Signs of anaphylaxis in babies and toddlers

What to do right now

If you think your baby is having anaphylaxis, act straight away. Don’t wait to see if it gets better on its own.

1. Give epinephrine, if your baby has been prescribed it. Use the auto-injector in the outer middle of the thigh, halfway between hip and knee. It works through clothing. Hold your baby’s leg firmly. Note the time.

2. Call for an ambulance. Call 911. Say “anaphylaxis” and ask for an ambulance with epinephrine.Call 999. Say you think it’s anaphylaxis.Call your local emergency number (such as 112 in Europe or 000 in Australia). Say you think it’s anaphylaxis. Use speaker so your hands are free. If you don’t have epinephrine, make this call first. If you’re alone with your baby, use the auto-injector first if they have one, then call on speaker straight away. Don’t leave your baby to find a phone.

3. Keep your baby lying down. Hold or lay them flat rather than upright. If they’re vomiting, turn them on their side. If breathing is hard, you can raise their head and shoulders a little (NHS), and an older toddler can sit with legs out straight (ASCIA). Don’t stand them up or let them walk, even if they seem better.

4. Stay with them. If symptoms get worse, carry on, or don’t improve after 5 minutes, give a second dose of epinephrine if you have one.

5. Go to hospital, even if your baby seems fine. Symptoms can come back a few hours later, so your baby needs to be watched by a medical team.

An antihistamine can be given afterward if your doctor has prescribed one, but never in place of epinephrine.

Signs of anaphylaxis

Anaphylaxis usually starts within minutes of eating the food, but it can take up to 2 hours, and sometimes longer. Call for emergency help if your baby has any of these:

• Breathing: trouble breathing, breathing very fast, wheezing, noisy breathing, or a cough that won’t stop
• Throat and mouth: swelling of the tongue or throat, lips or mouth that suddenly swell, a hoarse cry or voice, sudden drooling, or trouble swallowing
• Color and circulation: pale, gray or blue skin, lips or tongue, or skin that feels cold to the touch. On darker skin, color changes can be easier to see on the palms or the soles of the feet
• Behavior: limp or floppy, very sleepy, hard to wake, or not responding like they usually do. Their head may flop, or they may not be able to focus on your face
• More than one part of the body at once, such as hives with repeated vomiting, or a rash with coughing

Babies can’t tell you how they feel, so changes in behavior matter. The AAP notes that babies may also become very fussy or cry and can’t be settled, or suddenly become unusually sleepy.

There may also be hives or a swollen, raised, itchy rash, but don’t wait for a rash before acting on the signs above.

Milder reactions

Some allergic reactions are mild, for example:

• a few hives or a red, itchy rash, especially around the mouth
• mild puffiness of the face or around the eyes
• vomiting once, or tummy pain
• sneezing or a runny nose

If it’s only one mild sign, stop offering the food, stay with your baby, and watch them closely for the next couple of hours. Call your pediatrician or GP before offering that food again. If the lips or mouth suddenly swell, if any of the severe signs above appear, or if signs show up in more than one part of the body, treat it as anaphylaxis: give epinephrine if you have it and call for an ambulance.

For how to introduce allergens safely in the first place, see how to introduce allergens.

If your baby has been prescribed epinephrine

If your baby has had anaphylaxis before, or is at high risk, your doctor may prescribe epinephrine and give you a written plan for what to do in a reaction.

• Keep 2 doses with your baby at all times. A second dose may be needed.
• Know your device. Each brand works a little differently. Ask for a trainer device (no needle, no medicine) and practice.
• Teach everyone who cares for your baby, including grandparents, babysitters and child care staff, how and when to use it.
• Check expiry dates and replace devices before they run out.
• Store it properly. Don’t leave it somewhere too hot or too cold, such as in the fridge or out in the sun.
• Use it if you’re not sure. If you think it might be anaphylaxis, give epinephrine. It’s the recommended first treatment.

Auto-injectors come in different doses based on weight, so ask your doctor to check the dose as your baby grows. Epinephrine nasal sprays are available too, but in the US they’re approved only for children who weigh 33 lb (15 kg) or more, so babies usually need an auto-injector.

After a reaction

Even if your baby recovers quickly, they should be checked by a doctor and referred to an allergist. The allergist can work out the cause, explain what to avoid, and help you make a plan.

Until then, keep the suspected food out of your baby’s diet. Don’t cut out other major foods without medical advice: that can make it harder for your baby to get the nutrients they need.

A reaction that is delayed by a few hours and causes repeated vomiting, paleness or floppiness without hives can be a different condition called FPIES. If your baby vomits once or twice a few hours after a food and is alert and like themselves, call your pediatrician or GP. Call 911 or go to the emergency room if your baby is vomiting again and again, or is pale, floppy, very sleepy or hard to wake.Call 999 or go to A&E if your baby is vomiting again and again, or is pale, floppy, very sleepy or hard to wake.Call your local emergency number (such as 112 in Europe or 000 in Australia) or go to the emergency department if your baby is vomiting again and again, or is pale, floppy, very sleepy or hard to wake. See FPIES.

Where US and UK advice differs

The main steps are the same in both countries: give epinephrine first, call for an ambulance, keep your baby lying down (never standing or walking), and go to hospital. A few details differ.

• The name. In the UK, epinephrine is called adrenaline.
• Position when breathing is hard. The AAP says to keep a child lying on their back, and on their side if they vomit or have trouble breathing. The NHS says to lie down with the legs raised, and if breathing is hard, to raise the shoulders or sit up slowly. The steps above combine the two for babies: lying down, on their side if vomiting, head and shoulders a little raised if breathing is hard. Follow the call handler’s advice.
• Swelling of the lips or mouth. The NHS lists lips, mouth, throat or tongue that suddenly swell as a reason to call 999. This guide treats sudden lip or mouth swelling as a severe sign for that reason, and mild puffiness of the face or around the eyes on its own as a milder one.
• Mild symptoms. The NHS says to use an adrenaline auto-injector if you think it may be anaphylaxis, even if symptoms are mild. FARE’s plan says to give epinephrine for any one severe symptom, or for mild symptoms in more than one part of the body, and to watch closely if there’s only one mild symptom.
• Getting to hospital. The NHS advises not driving to A&E yourself: call 999 and follow the call handler’s advice. The AAP says to call 911 and ask for an ambulance with epinephrine.