November 25, 2025 • 23 mins
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
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Michael Pistiner, M (00:00):
epinephrine gets control.
And if you feel like you'relosing control, if you're afraid
you're gonna lose control, ifyou can't even wrap your head
around it'cause you're freakingout so hard, then go ahead and
administer the epinephrine tothe kid.
And then that gives you time tothink.
We always talk about whathappens if you don't give it,
(00:22):
but when you do give it, itmakes you feel better fast.
And why make a kid sit there andfeel totally miserable?
Shut
Amanda Whitehouse, PhD (00:29):
Yes.
Speaker (00:31):
Welcome to the Don't Feed the Fear podcast, where we
dive into the complex world offood allergy anxiety.
I'm your host, Dr.
Amanda Whitehouse, food allergyanxiety psychologist and food
allergy mom.
Whether you're dealing withallergies yourself or supporting
someone who is, join us for anempathetic and informative
journey toward food allergy calmand confidence..
(00:52):
Welcome back for part two ofthis wonderful conversation with
Dr.
Michael Pistiner, pediatricallergist and director of Food
allergy advocacy, education andprevention at Mass General for
Children Harvard Medical School.
If you missed part one lastweek.
Go back and listen.
We talked about the updatedcriteria for diagnosing
anaphylaxis in infants andtoddlers.
What's changed and what to lookfor during a reaction in very
(01:15):
young children.
In this episode, we'recontinuing that conversation
with a practical focus onepinephrine, specifically, which
device is appropriate forinfants and toddlers, and how to
administer it safely andeffectively in such small
children.
Dr.
Pistiner walks us through thetechnique, step-by-step, shares,
tips for helping parents feelmore confident and explains how
(01:35):
caregivers can prepare inadvance.
It's such a valuableconversation.
I wanted you to have this rightbefore the holidays going into
the time of the year whereunfortunately we do experience
reactions, hopefully none of youwill have a reaction at your
holiday dinners, but if you do,let's stop it in early
anaphylaxis, rather than lettingit progress further.
For those who prefer visuallearning, you will find Dr.
(01:56):
Pistiner demonstrating this onvideo on my Instagram page
@thefoodallergypsychologist.
Michael Pistiner, MD, MMSc, F (02:02):
I would never call it mild
anaphylaxis because that's anoxymoron.
I'd call it early anaphylaxis,the perfect time to use
epinephrine'cause we're notinterested in seeing what's
gonna happen.
And as I mentioned it before,you don't need to wait for your
five sneezes to turn intocoughing, wheezing, respiratory
distress.
(02:23):
You don't need to wait untilyour local hives turn into full
body hives with swelling,angioedema, and then a floppy
kid who's having cardiovascularsymptoms.
Let's just treat'em early on.
As I was mentioning before,those mast cells and basophils,
they get more stable when epi isaround.
(02:46):
Making it less likely for themto then keep going and then act
kind of to trigger others?
Amanda Whitehouse, PhD (02:53):
I like people to hear it from you'cause
you're the doctor, not me.
But It won't be harmful to usethe epinephrine, right?
People are still afraid of it,and I wanna keep dispelling that
fear.
Michael Pistiner, MD, MMS (03:03):
Yeah, so Epinephrine is the medicine
version of adrenaline.
And so as I was mentioning, notonly does it work on those
allergy cells, but it also workson all the end organs that we
want it to.
Um, and we always talk about.
The bad things that happen ifyou don't treat, but we don't
(03:23):
really talk about the fact thatit's gonna make your kid feel
better.
If your kid is in the middle ofan allergic reaction and they're
barfing and they feel terribleand they're itching and they're
getting cranky and irritable,um, make'em feel better with the
epinephrine.
I think that one of the thingsthat freaks people out is that.
It has traditionally beendelivered through the
(03:45):
intramuscular route, whichpeople aren't used to.
It happens to be safe.
Um, and for now, theintramuscular route is the only
route available for, uh, kidsunder age four and under.
15 kilos.
Um, and so, uh, there'sintranasal epinephrine available
(04:07):
for bigger older kids.
Um, and then there are othermodalities of epinephrine that
look like they'll have FDAapproval soon.
But for now, intramuscular iswhat's available and it works
great.
Amanda Whitehouse, PhD (04:23):
And you brought demonstration tools.
Michael Pistiner, MD, MMSc, F (04:25):
I think so.
Like one of the things I like toteach parents is you guys need
to teach the people who aregonna take care of your kids.
So you need to feel comfortableteaching others.
And so that's tricky and that'sthe challenge.
Um, one of the things that'sgonna help you in the
perspective of.
(04:45):
Anaphylaxis and epinephrine isgonna be those action plans that
we were talking about before.
So getting one of those is gonnabe good.
And then you'll wanna get thetrainer for whatever delivery
system you have for your kid.
So currently available, so theTeva generic epinephrine and the
(05:07):
myelin generic epinephrine.
Come with trainers, the KaleoAuviQ comes with trainers.
The impacts generic.
