Safe Epi Use in Infants and Toddlers with Dr. Michael Pistiner

In Part 2 of my conversation with Dr. Michael Pistiner, pediatric allergist at Mass General for Children, we focus on anaphylaxis management in young children and epinephrine use.

Dr. Pistiner walks us through which epinephrine devices are appropriate for infants and toddlers, and demonstrates the best techniques for administering them safely. He shares practical guidance for holding a squirming baby, minimizing fear, and building confidence in epinephrine.

-->We encourage you to watch what this looks like in action. You can find the video demonstration on my Instagram and Facebook pages @thefoodallergypsychologist or here:
*Infant epi administration: https://drive.google.com/file/d/1BrzXaONN9yQy6KgMAn4LXNSh8jJ8rpS7/view?usp=sharing
*-->Toddler epi administration: 
https://drive.google.com/file/d/1J0EIzwE7zAV3vwzLQQ3EvstBM2SgtEvR/view?usp=sharing

This episode is a must-listen for anyone caring for a child with food allergies, because preparation and confidence can make all the difference in an emergency.

How to Use an Epi Autoinjector:
https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/How-to-Use-an-Epinephrine-Auto-Injector.aspx

Parental experience administering epinephrine for systemic reactions during infant and toddler oral food challenges: https://www.jaci-inpractice.org/article/S2213-2198(24)00687-1/fulltext

Joint Task Force Practice Parameters:
https://www.allergyparameters.org/

Food Allergy Management and Prevention
Support Tool for Infants and Toddlers:
https://famp-it.org/

Creating an Allergy and Anaphylaxis Plan:
https://www.healthychildren.org/English/health-issues/conditions/allergies-asthma/Pages/Create-an-Allergy-and-Anaphylaxis-Emergency-Plan.aspx?sfns=mo

AAP Allergy and Anaphylaxis Emergency Plan:
https://publications.aap.org/pediatriccare/resources/17512/AAP-Allergy-and-Anaphylaxis-Emergency-Plan?autologincheck=redirected

Special thanks to Kyle Dine for permission to use his song The Doghouse for the podcast theme!
www.kyledine.com

Find Dr. Whitehouse:
-thefoodallergypsychologist.com
-Instagram: @thefoodallergypsychologist
-Facebook: Dr. Amanda Whitehouse, Food Allergy Anxiety Psychologist
-welcome@dramandawhitehouse.com

Transcript

Michael Pistiner, MD, MMSc, FAAP: 0:00

epinephrine gets control. And if you feel like you're losing control, if you're afraid you're gonna lose control, if you can't even wrap your head around it'cause you're freaking out so hard, then go ahead and administer the epinephrine to the kid. And then that gives you time to think. We always talk about what happens if you don't give it, but when you do give it, it makes you feel better fast. And why make a kid sit there and feel totally miserable? Shut

Amanda Whitehouse, PhD: 0:29

Yes.

Speaker: 0:31

Welcome to the Don't Feed the Fear podcast, where we dive into the complex world of food allergy anxiety. I'm your host, Dr. Amanda Whitehouse, food allergy anxiety psychologist and food allergy mom. Whether you're dealing with allergies yourself or supporting someone who is, join us for an empathetic and informative journey toward food allergy calm and confidence..

0:52

Welcome back for part two of this wonderful conversation with Dr. Michael Pistiner, pediatric allergist and director of Food allergy advocacy, education and prevention at Mass General for Children Harvard Medical School. If you missed part one last week. Go back and listen. We talked about the updated criteria for diagnosing anaphylaxis in infants and toddlers. What's changed and what to look for during a reaction in very young children. In this episode, we're continuing that conversation with a practical focus on epinephrine, specifically, which device is appropriate for infants and toddlers, and how to administer it safely and effectively in such small children. Dr. Pistiner walks us through the technique, step-by-step, shares, tips for helping parents feel more confident and explains how caregivers can prepare in advance. It's such a valuable conversation. I wanted you to have this right before the holidays going into the time of the year where unfortunately we do experience reactions, hopefully none of you will have a reaction at your holiday dinners, but if you do, let's stop it in early anaphylaxis, rather than letting it progress further. For those who prefer visual learning, you will find Dr. Pistiner demonstrating this on video on my Instagram page@thefoodallergypsychologist.

