ACT to Prevent Allergic Reactions
If a young child is having an allergic reaction to a food, any of the severe symptom below suggest likely anaphylaxis and that caregivers should treat with epinephrine (1,2):
Severe symptoms that suggest trouble with breathing or swelling involving the airway:
Severe symptoms that suggest cardiovascular involvement:
Severe Skin symptoms (quickly progressing or all over):
Severe Gastrointestinal Symptoms:
Severe Neurologic Symptoms:
Other symptoms can also be seen in infants and toddlers, and if they are from more than one system or progress then these can signify anaphylaxis as well and require epinephrine(1,2,):
Skin symptoms:
Mucosal or upper airway symptoms:
Gastrointestinal Symptoms:
Neurological Symptoms:
Treat all anaphylaxis with epinephrine.
References
These sections contain the same information as in the PDF handouts throughout this section, but are formatted for easier placement within EMR systems to place in after visit patient handouts.
Read Every Label, Every Time
Milk or Dairy
Eggs
Peanuts
Tree nuts (almonds, hazelnuts, walnuts, pecans etc.)
Soy
Wheat
Fish (cod, bass, salmon, tuna etc.)
Crustacean shellfish (lobster, shrimp, crab, etc.)
Note: While the 8 major allergens are responsible for the majority of allergic reactions, ALL allergens must be taken seriously.
The Food and Drug Administration (FDA) enforces the Food Allergen Labeling and Consumer Protection Act (FALCPA) labeling law. FALCPA applies to all domestic and imported packaged foods and the 8 major allergens, which must be written in clear, plain language and labeled when in flavorings, colorings or other additives.
Note: FALCPA only applies to the 8 major allergens!
The allergens below are not included in the major 8 allergens and therefore are not included in the labeling law:
The following items are not regulated by the FDA or the labeling law:
1 WITHIN THE BODY OF THE INGREDIENTS
Be aware that allergens may be written in plain language in the body of a products ingredient list.
OR
2 FOLLOWING A CONTAINS STATEMENT
A “Contains” statement:
Remember “contains” statements only apply to the 8 MAJOR allergens and companies can choose to not use them.
Advisory or Precautionary Statements
Note: For children with celiac disease or gluten sensitivities, it may be best to look for “gluten-free products” because labeling can be inconsistent. Wheat is one of the major eight allergens, but other sources of gluten such as barley, rye and oat are not.
Cross contact is the unplanned presence of food allergens. It occurs when an allergen protein is unintentionally transferred to an allergen free food or object. Cross contact can be invisible to the eye and can come from many places. Even small amounts of an allergen can cause an allergic reaction.
This means that your child can accidently be exposed to an allergen through:
Objects (Utensils, cooking surfaces, highchairs, pacifiers, sponges, bib, apron, etc.)
Food (Steam, splatter, accidental contamination, frying oil)
Saliva (People, pets, binky, Sophie the Giraffe, musical instrument, etc.)
Who needs to know about allergen cross contact?
Any caregiver for your child. Babysitters, siblings, grandparents, extended family, friends, teachers, etc. Routine teaching of all caregivers about sources of cross contact and prevention of exposure is essential.
Children explore their environments with their hands and often put them, or other objects in their mouths.
Younger children are more likely to put their hands in their mouths and noses; therefore, caregivers should have increased awareness and wash their children’s hands often Avoid sharing of food, utensils, water bottles and anything else that may go in their mouth, such as musical instruments.
Cross Contamination vs Cross Contact
Cross contamination occurs when microorganisms such as bacteria contaminate food and result in a food borne illness. Unlike cross contact, the risks of cross contamination may be eliminated with proper cooking techniques, whereas proper cooking does not reduce or eliminate the chances of a food allergy reaction.
Preparing
Cooking
Cleaning
Keep it simple, limit multiple ingredient dishes, cook from scratch.
This article is being displayed from Early Food. Any changes to Early Food’s article will be reflected here as well.
Placing a Referral for an Allergist
A pediatric allergist is a medical doctor who specializes in managing allergic issues for children. Allergists perform the following procedures to screen patients for allergies and can help patients interpret the results to proceed with allergy management:
When experiencing any of the following allergic issues, an allergist can also assist patients in determining the best course of treatment:
Pediatric allergists also help managing non-IgE mediated allergies and various atopic conditions, including the following:
Older populations can participate in studies that utilize immunotherapies (including oral immunotherapy, subcutaneous immunotherapy, or sublingual immunotherapy), which may help research subjects decrease the likelihood of reacting to foods that they are allergic to.
