Electronic Medical Record Documentation
Early Food Introduction
Allergenic Food History:
This section can be used to document the patient’s history of exposure or reaction to the most common allergens. You can copy and paste it into your EMR system to use during well-child visits or follow up appointments.
Egg: [SELECT ONE: in diet and tolerated, never, tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Peanut: [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Tree nut (e.g. almond, walnut, cashew, pecan, pistachio, hazelnut, brazil nut): [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Dairy: [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Wheat: [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Soy: [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from
touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Sesame: [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Fish: (e.g. cod, tuna, salmon, haddock, tilapia, etc): [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Shellfish: (e.g. shrimp, clam, lobster, crab, scallop, mussels): [SELECT ONE: in diet and tolerated, never tried, reaction from eating, reaction from touching, positive skin prick test, positive blood test, previously tolerated but no longer eaten]
Allergenic Introduction Assessment and Plan:
This text includes information on how to manage peanut introduction for infants at high risk of developing a peanut allergy, as well as how to guide parents on early food introduction for foods other than peanut. You can copy and paste it into your EMR system to use during well-child visits or follow up appointments.
[PLEASE LEAVE IN IF PATIENT HAS NOT EATEN PEANUT]
Food Introduction (Peanut)
Per the addendum NIAID/LEAP guidelines, babies at high risk for peanut allergy should be introduced to peanut between 4-6 months of age in an age-appropriate way (i.e. no loose nuts until age 5 and use of thinned-out peanut butter). The Guidelines define high risk as patients with severe eczema, egg allergy, or both. Per the NIAID guidelines, if the eczema is severe then a peanut-specific IgE and/or peanut skin testing should be done before introduction.
[FOR PROVIDER: PLEASE CONSIDER SPEAKING TO A COMMUNITY ALLERGIST TO DISCUSS IF A BLOOD TEST SHOULD BE SENT BY THE PROVIDER OR IF THE PATIENT SHOULD BE REFERRED TO AN ALLERGIST FOR SKIN TESTING].
Pathway:
Referral to Allergist
The patient is considered high risk for peanut allergy due to their severe eczema or IgE-mediated food allergy to another food. The patient will be referred to an allergist for peanut skin testing evaluation. Until the testing has been done the patient should avoid any consumption of peanuts. After the peanut skin test, the allergist will decide if it is safe for the patient to eat peanut. The patient was given a handout on how to read a label and cross-contact patient education.
[NOTE TO DOCTOR TO PROVIDE LABEL READING AND CROSS-CONTACT PATIENT EDUCATION].
Blood test
The patient is considered high risk for peanut allergy due to their severe eczema or IgE-mediated food allergy to another food. Peanut IgE with reflex components was ordered. If the testing is negative (<0.35), please introduce peanut into the child’s diet using the introduction resource as guidance. If the testing is positive, an appropriate epinephrine auto-injector two pack will be prescribed and a referral for Pediatric Allergy/Immunology evaluation will be placed as well as an allergy anaphylaxis plan. Instructions on allergen avoidance and label reading will be provided.
[NOTE TO DOCTOR TO PROVIDE LABEL READING, ALLERGY ANAPHYLAXIS PLAN, AND CROSS-CONTACT PATIENT EDUCATION].
If the patient is able to introduce peanut at home the office will provide a handout on peanut introduction at home.
Food Introduction (Allergenic Foods OTHER THAN Peanut)
The 2019 AAP Clinical Report recommends dietary interventions to prevent atopic disease and states that there is no evidence that delaying the introduction of other allergenic foods beyond 4-6 months prevents atopic disease. The dual exposure hypothesis theorizes that tolerance to a food is developed by exposure through the GI tract, whereas sensitization to a food is developed by cutaneous exposure. There is also data to show that the sensitization is increased by eczema and compromises in the skin barrier. Therefore the family was counseled that repeated cutaneous exposure to highly allergenic foods not yet eaten can lead to sensitization and if there are any concerns please call the office. Discussed that in order to limit the child’s cutaneous exposure to allergenic foods not eaten it is best to avoid them in the child’s play area; restrict eating to a table that is thoroughly cleaned after ingestion as well as dishware and wash hands after handling foods and before touching the child or applying creams or lotions.
We recommend food introduction in an age-appropriate (and culturally appropriate) manner free of choking hazards (i.e. do not give whole peanuts, tree nuts, and/or seeds; recommend thinned nut butter mixed in cereal/formula/breastmilk/pureed fruit or vegetables). We recommend gradual introduction, starting with a pea sized amount and doubling this every 10 to 20 minutes until they have reached about 2 tablespoons, but this can be done more slowly in a higher risk patient. When introducing foods at home the family was counseled to be aware of the signs of anaphylaxis. Symptoms of anaphylaxis can include hives, swelling, wheezing, cough, shortness of breath, nausea, vomiting, difficulty breathing, dizziness, or loss of consciousness. If foods are introduced and tolerated it is important to keep them in the diet at a regular interval.
If there is any concern please call our office at [INSERT PHONE NUMBER] or call 911.
Skincare and Eczema Management
This text can be used in the patient history to document how the patient’s family manages and treats the patient’s eczema. You can copy and paste it into your EMR system to use during well-child visits or follow up appointments.
Eczema History:
The patient [HAS/HAS NOT] not been prescribed topical steroids. If so, they are [LIST STEROIDS WITH POTENCY AND FORMULATION)]. The patient uses it [INSERT AMOUNT PER DAY] a day and needs it [INSERT FREQUENCY/MONTH] month. Other skincare regimen consists of [INSERT SKINCARE REGIMEN – INCLUDE MOISTURIZATION AND OTHER MEDS, SUCH AS CALCINEURIN INHIBITOR]. Eczema has been complicated by [CHOOSE ONE OR MORE: NONE, HYPOPIGMENTATION, SCARRING, SUPER INFECTION, NEED FOR ORAL STEROIDS, NEED FOR ORAL ANTIBIOTICS, NEED FOR ORAL ACYCLOVIR]. The caregiver [DOES/DOES NOT] wash his/her/their hands before applying topical creams and/or ointments.
IgE Mediated Food Allergy
Food Reaction Evaluation (Food Reaction History):
This 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].
Food Reaction Evaluation (Food Reaction Assessment and Plan):
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.
Non-IgE Mediated Food Allergy
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.