Michael Pistiner, MD, MMSc, FAAP: 2:02

I would never call it mild anaphylaxis because that's an oxymoron. I'd call it early anaphylaxis, the perfect time to use epinephrine'cause we're not interested in seeing what's gonna happen. And as I mentioned it before, you don't need to wait for your five sneezes to turn into coughing, wheezing, respiratory distress. You don't need to wait until your local hives turn into full body hives with swelling, angioedema, and then a floppy kid who's having cardiovascular symptoms. Let's just treat'em early on. As I was mentioning before, those mast cells and basophils, they get more stable when epi is around. Making it less likely for them to then keep going and then act kind of to trigger others?

Amanda Whitehouse, PhD: 2:53

I like people to hear it from you'cause you're the doctor, not me. But It won't be harmful to use the epinephrine, right? People are still afraid of it, and I wanna keep dispelling that fear.

Michael Pistiner, MD, MMSc, FAAP: 3:03

Yeah, so Epinephrine is the medicine version of adrenaline. And so as I was mentioning, not only does it work on those allergy cells, but it also works on all the end organs that we want it to. Um, and we always talk about. The bad things that happen if you don't treat, but we don't really talk about the fact that it's gonna make your kid feel better. If your kid is in the middle of an allergic reaction and they're barfing and they feel terrible and they're itching and they're getting cranky and irritable, um, make'em feel better with the epinephrine. I think that one of the things that freaks people out is that. It has traditionally been delivered through the intramuscular route, which people aren't used to. It happens to be safe. Um, and for now, the intramuscular route is the only route available for, uh, kids under age four and under. 15 kilos. Um, and so, uh, there's intranasal epinephrine available for bigger older kids. Um, and then there are other modalities of epinephrine that look like they'll have FDA approval soon. But for now, intramuscular is what's available and it works great.

Amanda Whitehouse, PhD: 4:23

And you brought demonstration tools.

Michael Pistiner, MD, MMSc, FAAP: 4:25

I think so. Like one of the things I like to teach parents is you guys need to teach the people who are gonna take care of your kids. So you need to feel comfortable teaching others. And so that's tricky and that's the challenge. Um, one of the things that's gonna help you in the perspective of. Anaphylaxis and epinephrine is gonna be those action plans that we were talking about before. So getting one of those is gonna be good. And then you'll wanna get the trainer for whatever delivery system you have for your kid. So currently available, so the Teva generic epinephrine and the myelin generic epinephrine. Come with trainers, the Kaleo AuviQ comes with trainers. The impacts generic. Epinephrine does not. And so if you go to the pharmacy and you pick up your auto-injectors for your kid and you don't have the trainer, then. You could either call the company, ask for trainers, because you're gonna need to train secondary care providers. You can't just wing it. Um, and so for all of these, you could check out the companies to see their training videos, but then you also could check out the nonprofits because all the nonprofits are, um, having different videos and ways to get comfortable training other people. So check them out, whoever you guys use.

Amanda Whitehouse, PhD: 5:58

Yes, and I will put links for that in the show notes too. And for those listening to the audio podcast, find me on Instagram at the Food Allergy Psychologist, and you'll be able to see the videos of this too, of Dr. Pistiner showing us.

Michael Pistiner, MD, MMSc, FAAP: 6:09

And so like oftentimes when we use the trainers, usually use'em on ourselves, right? And so that's easy. But now imagine a little squirmy, wormy kid. Who's like really pissed and then you know, you are the uncle taking care of this kid and you don't even really know how to like hold him or anything. This is gonna be what the parents we are all up against, right? We gotta get these like crazy Uncle Mike. We gotta get him trained up. And so that's where you're gonna wanna use these trainers, but then also them how to hold and feel good about holding. I have some rescue mannequins. And so with the little kids, they're not gonna be able to not take their hand and grab the autoinjector. When you take that short, skinny needle and you stick it in there. Um, in their muscle now. So first off, we're putting it in the, um, lateral thigh, um, halfway between the knee and the hip, and the meaty part of the outer thigh muscle. Kind of hard just to say, but I'm gonna show you And so here for a grownup, giving it to myself, I just took off the safety with my non-dominant hand. I'm holding this particular autoinjector in my dominant hand. I'm a righty. So now halfway between my knee and my hip. And I don't have a cell phone in here or anything. Um, gentle pressure. I'm looking. Yes, it's a trainer. 1, 2, 3, and I got the dose. Now the point, what I was saying before is you're not coming straight in. You're not coming straight out from the side, but in that meatiest part of the thigh muscle.

