3 Practice Changes for Pediatric Anaphylaxis Care in the ED

Children with anaphylaxis do not always arrive in the emergency department (ED) with textbook symptoms. That can make recognition difficult and help explain why many patients are still managed according to older habits rather than the latest evidence.

Brian Schroer, MD, a pediatric allergist and immunologist at Cleveland Clinic, says the 2023 American College of Allergy, Asthma and Immunology practice parameters urge clinicians to rethink several long-standing approaches to pediatric anaphylaxis care. Below, he highlights three practice changes clinicians should know: how to recognize anaphylaxis in real-world presentations, which medications to prioritize and how to tailor observation for biphasic reactions.

1. Diagnosing anaphylaxis requires the whole clinical story

In children, food is an increasingly common trigger of anaphylaxis, along with medications and stinging insects. However, anaphylaxis is often missed or underrecognized because its symptoms overlap with many common pediatric conditions, Dr. Schroer says.

Symptoms may include:

• Diffuse hives
• Coughing or wheezing
• Sneezing or nasal congestion
• Abdominal pain, nausea or vomiting
• Throat swelling
• Hypotension

“It can be difficult to differentiate anaphylaxis because the symptoms can mimic viral infection, asthma, isolated urticaria and other conditions,” Dr. Schroer says. “In addition, the rigid definitions of anaphylaxis used in research studies typically don’t match the real-world presentations we see in the ED.”

Children may present with only one symptom or with multiple mild symptoms, he says. That is why exposure history is essential.

“A child who comes to the ED covered in hives may not look like a classic anaphylaxis case,” he says. “But if that child has a known peanut allergy and just ate peanut, the whole story helps make the diagnosis.”

For frontline clinicians, this means exposure history should carry as much weight as the number of organ systems involved.

2. Epinephrine should come first — and early

Perhaps the biggest treatment update is not a new medication, but a reprioritization of existing ones. Epinephrine remains the first-line treatment for anaphylaxis.

“It is the most useful medication for treating any or all symptoms of anaphylaxis,” Dr. Schroer says. “It essentially stops the allergic reaction, improving existing symptoms fairly quickly, while reducing the risk of other symptoms starting later.”

Yet many patients still do not get epinephrine when they should. Dr. Schroer says delays often reflect a longstanding tendency to reserve epinephrine for only the most dramatic presentations, such as airway compromise, hypotension or multisystem involvement.

Instead, patients may receive medications with less evidence of benefit, including:

• Antihistamines, particularly diphenhydramine. These medications can help relieve itching, hives and sneezing, but they do not treat bronchospasm, airway swelling, vomiting or hypotension. As such, they are not first-line therapy for anaphylaxis. If an antihistamine is used, newer nonsedating medications such as cetirizine are preferred over diphenhydramine. Cetirizine has a similar onset and efficacy, lasts longer and avoids sedation that can complicate assessment.
• Histamine-2 receptor antagonists. H2 blockers such as famotidine were historically used in anaphylaxis care, but evidence does not show meaningful benefit over H1 antihistamines.
• Steroids. Steroids have long been used in patients with hives or asthma-like symptoms, but updated guidance emphasizes that they do not meaningfully improve acute anaphylaxis symptoms or prevent biphasic reactions. They also carry short- and long-term risks.

3. Observation should be guided by biphasic reaction risk

The updated guidance supports shorter observation for lower-risk patients and longer monitoring for those at higher risk of persistent or biphasic symptoms.

“Patients who present with more mild symptoms, even if treated with one dose of epinephrine, generally don’t need more than two to three hours of monitoring,” Dr. Schroer says.

The risk of continued or biphasic symptoms is higher in patients who:

• Present with more severe initial symptoms
• Require more than one dose of epinephrine

These higher-risk patients may need four to six hours of monitoring or hospital admission. The anaphylaxis trigger also matters. Observation may be shorter for food- or insect sting-related reactions, but longer for medication-related reactions if the drug may still be active in the patient.

“There’s no strict rule about how long to monitor individual patients,” Dr. Schroer says. “Clinical judgment is essential.”

Real-world implementation

At Cleveland Clinic, clinician education and updated anaphylaxis order sets have already begun to shift practice in pediatric EDs. Dr. Schroer and his colleagues presented early results from this quality improvement initiative at the 2026 American Academy of Allergy, Asthma and Immunology meeting.

Results from nearly 500 patients with anaphylaxis seen in Cleveland Clinic pediatric EDs from 2024 to 2025 showed:

• Diphenhydramine use fell from 54% to 37%.
• Cetirizine use rose from 13% to 36%.
• Famotidine use fell from 64% to 31%.
• Oral steroid use fell from 73% to 45%.

Mean ED length of stay also fell, from 215 minutes to 164 minutes.

“Even when the trigger is not obvious, epinephrine remains the best single medication when symptoms and history suggest anaphylaxis,” Dr. Schroer says. “We don’t need to wait until a child is having multiple symptoms, severe symptoms or a true emergency. Using epinephrine right away can help prevent the emergency.”