After there is a reaction concerning for food allergy or the patient has a known food allergy, then the patient should be counseled to avoid that food and for cases of likely IgE mediated food allergy, an epinephrine auto-injector and anaphylaxis emergency care plan should be provided.

In addition, if the patient has a reaction to peanut and/or a tree nut and there are additional nuts eaten in the house regularly but the child has not yet consumed these then consider targeted avoidance to those specific nuts until further testing.

It is not recommended to test for all possible allergenic foods as a potential source of allergy because IgE sensitization does not necessarily correlate with clinical reactions.  If the patient is already consuming additional allergenic foods in the diet regularly then it is essential that the patient should be advised to continue eating these foods.

The American Academy of Pediatrics states that: “There is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4 to 6 months prevents atopic disease”.

When counseling families on food introduction, it is important to discuss how to tell when an infant is ready for solid food and what foods are developmentally appropriate. An infant’s first foods should have a very smooth texture and not require chewing. For thicker foods, such as nut butters, it is best to thin them out with warm water or mix them into something smoother, such as applesauce. Some signs that a baby is ready to try solid foods are:

• Loss of tongue-thrust reflex
• Good head control
• Ability to sit on their own
• Opens mouth and leans forward when offered food

For more information, see the CDC’s “When, What, and How to Introduce Solid Foods“.

There are many factors to take into account when deciding what foods parents should introduce to their children, and when each food should be introduced. Because there are no official guidelines for most foods, it is important to utilize a shared decision-making process with the family and take into account preferences they may have. This allows for personalized application of recommendations based on the most current and promising research. See Shared Decision Making for the Allergist for the full study (1).

An important aspect to consider when deciding what foods to introduce is to consider what foods the family eats regularly, as environmental exposures to allergenic foods may be a risk factor in developing allergies. Under the dual-exposure hypothesis, if a child avoids oral exposure of an allergenic food (e.g. peanuts), but experiences frequent environmental exposures through their skin, they may be more likely to develop a sensitivity or allergy to peanut. When a child is exposed to a food allergen via the skin (e.g. food touches the skin), the immune cells of the skin are more likely to cause sensitization to that food. This is especially true if the skin is inflamed or irritated, as is the case with eczema. However, when a child is exposed to a specific food via the oral route (e.g. food is consumed), the immune cells in the digestive system create tolerance to that food. (2,3)

Dual Exposure Hypothesis

Under the dual-exposure hypothesis, if a child does not already have an allergy and is routinely exposed to the allergen (e.g. peanut) orally, through the gut this may lead to induction of tolerance to that allergen. T-regulatory cells within mesenteric lymph nodes may play a role (lack).

References:

1. Blaiss MS, Steven GC, Bender B, Bukstein DA, Meltzer EO, Winders T. Shared decision making for the allergist. Annals of Allergy, Asthma & Immunology. 2019 May 1;122(5):463-70.
2. Du Toit G, Sampson HA, Plaut M, Burks AW, Akdis CA, Lack G. Food allergy: Update on prevention and tolerance. Journal of Allergy and Clinical Immunology. 2018 Jan 1;141(1):30-40.
3. Lack G. Update on risk factors for food allergy. Journal of Allergy and Clinical Immunology. 2012 May 1;129(5):1187-97.

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.

Pediatric Gastroenterologist

We have put in a referral for a pediatric gastroenterologist. A pediatric gastroenterologist is a medical doctor who specializes in managing issues related to the GI tract, including the esophagus, stomach, small and large intestine, liver as well as the pancreas. Gastroenterologists perform many procedures like endoscopy and colonoscopy and treat many diseases, such as Crohns disease, celiac disease, ulcerative colitis, irritable bowel syndrome to name a select few. Non IgE mediated food allergies, such as eosinophilic esophagitis and food protein enterocolitis, are often co-managed by the gastroenterologist with the allergist for optimal results. In addition to this they work closely with a patient’s pediatrician in order to create the best care plan for a patient’s needs.

To find a pediatric gastroenterologist in your area you can use this search engine found at the North American Society for Pediatric Gastroenterologist, Hepatology, and Nutrition.

Label Reading for Food Allergens

Read Every Label, Every Time

• You never know what’s inside a product when visually inspecting, smelling, or tasting and this can be dangerous. Label reading is the only way to know if a food is safe.
• Manufacturing, processing and ingredients of products can change at any time without giving warning.
• Anyone serving or preparing food for a child needs to know how to read a food label.

The 8 Major Allergens Are:

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.)

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:

• Sesame and other seeds.
• Molluscan shellfish (oysters, clams, mussels, scallops).

The following items are not regulated by the FDA or the labeling law:

• Fresh meat and poultry products.
• Certain egg products.
• Alcoholic beverages.
• Non-food items such as lotions, and cosmetics.
• Gluten-containing grains (other than wheat barley, rye, and oats).