Amanda Whitehouse, PhD: 7:56

And you said gentle pressure, not swing and stab, which is what most people.

Michael Pistiner, MD, MMSc, FAAP: 7:59

I personally wouldn't wanna swing and stab myself, but now think about a little magoo. If a grownup swings and jabs, they might miss, they might embed the needle and it might hurt. So just enough to actually trigger the needle is ultimately what you would do. And that's about 10 pounds of pressure now. So now let's say we have a toddler here, and. If they're having an allergic reaction, in infants and toddlers you can actually take their pants down. The reason you wouldn't necessarily think of it in a grownup or in a big kid is because in public dropping their pants could be a little embarrassing, and we don't want people to have to go. Walk away and go into a bathroom. But in little kids, it's really easy to get access to that thigh, so drop their pants so you won't have the clothes to go through. And now I'm holding this autoinjector in my right hand, my dominant hand. Um. my non-dominant hand, I take off the outer carrying case. This trainer contains no needle or drug. This one talks for me only. Do not use this trainer during allergic emergency. Ready to use pull red safety guard down and off of this trainer, non-dominant hand place black end against outer thigh. Then push verbally until you hear A and his. Now let's pretend this kid doesn't really want me to be doing this, doesn't really know what's going on, and even if they let me. Once the needle touches them, they may grab it. So now what I'm doing is I'm gonna come across this child with my non-dominant armpit, my left armpit like a seatbelt. Now I have control of the thigh with my non-dominant hand, and now I can give the child their dose. The best they could do is punch me in the back of the head, and then I can give them hugs and kisses used for training purposes.

Amanda Whitehouse, PhD: 10:11

Perfect. And so yeah. Then your, the child's arm that's on the side of the needle is kind of trapped underneath your ribs into your armpit. You can hold the legs so that they're not kicking. Yeah.

Michael Pistiner, MD, MMSc, FAAP: 10:21

So

Amanda Whitehouse, PhD: 10:21

Very helpful.

Michael Pistiner, MD, MMSc, FAAP: 10:22

yeah, so what we can do there is now I'm using my armpit across their waist. legs are right in front of me, and the kid would be facing behind me kinda like this. So then I'd have the thigh right there. Now you don't need a surface. You could put the kid on the floor. They're not gonna fall. Um, and so everybody's got a floor. Um, if there's two grownups together, then somebody can hold their hands and give them kisses while the other one has control of the thigh.

Amanda Whitehouse, PhD: 10:58

So helpful to see. Thank you so much for showing that. What else do you wanna show visually?

Michael Pistiner, MD, MMSc, FAAP: 11:02

Well, I mean the, I just showed the rescue mannequin for a bigger kid for the equivalent of a toddler, but the infant would be very similar. Now, the difference there though is that epinephrine is excellent to shut down an allergic reaction. It only works if you give it, and it only works if you have it. And so there are different doses that can be used for young kids. And so where AuviQ 0.1 is available, it's not available for everyone. There are some people who haven't had access to it, so. is available are the 0.1 fives from the other auto-injector companies. And so before the 0.1 dose was ever available, only the 0.15 was accessible. And so what the American Academy of Pediatrics and then also what the practice parameters from the Allergy Society say, is that 0.15works, and if you don't have the 0.1, that's fine. Use the 0.15. Um, now the additional guidance that I like to give is a slight adjustment because the amount of epinephrine likely isn't gonna cause. Significant side effects. The length of the needle might be something we can adjust for. And so in a small kid and their parents have the 0.15, I recommend bunching up the muscle away from the thigh bone, away from the femur. And so when you do the hold that I just talked about, then it gives the opportunity with the non-dominant hand. To pull up the thigh muscle away from the femur, not going under the skin. So you don't wanna go into the fat, which is subcutaneous. So you don't wanna pinch the skin away from the muscle, but you wanna bunch up the thigh muscle and then you'd be able to then give that dose. While the muscles bunched up away from the thigh. Now nobody's gonna pick up their baby and do it in the air, but I'm just doing it for the camera here. 1, 2, 3.

