Response Opposing Mandatory Stock Epinephrine and Untrained Dosage Determination in Childcare Settings

We oppose the proposed amendments to the Child Care Program regulation (8VAC20-790) that mandate the stocking of epinephrine and delegate its administration and dosage determination to non-medical personnel. While the intent to protect children during anaphylactic emergencies is commendable, these regulations introduce significant safety hazards by requiring individuals without proper medical training to manage powerful emergency medications and make critical, high-stakes decisions regarding a child’s health.

Our primary objections center on two major concerns:

1. Significant Hazards of Non-Medical Personnel Stockpiling and Administering Medication

The regulations require childcare center employees or family day home providers—individuals whose primary expertise lies in early childhood education and care, not emergency medicine—to be trained in epinephrine administration. This approach raises several critical safety issues:

• Risk of Misdiagnosis and Inappropriate Administration: Anaphylaxis can mimic other conditions, some of which do not require epinephrine. Administering epinephrine to a child who does not need it can cause serious side effects, including dangerous spikes in blood pressure, heart palpitations, anxiety, and other cardiovascular complications. Childcare staff are not qualified to make a definitive differential diagnosis in a high-stress, emergency situation.
• Liability and Training Limitations: Standardized Medical Administration Training (MAT training) for staff cannot replicate the clinical judgment and expertise of a licensed medical professional. Staff turnover necessitates continuous, costly retraining, and the inherent stress of an anaphylactic emergency increases the likelihood of human error during administration, such as injection site errors or hesitation that delays care.

2. The Inherent Dangers of Determining Weight-Based Dosages Without Medical Training

A core component of the proposal requires providers to store "an appropriate weight-based dosage of epinephrine." This places an unacceptable burden and risk on non-medical personnel:

• Dosage Complexity: Epinephrine dosing for children is highly specific and depends entirely on the child's precise weight. The difference between a safe and a harmful dose is narrow. Childcare providers are not medical professionals trained to accurately weigh children, calculate dosages, and assess contraindications.
• The Problem of "Stock" Doses: Mandating "stock" epinephrine requires providers to guess the likely weight range of the children in their care or stock multiple dosages, further increasing the complexity and potential for error. A child’s weight changes rapidly, and relying on outdated information or estimations is inherently dangerous. Using an adult dose on a small child, or an infant dose on a larger child, could have fatal consequences.
• Undermining Medical Authority: Decisions regarding which medication a child should receive and at what dosage should remain solely within the purview of the child’s parents and their prescribing physician. These regulations effectively require non-medical staff to act as pharmacists and emergency physicians, a role they are neither trained nor legally qualified to assume.

Conclusion

While rapid response to anaphylaxis is vital, the solution should not introduce new, significant hazards. The current proposal shifts complex medical decision-making from trained professionals to laypersons, creating substantial risks of misadministration, incorrect dosing, and accidental exposure. The focus should remain on rapid access to emergency medical services (911) and clear communication protocols between parents and providers, rather than mandating the dangerous practice of non-medical individuals managing potent emergency drugs.