Emergency Preparedness – Allergic Reactions and Anaphylaxis

Introducing food allergens early is a great way to prevent food allergies from developing in your baby, but sometimes, even when the common food allergens are started at the right time (between 4 and 6 months of age and when developmentally ready), some infants may still develop a food allergy and have a reaction to something they eat. This is an allergic reaction. Allergic reactions can either be IgE-mediated or non-IgE-mediated. There are two types because there are different things that can happen in your baby’s body because of the food they ate, depending on which allergy type they have.

For babies, most IgE-mediated allergic reactions are mild. Serious allergic reactions, called anaphylaxis, are rare. Fortunately, there is a great treatment available that little ones respond very well to: epinephrine. Since your child can’t tell you how they feel yet, this guide will teach you exactly what to look for so you can act fast. Here you will learn how to:

Recognize the signs of an IgE-mediated allergic reaction, including mild symptoms and more severe ones
Give epinephrine if you think your baby or toddler is experiencing anaphylaxis
Create an Anaphylaxis Action Plan with your healthcare team
Use different epinephrine devices

A doctor smiles while examining a baby resting on their mother's shoulder. The baby has no clothes on, and the mother looks concerned. They are indoors with a bright background.

This guide is here to support you with easy-to-understand, medically reviewed food allergy and anaphylaxis information you can trust. Use this as a resource as you prepare to talk with your child’s healthcare team.

What does an allergic reaction look like in babies and toddlers?

While the sounds babies and toddlers make are adorable, they don’t always tell us a lot. Babies and toddlers can’t use all the right words to say what they are feeling or if something hurts. Older children may say things like, “My throat feels funny” or “My stomach hurts.” Babies instead show changes in how they act and how they look.

Allergic reactions do not all look the same. Some are mild and stay in one part of the body. Others are more serious and involve more than one body system or affect breathing or circulation. Sometimes it can be easy to mistake an allergic reaction for normal behavior. Knowing what to look out for helps guide us on what to do next.

Mild Signs and Symptoms

Mild reactions are usually limited to one body area and do not spread or get worse quickly. In these cases…

stop feeding your baby the food
watch for changes, and
talk with your healthcare team about next steps.

Body System	AAP Allergy and Anaphylaxis Emergency Plan (all ages)	In young children, also look for...
1: Upper Respiratory / Mucus Membranes	Itchy nose, sneezing, itchy mouth	Pushing out the tongue (called thrusting), pulling on the tongue, repetitive lip licking or licking of hands or objects, throat itching, ear pulling, scratching, putting fingers in the ears, eye rubbing, eye itching
2: Skin	A few hives	Skin scratching or rubbing skin
3: Gastrointestinal (Gut)	Mild stomach nausea or discomfort	Hiccups, spit-up that is not routine and more intense than normal, arching of the back, putting knees to chest

Severe Signs and Symptoms

A serious allergic reaction, called anaphylaxis, is when your baby has severe symptoms. Anaphylaxis also happens when your baby has mild symptoms but in more than one body area. For example, hives by itself is a mild symptom, and limited vomiting by itself is a mild symptom, but both hives and vomiting together would be anaphylaxis. Sometimes allergic reactions can start with mild symptoms, but get worse as time passes, leading to anaphylaxis.

Body System	AAP Allergy and Anaphylaxis Emergency Plan (all ages)	In young children, also look for...
1: Respiratory / Airways	Shortness of breath, wheezing, or coughing Tight or hoarse throat Trouble breathing or swallowing Swelling of lips or tongue that makes breathing more difficult	Belly breathing (in which the baby’s belly goes up and down in an obvious way), fast breathing, nasal flaring, chest or neck tugging (the skin around the chest or neck appears to suck in with breathing) Hoarse voice, hoarse cry, barky or croup-like cough, unexplained drooling
2: Cardiovascular (Heart)	Skin color is pale or has a bluish color Weak pulse Fainting or dizziness	Mottling of the skin (discolored patches or blotches on the skin), pale appearance in lighter skin or dusky appearance in darker skin, particularly on the lips, tongue or gums Fast heartbeat not related to crying or other causes, usually with other signs of an allergic reaction Wobbly appearance, limp, floppy or poor head control
3: Skin	Many hives or redness over the body	Hives that appear red on lighter skin or look darker, purplish or blend with skin tone in children with skin of color, obvious swelling on the face
4: Gastrointestinal (Gut)	Vomiting or diarrhea (if severe or combined with other symptoms)	Throwing up more than once or throwing up that occurs with other symptoms, large amounts of diarrhea or diarrhea that occurs with other symptoms
5: Neurologic (Behavior)	Feeling of "doom," confusion, agitation	Lethargic or very tired, difficult to wake up, withdrawn, unexpected crankiness, inconsolable or nonstop crying