For infants and toddlers specifically, pediatric allergists assist families to determine when and in what form to introduce commonly allergenic foods into the diet, and what strategies and steps to take in the lifestyle and in the home to prevent the development of food allergies. Allergists work closely with families to determine the best course of action for their child’s health needs and help guide families on how to integrate foods back into an infant or toddler’s diet over time and/or in a controlled setting. They are able to update families on the most up to date science when it comes to food allergies in this population.
The American Academy of Pediatrics Specialty Consult Request is a referral form that general pediatricians can use to refer their patients to see a pediatric specialist. If you would like to refer your child to see a pediatric allergist, pediatric dermatologist, pediatric gastroenterologist, or any other pediatric specialist, please complete this form and send it to the applicable specialist.
On these sheets, there are sections where you as the primary care provider can specify what clinical problems your patient may be experiencing where you would like a pediatric specialist to also assess. If you have specific questions related to your patient’s care that you would like addressed with the specialist, those can also be specified on this form. Directives to the specialists for care can also be provided on this sheet, including any prior interventions and relevant patient history.
If you would like to refer your patient to a pediatric allergist, American Academy of Allergy, Asthma and Immunology (AAAAI) and American College of Allergy, Asthma, and Immunology (ACAAI) both have information on how to find a local allergist in your community.
Anaphylaxis Action Plan
For patients who have a suspected or confirmed IgE-mediated food allergy, it is important to provide the family with an anaphylaxis action plan. An action plan provides families and caregivers with information on common signs and symptoms of an allergic reaction and when to give epinephrine.
We suggest using the American Academy of Pediatrics (AAP) anaphylaxis action plan. For current information from the AAP on how to fill out an action plan and current action plan, see Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan.
Anaphylaxis in infants and toddlers can look different than in older children and adults. Additionally, infants are unable to verbalize their symptoms, so it is important that parents and caregivers can recognize signs that may be indicative of an allergic reaction. We have included below a breakdown of the symptoms included and how they may present differently in infants and toddlers, as well as important take home points for discussing with families.
Important take home points for families:
| Symptoms | Infant/Toddler Specific Terms | Lay-Terms | Discussion points for parents/caregivers |
|---|---|---|---|
| “Shortness of breath, wheezing, or coughing” | Nasal flaring Grunting Exaggerated abdominal breathing Retractions (suprasternal and intercostal) Tripoding Wheezing Coughing | Widening of the nostrils to allow greater airflow Low-pitched groan indicating distress or difficulty breathing Larger than normal expansion of the infant’s tummy when breathing in Sucking in of skin around the chest and ribs Child leans forward with arched back and hands on legs, a position that allows increased airflow High-pitched squeaking sound when breathing in and/or out | Signs of shortness of breath in the infant/toddler, in layperson terms Identification of new or abnormal sounds and behaviors in the infant/toddler that may indicate difficulty breathing |
| “Skin color is pale or has a bluish color” | Perioral cyanosis Cyanosis of nailbeds/ Delayed capillary refill Mottling Pallor | Blueish color of/around the lips White/blue fingertips with slow (>3 seconds) return of pink color to nailbeds after pressure is applied Red, lacy, speckled appearance of the skin, particularly the arms and legs Pale/white appearance of the face | Identification of new or abnormal skin color in the infant/toddler Cyanosis identification |
| “Weak pulse; Fainting or dizziness” | Loss of consciousness Lethargy Sudden/abnormal onset of cold hands and feet | Child becomes unresponsive/passes out Child is very slow moving and takes longer than usual to respond to you; seems “out of it” Hands and/or feet feel very cold (typically accompanied by white/blue coloring) | Signs of cardiovascular compromise in the infant/toddler, in layperson terms Limited value of hypotension assessment in early anaphylaxis, with heart rate detection important for the healthcare provider |
| “Tight or hoarse throat; Trouble breathing or swallowing” | Change in pitch/tone of voice and cry Stridor Snoring Nasal congestion Excessive drooling/ protrusion of tongue Wheezing, grunting, nasal flaring | Sound of voice/ cry is different/ strained/ raspy High pitched crowing sound when breathing in Sound as if the infant is snoring when breathing in More drooling than normal with the infant repetitively sticking tongue out Sounds indicating trouble breathing as previously described | Signs the infant/toddler may be experiencing throat constriction or trouble breathing or swallowing, in layperson terms |