Epinephrine does not.
And so if you go to the pharmacyand you pick up your
auto-injectors for your kid andyou don't have the trainer,
(05:30):
then.
You could either call thecompany, ask for trainers,
because you're gonna need totrain secondary care providers.
You can't just wing it.
Um, and so for all of these, youcould check out the companies to
see their training videos, butthen you also could check out
the nonprofits because all thenonprofits are, um, having
(05:53):
different videos and ways to getcomfortable training other
people.
So check them out, whoever youguys use.
Amanda Whitehouse, PhD (05:58):
Yes, and I will put links for that in the
show notes too.
And for those listening to theaudio podcast, find me on
Instagram at the Food AllergyPsychologist, and you'll be able
to see the videos of this too,of Dr.
Pistiner showing us.
Michael Pistiner, MD, MMSc, (06:09):
And so like oftentimes when we use
the trainers, usually use'em onourselves, right?
And so that's easy.
But now imagine a littlesquirmy, wormy kid.
Who's like really pissed andthen you know, you are the uncle
taking care of this kid and youdon't even really know how to
like hold him or anything.
(06:31):
This is gonna be what theparents we are all up against,
right?
We gotta get these like crazyUncle Mike.
We gotta get him trained up.
And so that's where you're gonnawanna use these trainers, but
then also them how to hold andfeel good about holding.
I have some rescue mannequins.
And so with the little kids,they're not gonna be able to not
(06:56):
take their hand and grab theautoinjector.
When you take that short, skinnyneedle and you stick it in
there.
Um, in their muscle now.
So first off, we're putting itin the, um, lateral thigh, um,
halfway between the knee and thehip, and the meaty part of the
outer thigh muscle.
(07:16):
Kind of hard just to say, butI'm gonna show you And so here
for a grownup, giving it tomyself, I just took off the
safety with my non-dominanthand.
I'm holding this particularautoinjector in my dominant
hand.
I'm a righty.
So now halfway between my kneeand my hip.
And I don't have a cell phone inhere or anything.
(07:36):
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 sayingbefore is you're not coming
straight in.
You're not coming straight outfrom the side, but in that
meatiest part of the thighmuscle.
Amanda Whitehouse, PhD (07:56):
And you said gentle pressure, not swing
and stab, which is what mostpeople.
Michael Pistiner, MD, MMSc, F (07:59):
I personally wouldn't wanna swing
and stab myself, but now thinkabout a little magoo.
If a grownup swings and jabs,they might miss, they might
embed the needle and it mighthurt.
So just enough to actuallytrigger the needle is ultimately
what you would do.
And that's about 10 pounds ofpressure now.
(08:20):
So now let's say we have atoddler here, and.
If they're having an allergicreaction, in infants and
toddlers you can actually taketheir pants down.
The reason you wouldn'tnecessarily think of it in a
grownup or in a big kid isbecause in public dropping their
pants could be a littleembarrassing, and we don't want
(08:42):
people to have to go.
Walk away and go into abathroom.
But in little kids, it's reallyeasy to get access to that
thigh, so drop their pants soyou won't have the clothes to go
through.
And now I'm holding thisautoinjector in my right hand,
my dominant hand.
Um.
(09:02):
my non-dominant hand, I take offthe outer carrying case.
This trainer contains no needleor drug.
This one talks for me only.
Do not use this trainer duringallergic emergency.
Ready to use pull red safetyguard down and off of this
trainer, non-dominant hand placeblack end against outer thigh.
(09:27):
Then push verbally until youhear A and his.
Now let's pretend this kiddoesn't really want me to be
doing this, doesn't really knowwhat'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'mgonna come across this child
with my non-dominant armpit, myleft armpit like a seatbelt.
(09:52):
Now I have control of the thighwith my non-dominant hand, and
now I can give the child theirdose.
The best they could do is punchme in the back of the head, and
then I can give them hugs andkisses used for training
purposes.
Amanda Whitehouse, PhD (10:11):
Perfect.
And so yeah.
Then your, the child's armthat's on the side of the needle
is kind of trapped underneathyour ribs into your armpit.
You can hold the legs so thatthey're not kicking.
Yeah.
Michael Pistiner, MD, MMSc, (10:21):
So
Amanda Whitehouse, PhD (10:21):
Very helpful.
Michael Pistiner, MD, MMS (10:22):
yeah, so what we can do there is now
I'm using my armpit across theirwaist.
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 rightthere.
Now you don't need a surface.
(10:44):
You could put the kid on thefloor.
They're not gonna fall.
Um, and so everybody's got afloor.
Um, if there's two grownupstogether, then somebody can hold
their hands and give them kisseswhile the other one has control
of the thigh.
Amanda Whitehouse, PhD (10:58):
So helpful to see.
Thank you so much for showingthat.
What else do you wanna showvisually?
Michael Pistiner, MD, MMS (11:02):
Well, I mean the, I just showed the
rescue mannequin for a biggerkid for the equivalent of a
toddler, but the infant would bevery similar.