some symtoms of an allergic reaction in a baby, including coughing, vomiting, diarrhea, and hives

What to do if your child is having a serious allergic reaction

If your baby is having severe symptoms and…

They are NOT yet diagnosed with a food allergy and/or do not have epinephrine, call 911.
They are diagnosed with a food allergy and have epinephrine, give epinephrine and follow your baby’s Anaphylaxis Emergency Action Plan. An easy way to remember what to do is to follow the REAct steps outlined below.

R – Recognize anaphylaxis

Watch for serious symptoms like trouble breathing, vomiting, sudden sleepiness, swelling, or symptoms affecting two or more body systems. Use the above chart to see what symptoms might look like specifically in infants and toddlers.

E – Epinephrine first

Give epinephrine (the first-line medicine to stop the reaction) right away.

If your baby or toddler is experiencing some symptoms and you’re not sure it’s anaphylaxis, the best approach is to still give epinephrine. Early treatment can keep a reaction from getting worse and make your baby or toddler feel better quickly.

Position your baby after epinephrine. After giving epinephrine, position your baby based on their symptoms:

If there’s trouble breathing or coughing:

Hold your baby upright against your chest.
Support their head and make sure their legs aren’t dangling.

If the baby’s head and body are limp and floppy, or if they’re hard to wake up:

Lay your baby flat on the back with legs slightly raised.
Do not pick your baby up suddenly or let your baby move around too much.

If there’s vomiting:

Lay your baby on their side to prevent choking.

When to give a second dose of epinephrine

Give a second dose of epinephrine if:

Symptoms do not get better in about 5 minutes after the first dose, or
Symptoms come back or get worse

If you give a second dose of epinephrine, call 911.

Reminder: Keep two doses of epinephrine available at all times. Don’t forget to refill the prescription ASAP.

Act – Activate emergency plan

These days, guidelines allow a bit more flexibility on what happens after epinephrine is given for anaphylaxis. If your child’s anaphylaxis is treated early and symptoms quickly get better after a first dose of epinephrine, you may not need to call 911. Your healthcare team will discuss with you whether this is an option for your child.

In these cases…

there needs to be more than one dose of epinephrine available
your baby cannot have severe or life-threatening symptoms
another person is present
you’re comfortable managing the situation
symptoms largely get better after treatment, and
the healthcare team previously approved this for your child

Call 911 if…

you don’t have a second dose of epinephrine
symptoms return or worsen after the first dose of epinephrine
symptoms do not go away quickly or completely after the first dose of epinephrine
a second dose of epinephrine is needed

In the past, families were often taught to call 911 after giving epinephrine, no matter what. This was because emergency medical personnel could give additional epinephrine, IV fluids, oxygen, and other medications if the first dose of epinephrine wasn’t enough. The recommendation was NOT because epinephrine was unsafe or because epinephrine itself needed monitoring.

After a serious allergic reaction, whether you needed to call 911 or not, be sure to schedule a follow-up appointment with your child’s healthcare team. Discuss what happened and make a change to your child’s Anaphylaxis Action Plan, if needed.

FAMPIT Prevention and Emergency Preparedness Download

Get an Anaphylaxis Action Plan from your healthcare team

If your baby is diagnosed with a food allergy, your healthcare team will create an Anaphylaxis Action Plan. This guide makes it easy for you, your family, and other caregivers to be on the same page and know exactly what to do during an allergic reaction.