Amanda Whitehouse, PhD: 13:40

And that's another misconception because people used to think 10 seconds for the EpiPen and the, and the generics that look like.

Michael Pistiner, MD, MMSc, FAAP: 13:47

initially, um, that's the way it was written and then the. Mylan generic and the Teva generic dropped the whole time. impacts team didn't necessarily drop the whole time, and now it still says 10 seconds, but 10 seconds is likely way longer than we need, and a very, very long time to hold a child and keep them from moving with potential laceration. So when I recommend and have the conversation with families, I say, hold for five if you can. And then if it starts getting tough, then pull out the needle. Now, what's different about the generic from Impacts is that the needle will be out of the device without. A needle end for protector even after it was administered. So that's what's a little different than the two generic epinephrine that are available. And the Avi q um, the needle is in the child for about 0.3 seconds, gives the medication itself retracts, decreasing the chance that somebody would then have a laceration. Um, but they have a two second hold.

Amanda Whitehouse, PhD: 15:07

Thank you so much for explaining this. It's incredibly helpful. Is there other stuff that we didn't touch on that you wanna add

Michael Pistiner, MD, MMSc, FAAP: 15:13

I mean, well, so one of the things that people are starting to hear about and should talk to their. Clinicians about, and if they have allergists, talk to their allergists. But, um, the practice parameters, which is put out by what's called the joint task force, which is, um, the two American allergy societies, um, and others, um, have a work group that focuses on different things and. The 2023 Anaphylaxis practice parameter update includes conversations that we can have with the families that we take care of that make it so every time you use epinephrine, we're not telling you to call an ambulance. We're not telling people to call 9 1 1, but now this is, it's important to have shared decision making. It's important to talk to your clinician to decide if this is right for you and what circumstances you would consider this. And so what the practice parameters suggests that in this conversation that talk about how you need to have two autoinjectors available. First off, if you're gonna be thinking about this,'cause you need backup if the first one doesn't take care of business. One thing to know is that we were always were, or when people hear people say, use epinephrine and call 9 1 1, it's not because the epinephrine's bad, it's because we're actually concerned that maybe the epinephrine isn't gonna take care of it entirely. And then you might need IV fluid, you might need oxygen. You might need more epinephrine and you might need more friends, and it's a nice, safe way to get to the ambulance instead of hauling ass while you're driving at 65 miles an hour with your kid in the back. Um, and so those are the reasons why people have been saying call 9 1 1. But we now are saying that if you have two available doses, if. Yes, it is anaphylaxis, but you only have mild symptoms and there's no severe symptom. If you are feeling like it is under control and that when it works, it almost entirely takes care of it, it doesn't progress, and it goes away and doesn't come back, then you can then think about not calling 9 1 1. In which case then perhaps the. Allergists might have a triage line, uh, or your primary care team might have a triage line where you could call and then they could talk you through it. But of course, if there's any severe symptoms, if there's only one dose available, if it doesn't immediately go away, or if your child has other comorbidities or things to be thinking about, then calling 9 1 1 is a great idea'cause you got backup.

Amanda Whitehouse, PhD: 18:11

Thank you for clarifying that. I think I tell people this a lot. You still can, you just don't. Have to anymore. Right.

Michael Pistiner, MD, MMSc, FAAP: 18:17

Yeah, I still am getting comfortable with this, and so if I happen to be talking to a family after they treated their kid with epinephrine and it has it completely gone away, I still feel a little angst and I'm still kinda like calling them back in five minutes and making sure that in fact the kid legit is doing better. Um, that idea of the ambulance coming as backup in case something doesn't go as planned, that always has felt like a security blanket to me. But when you think about it. of people have delayed shutting things down with their epi because they don't want to call an ambulance. And especially if your brain is going there, then just treat, and then you can have angst about whether or not you want to call an ambulance. But the sooner you treat that kid, the less likely you then will need to call the ambulance because of all the things I talked to you about before. If you shut it down before they lose all that fluid, if you shut it down before they have the smooth muscle constriction in their lungs and mucus plugging, then you're not gonna need the oxygen or the IV fluid or more of the epi. Um, there's gonna be some kids who need a second dose, and that's why we say have the second dose. But the sheer majority, especially when early anaphylaxis is treated with epinephrine, the sheer majority only require the one dose and it shuts it down.

Amanda Whitehouse, PhD: 19:53

Thank you. That's helpful., Dr. Stukus was on the team that did that. Right.

Michael Pistiner, MD, MMSc, FAAP: 19:56

I think he was on the work group for the practice parameter.

Amanda Whitehouse, PhD: 20:00

Okay. And so he did an episode on the podcast talking about this too. I'll link to that for people'cause this is still a hot button topic too. And I'm glad you included it here. Tell me if this is a bad idea or not, but a lot of people feel the same way you did and want some kind of a middle ground. So if all of the, factors that you set are in place, if they've got the backup, the symptoms have subsided, all of those things. Um, another thing that's a lot of families, and I've done this with my son too, if there's another adult to stay with you and be in the car, we have just driven to the ER and sat in the parking lot for a little bit. Symptoms are gone, but someone's chatting with the kiddo and has eyes on him while we get ourselves close, just in case. But we didn't have an ambulance in an ER bill in the meantime. I don't know what you think about that.

Michael Pistiner, MD, MMSc, FAAP: 20:39

Being in a circumstance where then you can give your full attention to the child, see if any severe symptoms are coming, if it is in fact coming back, and if the second dose needs to be given is gonna be. What I ultimately would recommend, and so then that's gonna be where if you have those circumstances where you can go in the car to the emergency department, then that makes sense. But it also makes sense to be getting the information in the data in a safe place where then the ambulance ultimately would be able to get to you and would be able to be called if you need it. And so these are gonna be excellent conversations to have with your clinician. And a lot of this is gonna depend on also like where you live, how far away things are, um, you as a parent, and how you feel about it, and them as a clinician and how they feel about it. Some of us are still getting used to this

Amanda Whitehouse, PhD: 21:42

Yes, as we do, we just adapt and we take the new information in and then it takes time to emotionally and mentally adjust to it. Right.

Michael Pistiner, MD, MMSc, FAAP: 21:49

totally.

Amanda Whitehouse, PhD: 21:50

Well, thank you for helping us do that. This is gonna be incredibly helpful for people. I appreciate it so much.

Michael Pistiner, MD, MMSc, FAAP: 21:55

Well, thank you so much for having me.

21:58

What an empowering discussion. I hope that Dr. Pistiner language and his approach to thinking about this will be a relief for you to hear and to have in your heads and to know that with the right information, tools, and practice, we really can be ready to respond Calmly and effectively in an emergency. So here are three action steps to help you put what you learned today into practice number one. Again, follow Dr. Pistiner's work. The website is mass general.org/children/allergy. You'll find so many resources, and so much information there, as well as links to their social media. On Facebook, you can find the food allergy center at mgh. And an account for their food allergy buddies program. Number two, watch the video of proper epinephrine administration for infants and toddlers on my Instagram page@thefoodallergypsychologist. Dr. Pitner will show you exactly what he's describing in this episode. And number three, review your family's allergy action plan. Check that your epinephrine devices are up to date. Your caregivers know where they're kept, how to use them, and everyone in your child's circle feels confident about when epinephrine is necessary. All the links to everything that we talked about in last week's episode, and this one will be in the notes. So when you have a chance, please take the time to find the resources that you wanna review more carefully. Thank you again so much to Dr. Pistiner for taking so much time with me the content of this podcast is for informational and educational purposes only, and is not a substitute for professional medical or mental health advice, diagnosis, or treatment. If you have any questions about your own medical experience or mental health needs, please consult a professional. I'm Dr. Amanda Whitehouse. Thanks for joining me. And until we chat again, remember don't feed the fear.