Now, the difference there thoughis that epinephrine is excellent
to shut down an allergicreaction.
It only works if you give it,and it only works if you have
(11:26):
it.
And so there are different dosesthat can be used for young kids.
And so where AuviQ 0.1 isavailable, it's not available
for everyone.
There are some people whohaven't had access to it, so.
(11:49):
is available are the 0.1 fivesfrom the other auto-injector
companies.
And so before the 0.1 dose wasever available, only the 0.15
was accessible.
And so what the American Academyof Pediatrics and then also what
the practice parameters from theAllergy Society say, is that
(12:14):
0.15works, and if you don't havethe 0.1, that's fine.
Use the 0.15.
Um, now the additional guidancethat I like to give is a slight
adjustment because the amount ofepinephrine likely isn't gonna
cause.
Significant side effects.
(12:35):
The length of the needle mightbe something we can adjust for.
And so in a small kid and theirparents have the 0.15, I
recommend bunching up the muscleaway from the thigh bone, away
from the femur.
And so when you do the hold thatI just talked about, then it
(12:58):
gives the opportunity with thenon-dominant hand.
To pull up the thigh muscle awayfrom the femur, not going under
the skin.
So you don't wanna go into thefat, which is subcutaneous.
So you don't wanna pinch theskin away from the muscle, but
you wanna bunch up the thighmuscle and then you'd be able to
(13:21):
then give that dose.
While the muscles bunched upaway from the thigh.
Now nobody's gonna pick up theirbaby and do it in the air, but
I'm just doing it for the camerahere.
1, 2, 3.
Amanda Whitehouse, PhD (13:40):
And that's another misconception
because people used to think 10seconds for the EpiPen and the,
and the generics that look like.
Michael Pistiner, MD (13:47):
initially, um, that's the way it was
written and then the.
Mylan generic and the Tevageneric dropped the whole time.
impacts team didn't necessarilydrop the whole time, and now it
still says 10 seconds, but 10seconds is likely way longer
(14:09):
than we need, and a very, verylong time to hold a child and
keep them from moving withpotential laceration.
So when I recommend and have theconversation with families, I
say, hold for five if you can.
And then if it starts gettingtough, then pull out the needle.
(14:31):
Now, what's different about thegeneric from Impacts is that the
needle will be out of the devicewithout.
A needle end for protector evenafter it was administered.
So that's what's a littledifferent than the two generic
epinephrine that are available.
(14:51):
And the Avi q um, the needle isin the child for about 0.3
seconds, gives the medicationitself retracts, decreasing the
chance that somebody would thenhave a laceration.
Um, but they have a two secondhold.
Amanda Whitehouse, PhD (15:07):
Thank you so much for explaining this.
It's incredibly helpful.
Is there other stuff that wedidn't touch on that you wanna
add
Michael Pistiner, MD, MMSc, F (15:13):
I mean, well, so one of the things
that people are starting to hearabout and should talk to their.
Clinicians about, and if theyhave allergists, talk to their
allergists.
But, um, the practiceparameters, which is put out by
what's called the joint taskforce, which is, um, the two
(15:36):
American allergy societies, um,and others, um, have a work
group that focuses on differentthings and.
The 2023 Anaphylaxis practiceparameter update includes
conversations that we can havewith the families that we take
care of that make it so everytime you use epinephrine, we're
(16:02):
not telling you to call anambulance.
We're not telling people to call9 1 1, but now this is, it's
important to have shareddecision making.
It's important to talk to yourclinician to decide if this is
right for you and whatcircumstances you would consider
this.
And so what the practiceparameters suggests that in this
(16:23):
conversation that talk about howyou need to have two
autoinjectors available.
First off, if you're gonna bethinking about this,'cause you
need backup if the first onedoesn't take care of business.
One thing to know is that wewere always were, or when people
hear people say, use epinephrineand call 9 1 1, it's not because
the epinephrine's bad, it'sbecause we're actually concerned
(16:46):
that maybe the epinephrine isn'tgonna take care of it entirely.
And then you might need IVfluid, you might need oxygen.
You might need more epinephrineand you might need more friends,
and it's a nice, safe way to getto the ambulance instead of
hauling ass while you're drivingat 65 miles an hour with your
kid in the back.
Um, and so those are the reasonswhy people have been saying call
(17:07):
9 1 1.
But we now are saying that ifyou have two available doses,
if.
Yes, it is anaphylaxis, but youonly have mild symptoms and
there's no severe symptom.
If you are feeling like it isunder control and that when it
(17:30):
works, it almost entirely takescare of it, it doesn't progress,
and it goes away and doesn'tcome back, then you can then
think about not calling 9 1 1.
In which case then perhaps the.
Allergists might have a triageline, uh, or your primary care
team might have a triage linewhere you could call and then
(17:53):
they could talk you through it.
But of course, if there's anysevere symptoms, if there's only
one dose available, if itdoesn't immediately go away, or
if your child has othercomorbidities or things to be
thinking about, then calling 9 11 is a great idea'cause you got
backup.