The plan usually includes:

Your child’s name, date of birth, weight, and a photo
A list of known food or drug allergies
Which symptoms to look for
When and how to give epinephrine
When to call 911
Information about the prescribed epinephrine device and dose
Primary caregivers’ contact numbers and any additional emergency contacts
Your child’s healthcare team information

Your healthcare team will work together with you to review the anaphylaxis action plan. They will review:

How to recognize allergic reactions
When epinephrine should be used
How to use the epinephrine auto-injector
Where and how to store the medication

If you have questions, you can bring them up at any time during these discussions.

Keep a copy of the Anaphylaxis Action Plan:

At home
In your diaper bag or travel kit
With daycare or other childcare providers
Anywhere your child spends a lot of time, like a relative’s house
On your phone

It may be helpful to take a photo of the completed plan and store it in a folder on your phone. You can include pictures of your child’s medications. This makes it easy to share the information with others if needed.

Including a photo of your child on the plan can help caregivers confirm they are following the correct plan for the correct child.

Download a copy of the AAP’s Anaphylaxis Action Emergency Plan

What to know about the different epinephrine devices

Not all epinephrine devices are the same. They can vary in look and how they are given. Some come with a trainer device (has no medicine and no needle in it) that you can practice with. Double check which device your child has and review the specific instructions below:

First, slide off the outer case.
A voice prompt will then begin to walk you through using the device.
Hold the device in the hand that you write with.
Position the black end (the needle end) facing down.
Gently remove the red safety guard (cover of the needle) down and off the black end of the AUVI-Q.
The device is now activated, and the medication is ready to inject!
Hold your baby’s leg steady with your free hand.
If using the 0.15 mg device, “squeeze up” the muscle of your baby’s thigh.
Press the black end against your baby’s thigh until you hear a “click and hiss.”
Hold the device in place for 2 seconds while it injects.
The needle will retract automatically after 0.3 seconds, and the injection
is complete.

Remove the device from its carrier case.
Hold the device in the hand you write with.
Use your other hand to remove the blue caps from either end.
Make sure the red end (needle end) is facing down.
The device is now activated, and the medication is ready to inject!
Hold your baby’s leg steady with your free hand.
Press and hold the device in the outer middle part of your baby’s thigh for at least 5
seconds, although 10 seconds is best.
Remove the injection from your baby’s thigh. Gently massage or rub the area for 10 seconds.
The injection is complete if you see the needle sticking out of the red tip.
Carefully cover the device in its carrier case.

Remove the plastic carrying case.
Hold the device in the hand you write with.
Point the blue end up to the sky and the orange end down.
Gently remove the blue safety release top.
The device is now activated and the medication is ready to inject!
Use your free hand to hold your baby’s leg steady.
Press the orange end of the device firmly into the outer middle part of your baby’s thigh and hold it there for 3 seconds. We recommend not to “swing-jab” the device because of injury risk.
After 3 seconds, stop pressing and pull away from the thigh. The orange plastic tip will cover the needle, and the injection is complete.

There is no carrier case for this epinephrine device.
Hold the device in the hand you write with.
With your other hand, twist off the green cap on the bottom, directed by the arrow on the cap.
Make sure the orange end (needle end) is facing downward, and be careful not to touch the orange end of the device.
Pull off the blue safety release from the top of the device.
The device is now activated, and the medication is ready to inject!
Hold your baby’s leg steady with your free hand.
Press and hold the orange end of the device into the outer middle part of your baby’s thigh.
You will hear a click, then continue to hold the device in place against the thigh for 3 seconds.
Remove the device from the thigh and the orange tip will extend to cover the needle.
Gently massage or rub the area for 10 seconds.

An intranasal device (given via the nose instead of an injection into the thigh) is available for toddlers above 15 kg (33 lbs).

Remove neffy from packaging.
Hold the nozzle between the tips of your pointer and middle fingers.
Rest your thumb against the bottom plunger.
Put the nozzle gently into your child’s nostril and hold straight. If possible, the tops of your fingers should touch your child’s nose.
Press the plunger firmly with your thumb until it snaps up. This will spray liquid into the nostril.
Inhaling (breathing in) through the nose is not required.
Try to avoid having your child sniff during or after the dose. Watch them for 5 minutes.
If symptoms continue or get worse, give a second dose of neffy. Try to use the same nostril, if possible.

