Published November 25, 2014 (revised December 23, 2024)
If you keep an EpiPen Jr (epinephrine) auto-injector on hand in case a child has a severe allergic reaction, you need to know about the risk of injury to the child if they move while the needle is under the skin. An EpiPen Jr auto-injector is a disposable automatic injection device filled with 1 dose of epinephrine. The dose is delivered when the orange tip is pressed against a child's outer thigh until it "clicks" and then held there for 10 seconds. Prompt treatment of severe allergic reactions in the home and community can be lifesaving and has resulted in better survival rates and fewer long-term effects. Most often, auto-injectors are used successfully without complications. But we heard of two children who sustained injuries when the EpiPen Jr was used.
A 4-year-old boy at daycare had an allergic reaction. The staff gave him an injection of epinephrine using an EpiPen Jr. The child was standing, and a daycare staff member was standing behind him for support. Another staff member held the child's leg and gave the injection. The child kicked while getting the injection, so the needle moved while under the skin, leaving a cut along his leg. Believing the device had not been held in place long enough to give the drug (for the recommended 10 seconds), the staff member attempted to re-inject the child using the same needle. This resulted in a second cut (Figure 1) when the child tried to get away again.
The child's allergic reaction symptoms improved without additional epinephrine. The two 3-inch cuts were closed with nonabsorbable sutures and tissue adhesive. X-ray imaging and inspection of the needle showed it had bent, which likely prevented the needle cover from locking back in place when the needle was initially kicked free by the child (Figure 2).
In a very similar case, a 3-year-old boy having an allergic reaction while at daycare was given a dose of EpiPen Jr in his outer thigh. The child jerked his leg and got a 1 and a half inch cut on his leg. The daycare worker then restrained the child with her body weight and attempted to reinject the medication using the same EpiPen Jr, holding the device in place for 10 seconds to ensure the drug had been fully delivered. The child was taken to the emergency department, where his symptoms improved without additional medicine. The cut was repaired with eight nonabsorbable sutures.
These cases highlight features of the EpiPen Jr and adult EpiPen design and instructions for use that contributed to the injuries. The instructions direct the user to hold the EpiPen firmly against the outer thigh, holding it in place for approximately 10 seconds. The needle stays under the skin until the EpiPen is pulled away from the thigh. Because of this, people may believe it takes 10 seconds for the medicine to be injected. However, the average time to inject the epinephrine is much shorter, less than 3 seconds in most cases.1 The instructions do not explain that the EpiPen should only be used once and should never be reinserted even if it comes out of the skin in less than 10 seconds. The instructions for EpiPen Jr also do not mention the need to restrain a child or the risk of injury if the child moves.
Another epinephrine device is also available, the Auvi-Q (epinephrine) auto-injector. With the availability of Auvi-Q, the risk of this type of injury is less likely to occur. The Auvi_Q auto-injector delivers the medicine quickly, and the needle retracts automatically in less than 1 second. There is little risk of needle injury since the needle retracts so quickly and there is zero risk once the needle is back in the device.
Here's what you can do: Be sure to restrain a child when using an epinephrine auto-injector to prevent movement during the injection. This is particularly important for EpiPen Jr and other similar epinephrine auto-injectors where the needle should remain in place for at least 10 seconds. If the needle is dislodged, reinsertion should never be attempted. If it was in place for at least 3 seconds, it is likely that the full dose of epinephrine was injected. It is important to seek medical attention after administering a dose of epinephrine because another dose may be needed but should be determined by emergency medical professionals. This information should be relayed to caregivers, daycare workers, teachers, and anyone else who might administer epinephrine to a child.
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