Amanda Whitehouse, PhD (18:11):
Thank you for clarifying that.
I think I tell people this alot.
You still can, you just don't.
Have to anymore.
Right.
Michael Pistiner, MD, MMS (18:17):
Yeah, I still am getting comfortable
with this, and so if I happen tobe talking to a family after
they treated their kid withepinephrine and it has it
completely gone away, I stillfeel a little angst and I'm
still kinda like calling themback in five minutes and making
(18:39):
sure that in fact the kid legitis doing better.
Um, that idea of the ambulancecoming 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 shuttingthings down with their epi
(19:02):
because they don't want to callan ambulance.
And especially if your brain isgoing there, then just treat,
and then you can have angstabout whether or not you want to
call an ambulance.
But the sooner you treat thatkid, the less likely you then
will need to call the ambulancebecause of all the things I
talked to you about before.
(19:22):
If you shut it down before theylose all that fluid, if you shut
it down before they have thesmooth muscle constriction in
their lungs and mucus plugging,then you're not gonna need the
oxygen or the IV fluid or moreof the epi.
Um, there's gonna be some kidswho need a second dose, and
that's why we say have thesecond dose.
But the sheer majority,especially when early
(19:45):
anaphylaxis is treated withepinephrine, the sheer majority
only require the one dose and itshuts it down.
Amanda Whitehouse, PhD (19:53):
Thank you.
That's helpful., Dr.
Stukus was on the team that didthat.
Right.
Michael Pistiner, MD, MMSc, F (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 thepodcast 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 ithere.
Tell me if this is a bad idea ornot, but a lot of people feel
the same way you did and wantsome kind of a middle ground.
So if all of the, factors thatyou set are in place, if they've
got the backup, the symptomshave subsided, all of those
things.
Um, another thing that's a lotof families, and I've done this
(20:22):
with my son too, if there'sanother adult to stay with you
and be in the car, we have justdriven to the ER and sat in the
parking lot for a little bit.
Symptoms are gone, but someone'schatting with the kiddo and has
eyes on him while we getourselves close, just in case.
But we didn't have an ambulancein an ER bill in the meantime.
I don't know what you thinkabout that.
Michael Pistiner, MD, MMS (20:39):
Being in a circumstance where then you
can give your full attention tothe child, see if any severe
symptoms are coming, if it is infact coming back, and if the
second dose needs to be given isgonna be.
What I ultimately wouldrecommend, and so then that's
gonna be where if you have thosecircumstances where you can go
(21:02):
in the car to the emergencydepartment, then that makes
sense.
But it also makes sense to begetting the information in the
data in a safe place where thenthe ambulance ultimately would
be able to get to you and wouldbe able to be called if you need
it.
And so these are gonna beexcellent conversations to have
(21:25):
with your clinician.
And a lot of this is gonnadepend 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 aclinician and how they feel
about it.
Some of us are still gettingused to this
Amanda Whitehouse, PhD (21:42):
Yes, as we do, we just adapt and we take
the new information in and thenit takes time to emotionally and
mentally adjust to it.
Right.
Michael Pistiner, MD, (21:49):
totally.
Amanda Whitehouse, PhD (21:50):
Well, thank you for helping us do
that.
This is gonna be incrediblyhelpful for people.
I appreciate it so much.
Michael Pistiner, MD, MMS (21:55):
Well, thank you so much for having me.
What an empowering discussion.
I hope that Dr.
Pistiner language and hisapproach to thinking about this
will be a relief for you to hearand to have in your heads and to
know that with the rightinformation, tools, and
practice, we really can be readyto respond Calmly and
effectively in an emergency.
So here are three action stepsto help you put what you learned
(22:15):
today into practice number one.
Again, follow Dr.
Pistiner's work.
The website is massgeneral.org/children/allergy.
You'll find so many resources,and so much information there,
as well as links to their socialmedia.
On Facebook, you can find thefood allergy center at mgh.
And an account for their foodallergy buddies program.
(22:37):
Number two, watch the video ofproper epinephrine
administration for infants andtoddlers on my Instagram page
@thefoodallergypsychologist.
Dr.
Pitner will show you exactlywhat he's describing in this
episode.
And number three, review yourfamily's allergy action plan.
Check that your epinephrinedevices are up to date.
Your caregivers know wherethey're kept, how to use them,
and everyone in your child'scircle feels confident about
(22:59):
when epinephrine is necessary.
All the links to everything thatwe talked about in last week's
episode, and this one will be inthe notes.
So when you have a chance,please take the time to find the
resources that you wanna reviewmore carefully.
Thank you again so much to Dr.
Pistiner for taking so much timewith me the content of this
podcast is for informational andeducational purposes only, and
(23:20):
is not a substitute forprofessional medical or mental
health advice, diagnosis, ortreatment.
If you have any questions aboutyour own medical experience or
mental health needs, pleaseconsult a professional.
I'm Dr.
Amanda Whitehouse.
Thanks for joining me.