The science behind an allergic reaction and epinephrine

A food allergy is when the immune system responds to a food in a way that is not normal. We use our immune system to fight germs such as viruses and bacteria. Sometimes, the immune system becomes confused and reacts to specific foods that are harmless to most people.

One type of food allergy, called an IgE-mediated food allergy, can cause reactions that affect one or more areas of the body. The signs and symptoms can be different from one person to another, or even from one reaction to the next in the same person.

IgE is a protein called immunoglobulin E. IgE is involved in most allergic reactions that can become severe, serious, and sometimes get worse quickly. IgE can move around in the body, but it is also found on allergy cells such as mast cells and basophils. These are important parts of the immune system that play a role in serious, potentially life-threatening allergic reactions.

If someone eats their allergen, such as peanut or cashew, the peanut or cashew protein can bind to IgE and trigger the signs and symptoms of an allergic reaction. Allergy cells, such as mast cells and basophils, can then release the substances stored inside them. These substances are chemicals such as platelet-activating factor, leukotrienes, cytokines, chemokines, and histamine. These cause symptoms in different organ systems. Often, these organ systems are grouped into the skin and mucosal surfaces (such as the inside of the mouth), respiratory system (lungs and upper airway), cardiovascular system (heart and blood vessels), gastrointestinal system (stomach and intestines), and neurologic system (brain).

Epinephrine is the treatment for serious allergic reactions, including anaphylaxis. Epinephrine works quickly and directly where it is needed. It acts on target organs such as the heart, lungs, and blood vessels to prevent a reaction from getting worse and to make symptoms better. Importantly, epinephrine also works on the cell membranes of allergy cells, such as mast cells and basophils. It can stabilize these cells and help prevent them from releasing additional inflammatory mediators.

A healthcare worker in blue gloves uses a stethoscope to listen to a baby’s chest while an adult holds the baby, providing comfort during the medical examination.

Additional resources for families

These trusted resources can help you find reliable information about anaphylaxis in infants, connect with other families, and feel more prepared:

Finding support

Managing food allergies and allergic reactions can feel overwhelming at times. It is common for caregivers to feel concerned, stressed, or uncertain, especially after an allergic reaction or emergency situation. Support can be helpful as part of ongoing care. This may include:

Talking with your child’s healthcare team
Learning more about food allergy management
Connecting with support resources or other families

Caregivers play an important role in recognizing and responding to allergic reactions. Over time, many families become more confident with experience and education.

Questions & answers (Q&A) on infant anaphylaxis

The more you know, the more confident you will feel when it comes to your child’s food allergy. Here are answers to some common questions we’re asked about infant anaphylaxis.

It’s helpful to think of antihistamines as “comfort medicine.” They may help you feel a little better, but they are not going to treat all the things happening during a severe allergic reaction. That’s because they only block histamine and do not affect the other chemicals involved.

We have a lot of histamine receptors on our skin and mucous surfaces, so antihistamines can help with skin symptoms, like itching and hives, during an allergic reaction. However, they can take about 30 to 60 minutes to start working.

Giving an antihistamine should never slow down treatment of a serious allergic reaction with epinephrine. Be cautious when giving diphenhydramine (Benadryl) because it can cause tiredness and has side effects. Non-sedating antihistamines like cetirizine (Zyrtec) are a better choice for treatment of mild and limited symptoms.

Many signs and symptoms of anaphylaxis look like other common problems in babies. For example:

Spitting up can look like vomiting from an allergic reaction.
Flushed skin can look like a mild rash or overheating.
Crying and fussiness can be mistaken for hunger or tiredness.

This can make it harder for parents to see that it is anaphylaxis right away.

Delayed anaphylaxis is a serious allergic reaction that occurs hours or even days after exposure to an allergen.

In addition, sometimes anaphylaxis symptoms can come back hours after initial symptoms appear. This is called a biphasic reaction.

These are why watching your child after anaphylaxis is recommended, so you can quickly catch new symptoms.

Symptoms can start within minutes after your child eats an allergen. Sometimes symptoms are delayed. They can also change or get worse over time.