| “Swelling of lips or tongue that bother breathing” | Bilateral lip swelling with difficulty breathing Swelling that is expanding Tongue obstructing airway Inability to visualize posterior pharynx Air hunger | Both lips are noticeably larger than usual Lips/mouth is puffy and keeps getting bigger Tongue is noticeably larger than usual and taking up most of the room in the mouth You cannot see the back of the throat with the child’s mouth wide open Child sounds like he/she is choking or gasping for air | Signs of compromised breathing that warrant epinephrine administration, in layperson terms How the extent of swelling may correlate with level of concern for true anaphylactic reaction |
| “Vomiting or diarrhea (that is severe or combined with other symptoms)” | Persistent vomiting Vomiting resulting in dehydration Vomiting uncharacteristic for the child Vomiting similar to that of previous allergic reaction | Vomiting that doesn’t stop once the child eats the food Vomiting so much that the child appears dehydrated (sunken eyes; flat, sunken fontanelle (soft spot on top of infant’s head); vomiting bile/ liquid after clearing food from stomach) -Vomiting that is different from the child’s usual “spit up” or vomiting Vomiting like the last time the child had an allergic reaction | Vomiting/diarrhea characteristics likely associated with anaphylaxis Identification of new or abnormal vomiting/diarrhea in the infant/toddler |
| “Many hives or redness over body” | Hives spreading to trunk Hives in areas of the body not in contact with the food | Round, raised, red blotches on the child’s chest, stomach, and/or back Round, raised, red blotches on the skin that the food did not touch | Significance of localized vs. full body hives in context of contact vs. systemic reactions |
| “Feeling of ‘doom’, confusion, altered consciousness, or agitation” | Excessive crying Increased irritability Lethargic Inconsolable | Crying relentlessly Abnormally angry, having a temper tantrum Abnormally sleepy or slow moving -Cannot be calmed or consoled by ways of soothing that usually work | Such ominous or ambiguous signs in the infant/ toddler that may be indicative of anaphylaxis, in layperson terms |
These symptoms may be the first signs of anaphylaxis. Therefore, it is important the child is monitored for progression of mild to severe symptoms. If the child has any of these symptoms in addition to any symptoms described previously, epinephrine should be administered. If the infant or toddler has symptoms that involve two or more body symptoms, epinephrine administration is warranted. Caution caregivers that change in behavior is only relevant if attributable to an allergic reaction.
| Symptoms | Infant/ Toddler Specific Terms | Lay-Terms | Discussion points for parents/caregivers |
|---|---|---|---|
| “Itchy nose, sneezing, itchy mouth” | Nasal/perioral itching Repetitive protrusion of tongue Appearing in distress | Child scratching or rubbing nose and/or mouth Child keeps sticking out tongue as if he/she has a bad taste in the mouth Signs of discomfort as described previously, such as inconsolable crying, irritability/ agitation, appearing uncomfortable | Signs of itchy nose/mouth, in layperson terms Identification of new or abnormal signs of irritation in the infant/toddler |
| “A few hives” | Progressive vs. localized hives Contact hives | Round, raised, red blotches that do not spread and appear in one area Round, raised, red blotches only on the area(s) of skin that the food touched | Description of appearance of hives Possibility for hive progression over time and need for monitoring of infant/toddler Reiteration of significance of localized vs. widely-distributed hive development |
| “Mild stomach nausea or discomfort” | Borborygmi Gagging, retching, dry heaving Excessive crying or irritability | Hiccup-like sounds with sucking in of stomach; gagging without vomiting Child will not stop crying and you cannot see any visible injury or sign of discomfort | Signs of nausea or stomach upset in the infant/toddler, in layperson terms |
References
Epinephrine is the first-line treatment for anaphylaxis, with delays in administration associated with increased mortality.(1) Epinephrine autoinjectors provide an effective way for individuals without clinical training to administer epinephrine to themselves or another person.
Recommended dosing is 0.01mg/kg up to 0.5mg IM 1:1000 epinephrine (1mg/ml)
In the US, there are 3 different dosage autoinjectors available:
If a child has a suspected IgE-mediated food allergy, it is important to prescribe an epinephrine autoinjector. There are currently 4 different epinephrine autoinjector models available in the United States. All autoinjectors come in two-packs, and patients should keep both devices with them at all times. While each autoinjector has similar general administration steps, there are slight differences for each one that should be discussed when training families. A comparison of each autoinjector and resources for training families on administration can be found in the table at the bottom of this page.