And until we chat again,remember don't feed the fear.
epinephrine gets control.
And if you feel like you'relosing control, if you're afraid
you're gonna lose control, ifyou can't even wrap your head
around it'cause you're freakingout so hard, then go ahead and
administer the epinephrine tothe kid.
And then that gives you time tothink.
We always talk about whathappens if you don't give it,
(00:22):
but when you do give it, itmakes you feel better fast.
And why make a kid sit there andfeel totally miserable?
Shut
Amanda Whitehouse, PhD (00:29):
Yes.
Speaker (00:31):
Welcome to the Don't Feed the Fear podcast, where we
dive into the complex world offood allergy anxiety.
I'm your host, Dr.
Amanda Whitehouse, food allergyanxiety psychologist and food
allergy mom.
Whether you're dealing withallergies yourself or supporting
someone who is, join us for anempathetic and informative
journey toward food allergy calmand confidence..
(00:52):
Welcome back for part two ofthis wonderful conversation with
Dr.
Michael Pistiner, pediatricallergist and director of Food
allergy advocacy, education andprevention at Mass General for
Children Harvard Medical School.
If you missed part one lastweek.
Go back and listen.
We talked about the updatedcriteria for diagnosing
anaphylaxis in infants andtoddlers.
What's changed and what to lookfor during a reaction in very
(01:15):
young children.
In this episode, we'recontinuing that conversation
with a practical focus onepinephrine, specifically, which
device is appropriate forinfants and toddlers, and how to
administer it safely andeffectively in such small
children.
Dr.
Pistiner walks us through thetechnique, step-by-step, shares,
tips for helping parents feelmore confident and explains how
(01:35):
caregivers can prepare inadvance.
It's such a valuableconversation.
I wanted you to have this rightbefore the holidays going into
the time of the year whereunfortunately we do experience
reactions, hopefully none of youwill have a reaction at your
holiday dinners, but if you do,let's stop it in early
anaphylaxis, rather than lettingit progress further.
For those who prefer visuallearning, you will find Dr.
(01:56):
Pistiner demonstrating this onvideo on my Instagram page
@thefoodallergypsychologist.
Michael Pistiner, MD, MMSc, F (02:02):
I would never call it mild
anaphylaxis because that's anoxymoron.
I'd call it early anaphylaxis,the perfect time to use
epinephrine'cause we're notinterested in seeing what's
gonna happen.
And as I mentioned it before,you don't need to wait for your
five sneezes to turn intocoughing, wheezing, respiratory
distress.
(02:23):
You don't need to wait untilyour local hives turn into full
body hives with swelling,angioedema, and then a floppy
kid who's having cardiovascularsymptoms.
Let's just treat'em early on.
As I was mentioning before,those mast cells and basophils,
they get more stable when epi isaround.
(02:46):
Making it less likely for themto then keep going and then act
kind of to trigger others?
Amanda Whitehouse, PhD (02:53):
I like people to hear it from you'cause
you're the doctor, not me.
But It won't be harmful to usethe epinephrine, right?
People are still afraid of it,and I wanna keep dispelling that
fear.
Michael Pistiner, MD, MMS (03:03):
Yeah, so Epinephrine is the medicine
version of adrenaline.
And so as I was mentioning, notonly does it work on those
allergy cells, but it also workson all the end organs that we
want it to.
Um, and we always talk about.
The bad things that happen ifyou don't treat, but we don't
(03:23):
really talk about the fact thatit's gonna make your kid feel
better.
If your kid is in the middle ofan allergic reaction and they're
barfing and they feel terribleand they're itching and they're
getting cranky and irritable,um, make'em feel better with the
epinephrine.
I think that one of the thingsthat freaks people out is that.
It has traditionally beendelivered through the
(03:45):
intramuscular route, whichpeople aren't used to.
It happens to be safe.
Um, and for now, theintramuscular route is the only
route available for, uh, kidsunder age four and under.
15 kilos.
Um, and so, uh, there'sintranasal epinephrine available
(04:07):
for bigger older kids.
Um, and then there are othermodalities of epinephrine that
look like they'll have FDAapproval soon.
But for now, intramuscular iswhat's available and it works
great.
Amanda Whitehouse, PhD (04:23):
And you brought demonstration tools.
Michael Pistiner, MD, MMSc, F (04:25):
I think so.
Like one of the things I like toteach parents is you guys need
to teach the people who aregonna take care of your kids.
So you need to feel comfortableteaching others.
And so that's tricky and that'sthe challenge.
Um, one of the things that'sgonna help you in the
perspective of.
(04:45):
Anaphylaxis and epinephrine isgonna be those action plans that
we were talking about before.
So getting one of those is gonnabe good.
And then you'll wanna get thetrainer for whatever delivery
system you have for your kid.
So currently available, so theTeva generic epinephrine and the
(05:07):
myelin generic epinephrine.
Come with trainers, the KaleoAuviQ comes with trainers.
The impacts generic.
Epinephrine does not.