Major 8 Allergens Can be Listed in 1 of 2 Way

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:

• Only applies to the 8 major allergens.
• They are voluntary and are only present when a company chooses to add them to their label.
• These should be located immediately under the list of ingredients.

Remember “contains” statements only apply to the 8 MAJOR allergens and companies can choose to not use them.

Advisory or Precautionary Statements

• Advisory statements come in numerous formats and are not under State or Federal regulation.
• Recommendations vary by allergen, physician, child and family considerations. Talk to your healthcare provider about what to do for your child.
• If you are waiting for your pediatrician or allergist consultation, avoid foods with advisory statements as children may be sensitive to even small amount of the allergen.
• For example: May contain, made in a facility that uses or processes, made on shared equipment with, contains traces of, not guaranteed to be free of, etc.

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

What is Cross Contact?

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.)

• 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. It is important to avoid these types of short cuts.

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.

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.

Tips for Preventing Cross Contact When Serving and Preparing Food

Preparing

• Wash your hands with soap and water after coming into contact with any allergens.
• Talk to anyone who serves or prepares food for your child as they need to understand the concepts of cross contact.
• Keep allergen free foods away from other foods while they are being stored in the refrigerator or pantry.
• Do not allow children with a food allergy to share food, drinks, plate, cups, or utensils.
• Saliva, whether from a person or a pet is another source of cross contact.
• When grocery shopping store problematic foods in a bag in your cart.
• Avoid foods in bulk bins, the deli counter, and hot and cold salad bars as these are common sights for cross contact.

Cooking

• If possible, prepare allergen-free foods first and then prepare food for the rest of the family.
• Use separate utensils and serving spoons
• Allergens cannot be destroyed by cooking, frying or freezing. Avoid foods prepared on surfaces that cannot be cleaned in-between us.
• Fried Foods (fryolators), deli slicer, seasoned wok, common grill surface.

Cleaning

• Carefully wash contact items and surfaces with soap and water or in the dishwasher before and after each use.
• Dishware, utensils, pots, pans, cutting boards, counter tops, tables, highchairs.
• Wipe down tables, highchairs, toys, pacifiers, menus, salt/pepper shakers or any other item your child could touch with their hands or put in their mouths.
• Consider carrying wipes with you and try not to rely on hand sanitizer products as they don’t fully remove food particles.

Keep it simple, limit multiple ingredient dishes, cook from scratch.

Assessment and Plan

This section contains guidance for an assessment and plan to manage suspected non-IgE mediated food reactions. You can copy and paste it into your EMR system to use during well-child visits or follow up appointments.

Eosinophilic Gastrointestinal Diseases (EGD)

Based on the patient’s reaction, there is a concern for a non IgE mediated food reaction called Eosinophilic Esophagitis. The patient should be referred to a pediatric allergist and/or gastroenterologist for further evaluation. The family was counseled to avoid [INSERT FOOD IF APPROPRIATE] as well as foods they have known allergies to including [LIST KNOWN ALLERGIES OR REMOVE IF N/A]. The family was counseled on label reading, cross contact avoidance and provided with relevant educational materials [NOTE TO DOCTOR TO PROVIDE LABEL READING, CROSS CONTACT PATIENT EDUCATION].

Food Protein-Induced Enterocolitis or FPIES

Based on the patient’s reaction, there is a concern for a non IgE mediated food reaction called Food Protein-Induced Enterocolitis or FPIES. The patient should be referred to a pediatric allergist and/or gastroenterologist for further evaluation. The family was counseled to avoid [INSERT FOOD] as well as foods they have known allergies to including [LIST KNOWN ALLERGIES OR REMOVE IF N/A]. The family was counseled on label reading, cross contact avoidance and provided with relevant educational material [NOTE TO DOCTOR TO PROVIDE LABEL READING, CROSS CONTACT PATIENT EDUCATION]. They were also provided with an FPIES Emergency Plan from the International FPIES Association at www.fpies.org.

Allergic Proctocolitis

Based on the patient’s reaction, there is a concern for a non IgE mediated food reaction called Allergic Proctocolitis (Food Protein-Induced). The family was counseled to avoid [INSERT FOOD] as well as foods they have known allergies to including [LIST KNOWN ALLERGIES OR REMOVE IF N/A]. The family was counseled on label reading, cross contact avoidance and provided with relevant educational. [NOTE TO DOCTOR TO PROVIDE LABEL READING, CROSS CONTACT PATIENT EDUCATION]. If there are any complications or concerns, a referral to a pediatric gastroenterologist will be considered.

Pediatric Gastroenterologist

A pediatric gastroenterologist sees a wide variety of diseases but works specifically with the allergist to manage non IgE mediated food reactions, such as food protein enterocolitis or eosinophilic esophagitis. Here they play an essential role in helping the allergist diagnosis, monitor, and treat the disease. In eosinophilic esophagitis endoscopy can be particular helpful when deciding what foods to remove or re-introduce based on esophageal biopsy. To find a pediatric gastroenterologist in your area you can use this search engine found at the North American Society for Pediatric Gastroenterologist, Hepatology, and Nutrition.

Pediatric 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:

• Skin prick testing (SPT): also known as a scratch test, a tiny droplet of an allergen is placed on the skin, then lightly scratched. Allergists wait 15 minutes to observe for a reaction in the form of a hive
• Blood testing: a blood test called Immunocap Specific IgE, measures the concentration of antibodies created in response to the presence of antigen that the body deems harmful
• Oral Challenges: a procedure where a patient is administered incrementally increasing doses of a food or drug to assess if they are tolerant to it.

When experiencing any of the following allergic issues, an allergist can also assist patients in determining the best course of treatment:

• Anaphylaxis, a severe allergic reaction involving one or more bodily symptoms
• Food Allergies, in which a patient may experience any of the following symptoms, including but not limited to urticaria, angioedema, itching, wheezing, or gastrointestinal symptoms, if they are exposed to a food allergen they are allergic to. Drug allergies, such as to different medications
• Environmental allergies, to things common in different environments, including pollen, dust, pet dander, and mold.
• Stinging insect allergies, such as to bees

Pediatric allergists also help managing non-IgE mediated allergies and various atopic conditions, including the following:

• Allergic rhinitis, inflammation of the nose in response to allergens in the air and surroundings. This may cause symptoms including stuffy nose or rhinorrhea (a runny nose)
• Asthma, and related issues including therapies,, reliver medications, and associated rhinitis or sinusitis
• Atopic Dermatitis (eczema), and all other issues related to eczema including, contact dermatitis, environmental allergies, etc.
• Eosinophilic GI disorders, and helping patients determine what foods may be causing GI issues

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.

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.

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.

Non IgE-mediated food allergies are reproducible, delayed reactions to a specific food or foods that are mediated by the immune system, but are not due to IgE activating the allergic cell called the mast cell. Below is a limited list of non IgE mediated diseases.

Eosinophilic Gastrointestinal Diseases (EGD) are made up of a group of gastrointestinal diseases that require endoscopic evaluation with mucosal biopsy for diagnosis. The most common in this group is Eosinophilic Esophagitis or EoE. Symptoms vary with age, but you can see emesis or refusal to eat in younger patients. In teenagers and adults, the typical symptoms include dysphagia and risk for food impaction. Diagnosis is made by an esophageal biopsy of greater than 15 eosinophils per high power field. Food allergens are thought to play a role in the pathogenesis of this disease, but there is little evidence to support the use of skin prick testing or specific IgE testing to eliminate specific foods. However, the removal of food allergens can improve symptoms and esophageal eosinophilia. If there is concern that the patient has EGD please consider referral to pediatric gastroenterology and/or pediatric allergy for management.

Food Protein-Induced Enterocolitis (FPIES) is a severe systemic reaction to food that occurs 1-4 hours after ingestion. Symptoms of FPIES include vomiting, diarrhea, and acidosis, and can lead to hypovolemic shock. There are no lab tests to diagnose FPIES; diagnosis is made based on the patient’s history and/or oral food challenge (OFC). If the history makes the diagnosis likely (ex. 2 or more episodes to the same food in a 6-month period) then an OFC is not necessary. It is recommended that the food be removed from the diet. FPIES may only last a few years, in which case an OFC is needed before the food can be re-introduced into the diet. An OFC should be done in a place where IV fluids are available due to the risk of hypotension becoming a significant symptom. More material can be found at the International FPIES Association. If there is concern that the patient has FPIES please consider referral to pediatric gastroenterology and/or pediatric allergy for management.

Allergic Proctocolitis (Food Protein-Induced) is a common disease in infancy that usually resolves between the first and second year of life. It frequently presents with mucous and blood-streaked stools in a healthy infant, though in more severe cases it can present with chronic emesis, diarrhea, and failure to thrive. It is usually triggered by the ingestion of human breast milk, cow’s milk, or soy milk and treatment involves removing these foods from the infant’s diet or the mother’s diet in the case of breastfeeding. Re-introduction in the diet can be considered at a future time point. If there are any concerns, please consider referral to a pediatric gastroenterologist and/or pediatric allergist.  

For the non-IgE mediated allergies mentioned above, complete avoidance is the most effective way to prevent symptoms. Please see the section “Reaction Prevention” of this website to help inform your patients on how to ensure these foods are appropriately removed from the diet.

References:

1. American Academy of Allergy, Asthma & Immunology. Eosinophilic Esophagitis: Symptoms, Diagnosis, and Treatment [Internet]. American Academy of Allergy, Asthma & Immunology. [updated 2020 February 24; cited 2020 October 2]. Available from AAAA&I
2. Boyce JA et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. Journal of Allergy and Clinical Immunology. 2010 Dec 1;126(6):S1-58.