduced by cooking or food processing.
  • Generalised urticaria alone without anaphylaxis following insect stings (e.g. bee, wasp or Jack Jumper ant stings) or following tick bites is not a routine indication for adrenaline autoinjector prescription, but may be considered (in conjunction with allergen specific immunotherapy if available) in selected cases. Decisions regarding immunotherapy will take into consideration factors such as the risk of progression to anaphylaxis (based on follow-up studies), patient age (more likely in adults than children), co-morbidity (significant cardiorespiratory disease) or living or working in remote areas (where access to emergency medical care may be more problematic) or occupational (e.g. bee keeping) or even recreational exposure to stinging insects (e.g. hiking in areas where Jack Jumper ants are endemic).
• Co-morbid conditions
  • Asthma. Unstable or moderate to severe, persistent asthma increases the risk of respiratory compromise in those allergic to food. Treatment to control asthma symptoms is important in this group (e.g. medication, allergen immunotherapy).
  • Cardiovascular disease (hypertension, ischaemic heart disease or arrhythmia) is associated with a relatively greater risk of fatal anaphylaxis from insect stings.
  • Systemic mastocytosis

This list is not comprehensive and if there is a concern, patients should be referred to a clinical immunology/allergy specialist for assessment.

• Limited access to emergency medical care
  • Remote residential locations. In some remote residential locations (e.g. remote rural areas), access to medical care and early administration of adrenaline may not be possible unless an adrenaline autoinjector is provided to the patient or their carers for administration. It is important to distinguish this situation of permanent risk from those at short-lived risk (e.g. bushwalking, school camps).
  • Prolonged travel abroad. Consideration of temporary availability to patients considered at lower risk, who are travelling abroad may also be considered, where language barriers and lesser control over food preparation may increase the risk of accidental exposure and access to medical care may also be limited.

These factors should be considered when deciding whether an adrenaline autoinjector is prescribed, as they are known risk factors for more severe or fatal allergic reactions. 

 Adrenaline injector prescription is not normally recommended as follows:

• Asthma without a history of anaphylaxis or generalised allergic reactions.
• If known allergen can be successfully avoided (e.g. drug allergy, latex allergy). Under these circumstances the wearing of medical identification jewellery is strongly recommended.
• Oral allergy syndrome - The likelihood of progression to anaphylaxis is very low.
• Elevated specific IgE only (positive blood or skin allergy test) without a history of clinical reactivity - A positive allergy test without a history strongly suggestive of allergy is an indication for specialist allergy assessment, which will include assessment of the risk of allergy and anaphylaxis, and sometimes include challenge testing.
• Family (rather than personal) history of anaphylaxis or allergy - Whilst the risk for allergic disease such as asthma, allergic rhinitis and atopic eczema is in part inherited, there is not a substantial genetic contribution to food, sting or drug allergy risk, and the risk of anaphylaxis is not inherited.
• Local reactions to insect stings in adults and children - Follow up studies demonstrate that these rarely progress to anaphylaxis.
• Generalised skin rash (only) to bee or wasp stings in children - Follow up studies of subsequent bee stings in children presenting with local reactions or generalised skin rash (only) show that these children are at a very low risk of experiencing anaphylaxis with subsequent stings.
• Resolved food allergy - This should be established by a clinical immunology/allergy specialist.
• Isolated angioedema - The risk of fatal angioedema (unrelated to food or insect sting allergy, hereditary angioedema or use of ACE inhibitor medication) is very low. If there is a concern, patients should be referred to a clinical immunology/allergy specialist for assessment.