And so if you go to the pharmacyand you pick up your
auto-injectors for your kid andyou don't have the trainer,
(05:30):
then.
You could either call thecompany, ask for trainers,
because you're gonna need totrain secondary care providers.
You can't just wing it.
Um, and so for all of these, youcould check out the companies to
see their training videos, butthen you also could check out
the nonprofits because all thenonprofits are, um, having
(05:53):
different videos and ways to getcomfortable training other
people.
So check them out, whoever youguys use.
Amanda Whitehouse, PhD (05:58):
Yes, and I will put links for that in the
show notes too.
And for those listening to theaudio podcast, find me on
Instagram at the Food AllergyPsychologist, and you'll be able
to see the videos of this too,of Dr.
Pistiner showing us.
Michael Pistiner, MD, MMSc, (06:09):
And so like oftentimes when we use
the trainers, usually use'em onourselves, right?
And so that's easy.
But now imagine a littlesquirmy, wormy kid.
Who's like really pissed andthen you know, you are the uncle
taking care of this kid and youdon't even really know how to
like hold him or anything.
(06:31):
This is gonna be what theparents we are all up against,
right?
We gotta get these like crazyUncle Mike.
We gotta get him trained up.
And so that's where you're gonnawanna use these trainers, but
then also them how to hold andfeel good about holding.
I have some rescue mannequins.
And so with the little kids,they're not gonna be able to not
(06:56):
take their hand and grab theautoinjector.
When you take that short, skinnyneedle and you stick it in
there.
Um, in their muscle now.
So first off, we're putting itin the, um, lateral thigh, um,
halfway between the knee and thehip, and the meaty part of the
outer thigh muscle.
(07:16):
Kind of hard just to say, butI'm gonna show you And so here
for a grownup, giving it tomyself, I just took off the
safety with my non-dominanthand.
I'm holding this particularautoinjector in my dominant
hand.
I'm a righty.
So now halfway between my kneeand my hip.
And I don't have a cell phone inhere or anything.
(07:36):
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 sayingbefore is you're not coming
straight in.
You're not coming straight outfrom the side, but in that
meatiest part of the thighmuscle.
Amanda Whitehouse, PhD (07:56):
And you said gentle pressure, not swing
and stab, which is what mostpeople.
Michael Pistiner, MD, MMSc, F (07:59):
I personally wouldn't wanna swing
and stab myself, but now thinkabout a little magoo.
If a grownup swings and jabs,they might miss, they might
embed the needle and it mighthurt.
So just enough to actuallytrigger the needle is ultimately
what you would do.
And that's about 10 pounds ofpressure now.
(08:20):
So now let's say we have atoddler here, and.
If they're having an allergicreaction, in infants and
toddlers you can actually taketheir pants down.
The reason you wouldn'tnecessarily think of it in a
grownup or in a big kid isbecause in public dropping their
pants could be a littleembarrassing, and we don't want
(08:42):
people to have to go.
Walk away and go into abathroom.
But in little kids, it's reallyeasy to get access to that
thigh, so drop their pants soyou won't have the clothes to go
through.
And now I'm holding thisautoinjector in my right hand,
my dominant hand.
Um.
(09:02):
my non-dominant hand, I take offthe outer carrying case.
This trainer contains no needleor drug.
This one talks for me only.
Do not use this trainer duringallergic emergency.
Ready to use pull red safetyguard down and off of this
trainer, non-dominant hand placeblack end against outer thigh.
(09:27):
Then push verbally until youhear A and his.
Now let's pretend this kiddoesn't really want me to be
doing this, doesn't really knowwhat'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'mgonna come across this child
with my non-dominant armpit, myleft armpit like a seatbelt.
(09:52):
Now I have control of the thighwith my non-dominant hand, and
now I can give the child theirdose.
The best they could do is punchme in the back of the head, and
then I can give them hugs andkisses used for training
purposes.
Amanda Whitehouse, PhD (10:11):
Perfect.
And so yeah.
Then your, the child's armthat's on the side of the needle
is kind of trapped underneathyour ribs into your armpit.
You can hold the legs so thatthey're not kicking.
Yeah.
Michael Pistiner, MD, MMSc, (10:21):
So
Amanda Whitehouse, PhD (10:21):
Very helpful.
Michael Pistiner, MD, MMS (10:22):
yeah, so what we can do there is now
I'm using my armpit across theirwaist.
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 rightthere.
Now you don't need a surface.
(10:44):
You could put the kid on thefloor.
They're not gonna fall.
Um, and so everybody's got afloor.
Um, if there's two grownupstogether, then somebody can hold
their hands and give them kisseswhile the other one has control
of the thigh.
Amanda Whitehouse, PhD (10:58):
So helpful to see.
Thank you so much for showingthat.
What else do you wanna showvisually?
Michael Pistiner, MD, MMS (11:02):
Well, I mean the, I just showed the
rescue mannequin for a biggerkid for the equivalent of a
toddler, but the infant would bevery similar.
Now, the difference there thoughis that epinephrine is excellent
to shut down an allergicreaction.
It only works if you give it,and it only works if you have
(11:26):
it.
And so there are different dosesthat can be used for young kids.
And so where AuviQ 0.1 isavailable, it's not available
for everyone.
There are some people whohaven't had access to it, so.
(11:49):
is available are the 0.1 fivesfrom the other auto-injector
companies.
And so before the 0.1 dose wasever available, only the 0.15
was accessible.
And so what the American Academyof Pediatrics and then also what
the practice parameters from theAllergy Society say, is that
(12:14):
0.15works, and if you don't havethe 0.1, that's fine.
Use the 0.15.
Um, now the additional guidancethat I like to give is a slight
adjustment because the amount ofepinephrine likely isn't gonna
cause.
Significant side effects.
(12:35):
The length of the needle mightbe something we can adjust for.
And so in a small kid and theirparents have the 0.15, I
recommend bunching up the muscleaway from the thigh bone, away
from the femur.
And so when you do the hold thatI just talked about, then it
(12:58):
gives the opportunity with thenon-dominant hand.
To pull up the thigh muscle awayfrom the femur, not going under
the skin.
So you don't wanna go into thefat, which is subcutaneous.
So you don't wanna pinch theskin away from the muscle, but
you wanna bunch up the thighmuscle and then you'd be able to
(13:21):
then give that dose.
While the muscles bunched upaway from the thigh.
Now nobody's gonna pick up theirbaby and do it in the air, but
I'm just doing it for the camerahere.
1, 2, 3.
Amanda Whitehouse, PhD (13:40):
And that's another misconception
because people used to think 10seconds for the EpiPen and the,
and the generics that look like.
Michael Pistiner, MD (13:47):
initially, um, that's the way it was
written and then the.
Mylan generic and the Tevageneric dropped the whole time.
impacts team didn't necessarilydrop the whole time, and now it
still says 10 seconds, but 10seconds is likely way longer
(14:09):
than we need, and a very, verylong time to hold a child and
keep them from moving withpotential laceration.
So when I recommend and have theconversation with families, I
say, hold for five if you can.
And then if it starts gettingtough, then pull out the needle.
(14:31):
Now, what's different about thegeneric from Impacts is that the
needle will be out of the devicewithout.
A needle end for protector evenafter it was administered.
So that's what's a littledifferent than the two generic
epinephrine that are available.
(14:51):
And the Avi q um, the needle isin the child for about 0.3
seconds, gives the medicationitself retracts, decreasing the
chance that somebody would thenhave a laceration.
Um, but they have a two secondhold.
Amanda Whitehouse, PhD (15:07):
Thank you so much for explaining this.
It's incredibly helpful.
Is there other stuff that wedidn't touch on that you wanna
add
Michael Pistiner, MD, MMSc, F (15:13):
I mean, well, so one of the things
that people are starting to hearabout and should talk to their.
Clinicians about, and if theyhave allergists, talk to their
allergists.
But, um, the practiceparameters, which is put out by
what's called the joint taskforce, which is, um, the two
(15:36):
American allergy societies, um,and others, um, have a work
group that focuses on differentthings and.
The 2023 Anaphylaxis practiceparameter update includes
conversations that we can havewith the families that we take
care of that make it so everytime you use epinephrine, we're
(16:02):
not telling you to call anambulance.
We're not telling people to call9 1 1, but now this is, it's
important to have shareddecision making.
It's important to talk to yourclinician to decide if this is
right for you and whatcircumstances you would consider
this.
And so what the practiceparameters suggests that in this
(16:23):
conversation that talk about howyou need to have two
autoinjectors available.
First off, if you're gonna bethinking about this,'cause you
need backup if the first onedoesn't take care of business.
One thing to know is that wewere always were, or when people
hear people say, use epinephrineand call 9 1 1, it's not because
the epinephrine's bad, it'sbecause we're actually concerned
(16:46):
that maybe the epinephrine isn'tgonna take care of it entirely.
And then you might need IVfluid, you might need oxygen.
You might need more epinephrineand you might need more friends,
and it's a nice, safe way to getto the ambulance instead of
hauling ass while you're drivingat 65 miles an hour with your
kid in the back.
Um, and so those are the reasonswhy people have been saying call
(17:07):
9 1 1.
But we now are saying that ifyou have two available doses,
if.
Yes, it is anaphylaxis, but youonly have mild symptoms and
there's no severe symptom.
If you are feeling like it isunder control and that when it
(17:30):
works, it almost entirely takescare of it, it doesn't progress,
and it goes away and doesn'tcome back, then you can then
think about not calling 9 1 1.
In which case then perhaps the.
Allergists might have a triageline, uh, or your primary care
team might have a triage linewhere you could call and then
(17:53):
they could talk you through it.
But of course, if there's anysevere symptoms, if there's only
one dose available, if itdoesn't immediately go away, or
if your child has othercomorbidities or things to be
thinking about, then calling 9 11 is a great idea'cause you got
backup.
