The Overlooked Symptoms of Anaphylaxis in Babies and Toddlers

Older children experiencing an allergic reaction can often describe what is happening: a scratchy throat, a tingling lip, an itchy mouth. Infants and toddlers cannot offer that kind of report, and according to Jay Lieberman, M.D., professor at the University of Tennessee Health Science Center and program director of the Allergy/Immunology Fellowship Program at Le Bonheur Children's Hospital, that gap changes how the earliest signs of a reaction appear.

Instead of naming a symptom, an infant might claw at the tongue, pull at an ear that has started to itch or simply become fussy in a way that looks like tiredness rather than a medical emergency. These behaviors have become clearer to allergists partly through the increased use of food challenges in young children, which have generated more real-world data on how reactions present before a child can talk.

The Lingering Stigma Around Epinephrine

Even when a reaction is recognized, epinephrine is often used less than doctors would like, and not just in infants. Lieberman pointed to fear of needles as a major driver, along with a cultural image of epinephrine injections as painful or dramatic. In reality, auto-injectors use a small needle to deliver the dose automatically, without the person having to inject themselves.

Worry about side effects also holds families back, despite epinephrine having a minimal side effect profile at the doses used for allergic reactions. Outdated guidance has contributed too. Older recommendations advised an emergency room (ER) visit after every use of epinephrine, while current allergy guidelines say that if a patient improves within a few minutes, an ER trip may not be necessary.

Why a Written Action Plan Matters

Standardized anaphylaxis action plans, such as those distributed by the American Academy of Pediatrics and other organizations, outline a child's allergies, risk factors such as uncontrolled asthma or a prior anaphylaxis episode, and specific steps to take based on symptom severity. These plans are designed to be shared with anyone who cares for the child, including babysitters, teachers and school staff.

Research has shown that having an action plan in place increases the likelihood that epinephrine will be used. One of the most common reasons families cite for not using epinephrine during a reaction is far simpler than fear or confusion: The medication was not with them at the time.

Lieberman said the larger goal is ongoing education, not a single fix. As allergists continue to gather data on how reactions present in younger children, he said the priority is helping caregivers recognize atypical symptoms early, feel confident using epinephrine without added ER visits when a child responds quickly and keep the medication within reach at all times.

These findings connect to two newly published papers exploring why anaphylaxis in infants and toddlers is often missed and undertreated: a review analyzing over a decade of literature on barriers to epinephrine use, and a plain-language review summarizing four related studies for parents and caregivers.