Electronic Medical Record (EMR) Templates

These templates support decision-making, workflow, and patient education on topics related to food allergy prevention and management. They were designed for use within electronic medical record (EMR) systems, such that practices or individual clinicians may use them to create personal or institution-specific dotphrases or SmartPhrases using the suggested titles. Templates are organized by clinical scenario and include suggestions for where to incorporate the content into a well-child or problem-focused visit.

Well-Child Visits

Well-Child Visits are structured to provide allergy guidance through:

• Clinical Instructions for Discussions with Families: Key recommendations and topics to discuss with families for food allergy guidance
• After Visit Summary (AVS) text: Patient-friendly language that can be pasted directly into the AVS, with branching content for a child’s specific early introduction timeline
• Family Resource/Links:  FAMP-IT Family resources to guide families to read further about topics discussed in well-child visit

Table of Contents:

• 2-Month Well-Child Visit
• 4-Month Well-Child Visit
• 6-Month Well-Child Visit
• 9-Month Well-Child Visit
• 12-Month Well-Child Visit

Specific Encounters/Problems

Specific encounters/problems are structured to provide allergy guidance during either a routine visit or a focused “sick” visit through: 

• Clinical Instructions for Families: Key recommendations and topics to discuss with families for food allergy or eczema guidance
• After Visit Summary (AVS) text: Patient-friendly language that can be pasted directly into the AVS
• Family Resource/Links:  FAMP-IT Family resources to guide families to read further about topics discussed in certain specific encounters

Table of Contents:

• Signs of Developmental Readiness/Early Introduction
• Maintenance of Allergens for Early Introduction Guidance
• Eczema
• Food Reaction
• Food Allergy

2-Month Well-Child Visit

Clinician Instructions: Considerations for discussions with families

Practice Shared Decision-Making (See Section Timing of Complementary Foods and Allergens) to create a plan for introducing solids and common food allergens.

• Eating a well-balanced diet, including the common food allergens, is important during breastfeeding
• Educate on signs of developmental readiness for your baby to start solids and common food allergens
• Educate families that allergen exposure through irritated skin may increase risk (“dual exposure”)

Consider referrals to agencies and programs such as WIC and SNAP, which can also provide information and assistance with breastfeeding support and other nutrition guidance for nutritious foods during breastfeeding.

Sources:
Bright Futures Information for Parents (AAP): 2 Month Visit

After Visit Summary (AVS): Consider copying and pasting into AVS for written instructions

It is important to pay attention to your baby’s skin. While your baby is not yet getting introduced to new foods to eat, they may still be coming into direct contact with specific food allergens on their skin. If this happens regularly, it may increase their chances of developing an allergy to that particular food. This is especially important for babies with inflamed or irritated skin, like with eczema. Studies show that while eating an allergen early (see below for more information) can protect your baby from that food allergy, routine contact with the skin puts them at higher risk. 

So what can you do to help protect your baby’s skin? 

Wash hands after:

• Eating, especially if the food eaten is a common allergen
• Or before handling your baby’s skin, such as during diaper changes and when applying lotions and creams. 

While your baby is not old enough, it is important to know that your healthcare provider may talk to you about starting the common food allergens soon. 

While it’s never too soon to start planning when and how you’ll introduce food allergens to your baby, there’s plenty you can do now if you’re a breastfeeding mom. When choosing your meals and snacks, pick a variety of healthy foods loaded with vitamins and minerals, as well as protein. Think: colorful fruits and veggies, healthy fats, and whole grains. Choose protein from meats; poultry; eggs; dairy; legumes like beans, lentils, and peas; nuts and seeds; and low-mercury seafood like salmon, cod, and shellfish. As much as possible, avoid highly processed foods with lots of added salt and sugar. Filling yourself up on nourishing foods can boost your breast milk with essential nutrients to grow a healthy baby.

If you are not allergic to the common food allergens, there’s no reason to avoid them while breastfeeding. They are rich in nutrients and should be included in a healthy, well-rounded diet. It may also be helpful to know that research suggests a diverse diet with a wide variety of nutritious foods may help lower the risk of food allergies.

The following section should be guided and added if by Shared Decision Making (See Exclusive Breastfeeding until 6 months of Age)

Finally, before your 4-month check-up with your healthcare team, look for these signs to understand when your baby is developmentally ready to eat solid foods and the common food allergens. This is usually around 6 months old, but can be as early as 4 months. What does “developmentally ready” mean? The common signs in babies are:

Sitting with only a little support

• Controlling their head and neck
• Bringing objects to their mouths
• Opening their mouth when food is offered
• Trying to grasp small objects
• Swallowing food instead of pushing it out with their tongue

Some infants may show developmental signs of readiness before age 6 months. Does this mean you can introduce complementary foods earlier? Introducing complementary foods before age 4 months is not recommended. Neither is waiting until after 6 months. Talk to your healthcare team at your 4-month well-child visit.

Family Resource/Links

This video shares tips for families and caregivers on what to consider during the first several months related to early allergen introduction. Access the video here:

What you and your family can do in the first several months

Read these resources about early introduction: 

How to Prevent Food Allergies in Infants: A Guide to Early Allergen Introduction

4-Month Well-Child Visit

Clinician Instructions: Considerations for discussions with families

Follow Shared Decision Making (See Section Timing of Complementary Foods and Allergens) to create a plan for the introduction of solids and common food allergens. 

If breastfeeding exclusively until 6 months: 

• Eating a well-balanced diet, while not avoiding the common food allergens, is important during breastfeeding
• Educate on signs of developmental readiness for your baby to start solids and common food allergens
• Remind families that allergen exposure through irritated skin may increase risk (“dual exposure”)

If not breastfeeding exclusively until 6 months: 

• Verify signs of developmental readiness for your baby to start solids and common food allergens
• Begin a few complementary foods before starting food allergens (in developmentally ready form)
• Discuss how to prepare and offer the allergenic foods 
• Discuss how to keep allergens in the diet in a fun and meaningful way, while being consistent
  • Keeping all of these foods in your baby’s diet can feel like a lot; mix and blend allergens into familiar meals that the baby’s caregivers and family members eat most often.

Consider referrals to agencies and programs such as WIC and SNAP, which can also provide information and assistance with breastfeeding support and other nutrition guidance for nutritious foods during breastfeeding.

Sources:
Bright Futures Information for Parents (AAP): 4 Month Visit

After Visit Summary (AVS): Consider copying and pasting into AVS for written instructions

[PASTE] IF EXCLUSIVE BREASTFEEDING IS NOT PLANNED THROUGH 6 MONTHS

Why Early Allergen Introduction Matters

Food allergies are common, but there are steps families can take to help reduce risk. Research shows that giving food allergens to your baby early, around 6 months old, and even as early as 4 to 6 months, and continuing to offer them regularly, can lower the risk of your child getting a food allergy later in life. Following the same thought, waiting to give food allergens until your baby is older may increase their chances of developing a food allergy. 

Visit https://fampitfamily.org/early-allergen-introduction/ for a more extensive guide on early introduction. 

Most babies can begin trying allergenic foods when they are developmentally ready for solids. 

How to know your baby is developmentally ready? 

• Sitting with only a little support
• Controlling their head and neck
• Bringing objects to their mouths
• Opening their mouth when food is offered
• Trying to grasp small objects
• Swallowing food instead of pushing it out with their tongue

Introducing food allergens doesn’t have to be hard. In fact, you can introduce them at the same time you start to offer other solid foods to your baby. These foods together are all called “complementary foods,” because you are giving them while still feeding your baby mainly through breastmilk or formula. In the early days of introducing food allergens, don’t worry if your baby isn’t reaching the goal amount right off the bat. The key here is to add each new allergen one at a time — say, every few days — and keep it in the diet as part of your baby’s weekly routine. 

Common food allergens include:

• Peanut 
• Egg 
• Milk (dairy) 
• Tree nuts 
• Soy 
• Wheat 
• Sesame 
• Fish 
• Shellfish 

When considering what foods to give, also keep in mind the foods to avoid:

• Cow’s milk as a drink shouldn’t be introduced until age 1.
• The same goes for honey — none before age 1.
• Loose nuts and seeds can be a choking risk. Wait until around age 5 for these. Also be careful with clumps or chunks of nut butters.
• Avoid high-mercury fish, like swordfish and some types of tuna. Fish like cod, tilapia, salmon, and flounder are better choices.
• Also avoid raw seafood, raw meats, and unpasteurized dairy that can cause foodborne illnesses.
• Limit added salt and sugar. *

Note: It can be hard to tell how much of each allergen your baby is eating and how close they are to the actual goal. The best you can do is aim for reasonable targets and be as consistent as possible. For example…

• Peanut: Around 2 teaspoons, 3 times a week.
• Tree Nuts and Sesame/Tahini: About 2 teaspoons, 2 times a week is a great target.
• Cow’s Milk Products: For plain whole milk yogurt, gradually increase to a goal of 2 ounces (4 tablespoons), at least 2-3 times a week.
• Eggs: Try for 1/3 of a large egg at least twice a week.
• Fish and shellfish: Fish and shellfish can be harder to keep in the diet, so aim for once every couple of weeks. A good serving is the size of your baby’s palm, in baby-friendly forms.

When your baby is trying a food allergen for the first time, it is important to watch them for signs of a food allergy. 

What is a food allergy?

A food allergy is when your body mistakes a certain food for something dangerous or unknown.

When you first start feeding your baby solids, you may be worried about allergic reactions. Severe allergic reactions are not common in babies. In most cases, symptoms will be mild. Your baby can’t tell you what they are feeling with words, but there are some signs that let us know that they may be allergic to a food.

These signs may include:

• A quickly appearing rash, like hives (red, itchy bumps)
• Vomiting
• A change in behavior soon after eating, like suddenly becoming fussy
• Coughing, sneezing, or a sudden increase in drooling can also occur in combination with other symptoms.

If one or more of these signs occur soon after adding a new food, stop feeding your infant, watch them, and if you have any concerns, call your healthcare team.

Babies rarely have a severe reaction. But if they do, it may look something like this: 

• Hives spreading to cover the entire body
• A lot of swelling of the lips, face, or tongue
• Perhaps some difficulty breathing or repetitive vomiting/diarrhea. 
• Repetitive coughing, changes in skin color, sudden tiredness, or going limp.

If you notice any of these more serious signs of an allergic reaction, get immediate medical care. Call 911.

If your baby has already been given an Allergy and Anaphylaxis Emergency Food Allergy Action Plan, follow the steps.

Example: How to Introduce Allergens

Why should I introduce peanut products to my baby so early in life?

Introducing peanut products to your baby early in life can help prevent them from developing a peanut allergy later on. 

Peanut butter is not only an easy, go-to food, but it is also an excellent source of protein, fat, and other essential nutrients. Peanut butter is thick and sticky right out of the jar, and by itself can be a choking hazard for a baby. To safely serve smooth peanut butter (not chunky!), simply thin it out by using breast milk, formula, plain water, or a pureed food your baby has already tried and tolerated. Don’t give your baby whole peanuts or pieces of peanuts.

Let’s look at how to thin peanut butter in 3 easy steps:

1. Start by taking 3 teaspoons of pureed fruit and place it into a bowl. 
2. Next, measure 2 leveled teaspoons of peanut butter and add it to the fruit puree.
3. Use a small whisk or fork to blend while mashing the peanut butter against the side of the bowl. Keep in mind that this process can take several minutes until the peanut butter and fruit puree are fully combined.

Once the peanut butter is thinned, it’s time to start eating. Slowly feed your baby a small amount on the tip of a spoon and wait about 10 to 15 minutes for any reaction. If there are no signs of a reaction, and your baby seems to enjoy the food, you can continue feeding. While it can be hard to tell how much allergen your baby is eating, try to aim for around 2 teaspoons a week, 3 times a week. 

You can also use this thinning method for other nut butters, such as almond or cashew, and seed butter or pastes like sesame tahini and sunflower seed butter, which are also full of nutrients.

Timing tips

Set aside at least 2 hours after the first taste to watch your baby for a reaction. Make sure you or another family member can give your baby full attention.

For the very first taste, give a small amount, the tip of a small spoon. Wait 10 minutes between the first and second taste. If your baby does not have any reaction after 10 minutes, give the rest of the peanut butter at his normal eating speed.

Give your baby 2 teaspoons (6 grams) of infant safe peanut products about 3 times per week. This will help prevent him from developing a peanut allergy later in life.

Tips while your child eats:

• Prepare a full serving of peanut butter from the recipe below.
• Offer the first taste on a small spoon.
• Do not give loose peanuts or thick or crunchy peanut butter, but smooth is okay
• Do not force your baby to eat more than they want.

Options for recipes for babies

Option 1: Peanut butter puree

You will need:

• 2 tsp. smooth, all-natural peanut butter (with no added ingredients)
• 2-3 tbsp. of plain yogurt or pureed (smooth) fruit or vegetable that your baby likes

Mix peanut butter and yogurt or fruit or vegetable puree. Add more water if you want the puree to be thinner.

Option 2: Peanut butter powder sauce

You will need:

• 2 tsp. powdered peanut butter or peanut flour
• 2-3 tbsp. of warm water, oatmeal, applesauce or mashed banana

Mix peanut butter or peanut flour with the water, oatmeal, applesauce or banana.

Let the mixture cool. Add more water if you want the mixture to be thinner.

Another option is egg. How should I introduce egg, and how much should I introduce? 

Start with well-cooked eggs, such as scrambled. Let cool and mash well using a fork. Mix with breastmilk or prepared formula until smooth.

Try to aim for at least ⅓ of a large egg at least twice a week. 

[STOP PASTE HERE]

[PASTE] IF EXCLUSIVE BREASTFEEDING IS PLANNED THROUGH 6 MONTHS

It is important to continue to pay attention to your baby’s skin. While your baby is not yet getting introduced to new foods to eat, they may still be coming into direct contact with specific food allergens on their skin. If this happens regularly, it may increase their chances of developing an allergy to that particular food. This is especially important for babies with inflamed or irritated skin, like with eczema. Studies show that while eating an allergen early can protect your baby from that food allergy, routine contact with the skin puts them at higher risk. 

So what can you do to help protect your baby’s skin? 

Wash hands after:

• Eating, especially if the food eaten is a common allergen
• Or before handling your baby’s skin, such as during diaper changes and when applying lotions and creams. 

While your baby is not yet eating solids, it is important to know that your healthcare provider may talk to you about starting solids and the common food allergens soon. 

While it’s never too soon to start planning when and how you’ll introduce food allergens to your baby, there’s plenty you can do now if you’re a breastfeeding mom. When choosing your meals and snacks, pick a variety of healthy foods loaded with vitamins and minerals, as well as protein. Think: colorful fruits and veggies, healthy fats, and whole grains. Choose protein from meats; poultry; eggs; dairy; legumes like beans, lentils, and peas; nuts and seeds; and low-mercury seafood like salmon, cod, and shellfish. As much as possible, avoid highly processed foods with lots of added salt and sugar. Filling yourself up on nourishing foods can boost your breast milk with essential nutrients to grow a healthy baby.

If you are not allergic to the common food allergens, there’s no reason to avoid them while breastfeeding. They are rich in nutrients and should be included in a healthy, well-rounded diet. It may also be helpful to know that research suggests a diverse diet with a wide variety of nutritious foods may help lower the risk of food allergies.

[STOP PASTE HERE]

Family Resource/Links

This video shares tips for families and caregivers on what to consider during the first several months related to early allergen introduction. Access the video here:

What you and your family can do in the first several months

These videos share tips for families and caregivers on how to approach early introduction of solids and allergens. Access the videos here:

What is a Food Allergy and how can families help prevent it

When and how do you introduce solid foods and allergens

Read these resources about early introduction: 

How to Prevent Food Allergies in Infants: A Guide to Early Allergen Introduction

Read this handout about early introduction: 

Introducing your baby to Solids and the Common Food Allergens

6-Month Well-Child Visit

Clinician Instructions: Considerations for discussions with families

Follow Shared Decision Making (See Section Timing of Complementary Foods and Allergens) to create a plan for the introduction of solids and common food allergens. 

[PASTE] If breastfed exclusively until 6 months: 

• Verify signs of developmental readiness for your baby to start solids and common food allergens
• Begin a few complementary foods before starting food allergens (in developmentally ready form)
• Discuss how to prepare and offer the allergenic foods 
• Discuss how to keep allergens in the diet in a fun and meaningful way, while being consistent
  • Keeping all of these foods in your baby’s diet can feel like a lot; mix and blend allergens into familiar meals that the baby’s caregivers and family members eat most often. 

[PASTE] If did not breastfeed exclusively until 6 months: 

• Assess progress with allergenic foods and identify barriers or reactions.
• Work toward introducing the common allergens and keeping tolerated allergens in the diet regularly.
• Slowly shift to family foods, but watch for choking hazards as textures get more solid – mash, chop, or blend as needed.

A common thread is to educate families that waiting to introduce food allergens until after 6 months may increase the chances of developing a food allergy.

Consider referrals to agencies and programs such as WIC and SNAP, which can also provide information and assistance with breastfeeding support and other nutrition guidance for nutritious foods during breastfeeding.

Sources:
Bright Futures Information for Parents (AAP): 6 Month Visit

After Visit Summary (AVS): Consider copying and pasting into AVS for written instructions

[PASTE] IF EXCLUSIVE BREASTFEEDING IS NOT PLANNED THROUGH 6 MONTHS

Now that you’re successfully introducing the food allergens, you can focus on keeping them in the diet as part of your baby’s weekly routine as you work towards goal amounts. A great way to do this is to mix the food allergens together with already tolerated foods. Having these foods in the diet over and over again is what will help your baby tolerate them throughout their childhood and as adults.

Keeping all of these foods in your baby’s diet can feel like a lot – especially if you have to do this 2 to 3 times per week. What’s something you can try? Mix and blend these foods into familiar meals, like nut butter in oatmeal or egg in muffins. Or combine already tolerated allergenic foods when possible.

For example:

• Stir peanut powder into yogurt
• Bake muffins made with egg, nut butter, and milk
• Make purees with mashed fish, tofu, and vegetables

Continue to look out for the signs of a food allergy. 

Again, most symptoms will be mild. Your baby can’t tell you what they are feeling with words, but there are some signs that let us know that they may be allergic to a food.

These signs may include:

• A quickly appearing rash, like hives (red, itchy bumps)
• Vomiting
• A change in behavior soon after eating, like suddenly becoming fussy
• Coughing, sneezing, or a sudden increase in drooling can also occur in combination with other symptoms.

If one or more of these signs occur soon after adding a new food, stop feeding your infant, watch them, and if you have any concerns, call your healthcare team.

Babies rarely have a severe reaction. But if they do, it may look something like this: 

• Hives spreading to cover the entire body
• A lot of swelling of the lips, face, or tongue
• Perhaps some difficulty breathing or repetitive vomiting/diarrhea. 
• Repetitive coughing, changes in skin color, sudden tiredness, or going limp.

If you notice any of these more serious signs of an allergic reaction, get immediate medical care. Call 911.

If your baby’s allergist (allergy doctor) has created a Food Allergy Action Plan, follow the steps.

[STOP PASTE HERE]

[PASTE] IF EXCLUSIVE BREASTFEEDING IS PLANNED THROUGH 6 MONTHS

Why Early Allergen Introduction Matters

Food allergies are common, but there are steps families can take to help reduce risk. Research shows that giving food allergens to your baby early, around 6 months old, and even as early as 4 to 6 months, and continuing to offer them regularly, can lower the risk of your child getting a food allergy later in life. Following the same thought, waiting to give food allergens until your baby is older may increase their chances of developing a food allergy. 

Visit https://fampitfamily.org/early-allergen-introduction/ for a more extensive guide on early introduction. 

Most babies can begin trying allergenic foods when they are developmentally ready for solids. 

How to know your baby is developmentally ready? 

• Sitting with only a little support
• Controlling their head and neck
• Bringing objects to their mouths
• Opening their mouth when food is offered
• Trying to grasp small objects
• Swallowing food instead of pushing it out with their tongue

Introducing food allergens doesn’t have to be hard. In fact, you can introduce them at the same time you start to offer other solid foods to your baby. These foods together are all called “complementary foods,” because you are giving them while still feeding your baby mainly through breastmilk or formula. In the early days of introducing food allergens, don’t worry if your baby isn’t reaching the goal amount right off the bat. The key here is to add each new allergen one at a time — say, every few days — and keep it in the diet as part of your baby’s weekly routine. 

Common food allergens include:

• Peanut 
• Egg 
• Milk (dairy) 
• Tree nuts 
• Soy 
• