Anaphylaxis recognition criteria have not been updated to reflect infant-specific presentations, even as newer international definitions already incorporate them.¹ A recent review found modified age-specific criteria improved detection by 23% in infants and 10% in toddlers compared with standard criteria.² The review also identified drooling, back arching, belly breathing, and tongue-thrusting as additional infant-specific presenting signs worth incorporating into recognition criteria.¹

A companion review found caregiver recognition and confidence gaps, not epinephrine access alone, drive delayed treatment, and 48% of caregivers in a surveyed cohort withheld epinephrine because they did not believe symptoms were severe enough.² Parents who watch a clinician administer epinephrine during a supervised reaction, such as a food challenge, report greater comfort giving it on their own afterward.² Caregivers with a written anaphylaxis action plan were also more likely to use epinephrine.²

In the following Q&A, Jay Lieberman, MD, professor at the University of Tennessee Health Science Center and program director of the Allergy/Immunology Fellowship Program at Le Bonheur Children's Hospital, discusses recognizing anaphylaxis in young children and closing the epinephrine treatment gap.

Q&A: Anaphylaxis Recognition and Epinephrine Use, With Jay Lieberman, MD

HCPLive: What's the single biggest clinical takeaway from these papers for clinicians treating infants and toddlers?

Lieberman: Infants and toddlers can have different reactions or can look different during severe allergic reactions. We have criteria for symptoms during a reaction that would meet the anaphylaxis definition and…[warrant] epinephrine, [but] infants and toddlers may behave differently, and clinicians need to be aware of [this]. When you see an infant or toddler having a reaction, look for different things to alert you that, wow, this is a multi-systemic allergic reaction or this [is] a more severe allergic reaction.

HCPLive: What behavior patterns signal a severe allergic reaction in nonverbal infants and toddlers?

Lieberman: Infants can't speak to tell you [what's happening], so they behave differently. They may be more fussy, they may be crying, they may be inconsolable. They can shove a finger in their mouth as a sign they're having an itchy mouth or throat… [or tug] at an ear as a sign of itching inside the ear canal. These are all signs they’re having an allergic reaction.

HCPLive: Which signs and symptoms do clinicians most often overlook as allergic reaction indicators in this age group?

Lieberman: In older kids, GI symptoms like vomiting. Often, [clinicians] may think the child just ate something bad. When I'm doing a challenge [in an infant and that] infant starts acting funny, my radar goes up, and I start looking a little more into it.

HCPLive: The review found that modified age-specific criteria improved anaphylaxis detection by 23% in infants and 10% in toddlers compared with the standard criteria. What does that mean in practice for an allergist evaluating a nonverbal patient?

Lieberman: They can use whichever criteria they want. As an allergist in practice, often we're not doing the check boxes of “okay, they meet this, they meet this.” I'm going to go ahead and give them epinephrine. It's more of a clinical feel for a lot of us.

HCPLive: Your review cites a survey in which 48% of caregivers didn't use epinephrine because they didn't believe symptoms were severe enough. How should clinicians reframe that threshold?

Lieberman: This is an issue at all ages. Underuse of epinephrine has been shown in every study, whether it's infants, toddlers, or adults, and epinephrine was more often used the older the child is. Infants shouldn't be treated any differently. If we think they're having anaphylaxis, they should get epinephrine.

It's fascinating when a clinician goes through giving epinephrine with a parent during a reaction, such as during a food challenge in [the] clinic…parents feel more comfortable giving epinephrine on their own [afterward]. All these education pieces, showing parents it's not a big deal and it's not harmful, [may contribute to the increase in] epinephrine use.

HCPLive: What should epinephrine training look like for daycare staff, school nurses, and other community caregivers?

Lieberman: Whatever training we can get helps, [whether] that's a physician or nurse practitioner going to a school district to talk with school nurses…videos that teach [parents and staff] about this…[or] parent volunteers [to] go into schools and give education on food allergy and epinephrine use.

HCPLive: What system-level or policy changes would have the biggest impact on closing this treatment gap?

Lieberman: The best evidence we have, now incorporated into our allergy anaphylaxis practice parameters, [supports] stock epinephrine. [That] means a school, for example, can have epinephrine available without a prescription that any child can use, whether or not we knew they had a food allergy or a bee sting allergy. It’s the same idea as having defibrillators in stadiums that anyone can use if someone has a heart attack.

HCPLive: Is there anything else clinicians should know about anaphylaxis in young children?

Lieberman: Newer [food allergy] guidelines suggest early introduction of allergenic foods, even something like peanut, which we used to say don’t feed kids and now say to feed as early as 6 months. Greater education and awareness will be very helpful.

Watch interviews with Lieberman here: Age-Specific Criteria Improve Anaphylaxis Detection in Infants and Stock Epinephrine Could Close Anaphylaxis Care Gap, With Jay Lieberman, MD.

References

1. Pistiner M, et al. Recognizing and Treating Serious Allergic Reactions (Anaphylaxis) in Infants and Toddlers: A Plain Language Review of Four Studies. Expert Rev Clin Immunol. 2026. doi:10.1080/1744666X.2026.2695166

2. Leeds S, Anagnostou A, Pistiner M, et al. Epinephrine Underuse for Anaphylaxis in Infants and Toddlers: A Practical Review for Pediatricians. Paediatr Drugs. 2026;28(4):373-385. doi:10.1007/s40272-026-00752-7