Amanda Whitehouse, PhD (18:11):
Thank you for clarifying that.
I think I tell people this alot.
You still can, you just don't.
Have to anymore.
Right.
Michael Pistiner, MD, MMS (18:17):
Yeah, I still am getting comfortable
with this, and so if I happen tobe talking to a family after
they treated their kid withepinephrine and it has it
completely gone away, I stillfeel a little angst and I'm
still kinda like calling themback in five minutes and making
(18:39):
sure that in fact the kid legitis doing better.
Um, that idea of the ambulancecoming 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 shuttingthings down with their epi
(19:02):
because they don't want to callan ambulance.
And especially if your brain isgoing there, then just treat,
and then you can have angstabout whether or not you want to
call an ambulance.
But the sooner you treat thatkid, the less likely you then
will need to call the ambulancebecause of all the things I
talked to you about before.
(19:22):
If you shut it down before theylose all that fluid, if you shut
it down before they have thesmooth muscle constriction in
their lungs and mucus plugging,then you're not gonna need the
oxygen or the IV fluid or moreof the epi.
Um, there's gonna be some kidswho need a second dose, and
that's why we say have thesecond dose.
But the sheer majority,especially when early
(19:45):
anaphylaxis is treated withepinephrine, the sheer majority
only require the one dose and itshuts it down.
Amanda Whitehouse, PhD (19:53):
Thank you.
That's helpful., Dr.
Stukus was on the team that didthat.
Right.
Michael Pistiner, MD, MMSc, F (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 thepodcast 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 ithere.
Tell me if this is a bad idea ornot, but a lot of people feel
the same way you did and wantsome kind of a middle ground.
So if all of the, factors thatyou set are in place, if they've
got the backup, the symptomshave subsided, all of those
things.
Um, another thing that's a lotof families, and I've done this
(20:22):
with my son too, if there'sanother adult to stay with you
and be in the car, we have justdriven to the ER and sat in the
parking lot for a little bit.
Symptoms are gone, but someone'schatting with the kiddo and has
eyes on him while we getourselves close, just in case.
But we didn't have an ambulancein an ER bill in the meantime.
I don't know what you thinkabout that.
Michael Pistiner, MD, MMS (20:39):
Being in a circumstance where then you
can give your full attention tothe child, see if any severe
symptoms are coming, if it is infact coming back, and if the
second dose needs to be given isgonna be.
What I ultimately wouldrecommend, and so then that's
gonna be where if you have thosecircumstances where you can go
(21:02):
in the car to the emergencydepartment, then that makes
sense.
But it also makes sense to begetting the information in the
data in a safe place where thenthe ambulance ultimately would
be able to get to you and wouldbe able to be called if you need
it.
And so these are gonna beexcellent conversations to have
(21:25):
with your clinician.
And a lot of this is gonnadepend 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 aclinician and how they feel
about it.
Some of us are still gettingused to this
Amanda Whitehouse, PhD (21:42):
Yes, as we do, we just adapt and we take
the new information in and thenit takes time to emotionally and
mentally adjust to it.
Right.
Michael Pistiner, MD, (21:49):
totally.
Amanda Whitehouse, PhD (21:50):
Well, thank you for helping us do
that.
This is gonna be incrediblyhelpful for people.
I appreciate it so much.
Michael Pistiner, MD, MMS (21:55):
Well, thank you so much for having me.
What an empowering discussion.
I hope that Dr.
Pistiner language and hisapproach to thinking about this
will be a relief for you to hearand to have in your heads and to
know that with the rightinformation, tools, and
practice, we really can be readyto respond Calmly and
effectively in an emergency.
So here are three action stepsto help you put what you learned
(22:15):
today into practice number one.
Again, follow Dr.
Pistiner's work.
The website is massgeneral.org/children/allergy.
You'll find so many resources,and so much information there,
as well as links to their socialmedia.
On Facebook, you can find thefood allergy center at mgh.
And an account for their foodallergy buddies program.
(22:37):
Number two, watch the video ofproper epinephrine
administration for infants andtoddlers on my Instagram page
@thefoodallergypsychologist.
Dr.
Pitner will show you exactlywhat he's describing in this
episode.
And number three, review yourfamily's allergy action plan.
Check that your epinephrinedevices are up to date.
Your caregivers know wherethey're kept, how to use them,
and everyone in your child'scircle feels confident about
(22:59):
when epinephrine is necessary.
All the links to everything thatwe talked about in last week's
episode, and this one will be inthe notes.
So when you have a chance,please take the time to find the
resources that you wanna reviewmore carefully.
Thank you again so much to Dr.
Pistiner for taking so much timewith me the content of this
podcast is for informational andeducational purposes only, and
(23:20):
is not a substitute forprofessional medical or mental
health advice, diagnosis, ortreatment.
If you have any questions aboutyour own medical experience or
mental health needs, pleaseconsult a professional.
I'm Dr.
Amanda Whitehouse.
Thanks for joining me.
And until we chat again,remember don't feed the fear.
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