Important Take-Home Points to Discuss with Families:
| Device | Doses | Trainer included? | Other Notes |
|---|---|---|---|
 EpiPen and Authorized Generic by Mylan | 0.15 mg 0.3 mg |
Yes | EpiPen and Mylan Savings Cards |
 Auvi-Q | 0.1 mg 0.15 mg 0.3 mg |
Yes | 0.1 mg dosing is recommended for children under 15 kg (33 lbs) Device includes voice instruction |
 Teva Epinephrine Auto-Injector |
0.15 mg 0.3 mg |
Yes | Teva Savings Card |
 Impax Epinephrine Auto-Injector (Generic of Adrenaclick) |
0.15 mg 0.3 mg | No Order Trainer Online |
Impax Savings Card |
References
The most important take-home points when discussing how to read a label are:
The Food and Drug Administration (FDA) enforces the Food Allergen Labeling and Consumer Protection Act (FALCPA) labeling law. FALCPA applies to all domestic and imported packaged foods and the 9 major allergens, which must be written in clear, plain language and labeled when in flavorings, colorings or other additives.
Milk or Dairy
Egg
Peanuts
Tree nuts (almonds, hazelnuts, walnuts, pecans etc.)
Soy
Wheat
Fish (cod, bass, salmon, tuna etc.)
Crustacean shellfish (lobster, shrimp, crab, etc.)
Sesame
Note: While the 9 major allergens are responsible for the majority of allergic reactions, ALL allergens must be taken seriously.
The following items are not regulated by the FDA or FALCPA:
The following items are not regulated by the FDA or the labeling law:
1 Within the body of the ingredients: Allergens can be written in plain language in the body of a products ingredient list.
or
2 Following a “contains” statement: These statements only apply to the 9 major allergens, and companies can choose to not use them.
What About Advisory or Precautionary Statements?
Note: For children with celiac disease or gluten sensitivities, it may be best to look for “gluten-free products” because labeling can be inconsistent. While wheat is one of the major eight allergens, other sources of gluten such as barley, rye and oat are not.
Cross contact is the presence of unintended food allergen
The following are just a few examples of common sources of cross contact. See the table at the end of this page for more examples of cross contact and potential alternatives.
Objects Utensils, cooking surfaces, highchairs, pacifiers, sponges, bib, apron, etc.
Using the same tongs to flip shrimp and a chicken breast. Without properly washing the tongs in-between use, allergens may be transferred to the chicken breast.
Food Steam, splatter, accidental contamination, frying oil
Removing nuts from a salad or scraping cheese off a cheeseburger.
Saliva People, pets, binky, Sophie the Giraffe, musical instrument, etc.
Sucking on another baby’s pacifier after they had a bottle of milk-based formula.
Any caregiver, including babysitters, siblings, grandparents, extended family, friends, and teachers. Routine teaching of all caregivers about sources of cross contact and prevention of exposure is essential.
Children explore their environments with their hands and often put them, or other objects in their mouths. Younger children are more likely to put their hands in their mouths and noses, therefore caregivers should have increased awareness and wash their children’s hands often. Avoid sharing of food, utensils, water bottles and anything else that may go in their mouth, such as musical instruments.
Cross contamination occurs when microorganisms such as bacteria contaminate food and result in a food borne illness. Unlike cross contact, the risks of cross contamination may be eliminated with proper cooking techniques, whereas proper cooking does not reduce or eliminate the chances of a food allergy reaction.
| Source | Examples | Ways to Avoid |
|---|---|---|
| Kitchen Utensils, Serving Spoons | Using a knife to spread peanut butter, not cleaning it properly, and then using it to spread jam. Serving mac and cheese, and then using the same spoon to serve green beans. | Wash utensils and serving spoons in the dishwasher or with soap and water in between each use. Use separate sets of serving spoons during meals for allergen vs non-allergen food items. |
| Cooking Surfaces, Cutting Boards, Counter Tops | Cooking fish or shellfish on the same grill as steak. Scrambling eggs and then cooking a grilled cheese on same griddle. Cutting cheese and then fresh fruit on the same cutting board. | Clean grill surface with soap and water in between uses. Prepare the allergic child’s food first. Consider having separate cooking surfaces and cutting boards as allergen-safe. Clean counters with soap and water or commercial wipes before and after cooking. |
| Deep Fryers, Cooking Oils, and Seasoned Wok | French fries that have been fried in the same oil as shrimp. Cooking allergen safe foods in a seasoned wok. | Avoid food cooked in a common deep fryer. Consider simple dished cooked on surfaces that are easily cleaned. |
| Pots, Pans, Cooling Racks, Small Appliances | Making wheat bread in a bread pan, and then making gluten free bread. Blending a smoothie with cow’s milk, and then one with plant-based milk. | Clean properly in-between uses or designate specific pans and small appliances as allergen-free. Consider cooking the allergy-safe foods first. |
| Source | Examples | Ways to Avoid |
|---|---|---|
| Saliva | Kissing your child or cleaning their binky with your mouth after you eat a granola bar with allergens. Sharing toys, teething rings, pacifiers with other infants. Sharing utensils, cups, plates, water bottles, food, or drinks. Pets eat treats with milk and then lick child’s face, or babies eating dog food. | Do not share food, drinks, cups, plates or eating utensils. Wash properly or wipe down toys, pacifiers, teething rings regularly. Keep pet food and treats out of reach of children. |
| Source | Examples | Ways to Avoid |
|---|---|---|
| Airborne | Steam from cooking allergens, such as shellfish in a pot on the stove. Allergic child inhaling wheat, peanut, etc. flour while preparing baked goods. | Consider not cooking allergens that could travel through steam while the allergic child is home, or avoid these allergens in your home. Do not prepare or cook allergens in your home. |
| Hands | Failing to wash your hands after handling nuts, and then preparing your child’s meal, or setting them up in their highchair. Siblings playing with a toy after eating allergen, and then handing it to allergic child. | Wash hands with warm water and soap before and after preparing each meal and setting up highchair. Regularly wipe down toys to decrease risk of exposure from child to child. |
| Sponges, Dish Towels, Oven Mitts, Aprons | Used a sponge to clean a mac and cheese baking pan, and then the child’s sippy cup. Wiping hands on apron instead of washing them in between each task. | Considering using disposable wipes, or paper towels, or designating specific cleaning instruments for allergen free cookware, and dinnerware. Wash hands properly in-between tasks. |
When dining out with a child who has food allergies, clear communication is key. Talk to the manager and/or chef, in addition to your server, to ensure that they understand your child’s needs. It’s best to avoid restaurants where there is a language barrier, and clear communication is difficult. If possible, call ahead and discuss your child’s allergy with a manager.
To minimize the risk of cross-contact, avoid ordering combination dishes like stews, soups, and sauces, as they often contain hidden ingredients and may have been prepared before your arrival. Fried foods, salad bars, and buffets are also common sources of cross-contact. Note that certain types of restaurants may be riskier for those with specific allergies (like an ice cream parlor for a child with dairy, peanut, or tree nut allergies), so research beforehand can help mitigate risks.
Finally, never share food that was not prepared specifically for your child with food allergies. The precautions taken in the preparation of your dish may not have been taken for others.
For AllergyThis text can be used for patients who have either suspected or confirmed food allergies, based on testing or prior reactions. You can copy and paste it into your EMR system to use during well-child visits or follow up appointments.
There is concern that patient had food reaction to [LIST FOODS].
The patient has known food allergies to [LIST FOODS].
This text can be used to document that the family was provided guidance on their child’s suspected food allergy and that a referral will be placed for pediatric allergy. This section also includes information on what educational resources to provide the family and what dosage of epinephrine auto-injector to prescribe. You can copy and paste it into your EMR system to use during well-child visits or follow up appointments.
Based on the patient’s reaction, there is a concern for an IgE mediated food allergy. The patient should be referred to an allergist for further evaluation. The family was counseled to avoid [INSERT FOOD] as well as foods they have known allergies to including [LIST KNOWN FOOD ALLERGIES OR REMOVE IF N/A]. The family was counseled on label reading, cross contact avoidance and provided with relevant educational material in addition to an anaphylaxis action plan [NOTE TO DOCTOR TO PROVIDE LABEL READING, CROSS CONTACT PATIENT EDUCATION, AND ANAPHYLAXIS PLAN]. The family was counseled to continue to eat allergenic foods they are tolerating regularly so they do not lose their tolerance.
An epinephrine autoinjector two-pack [CHOOSE DOSE: 0.1 MG FOR WT LESS THAN 13KG OR 0.15 MG IF 0.1 MG NOT AVAILABLE; 0.15 MG FOR WT 13 to 25 KG; 0.3 MG FOR WT GREATER THAN 25 KG] was prescribed and should be available at all times. Epinephrine auto-injector training was provided and indications for use of epinephrine reviewed.
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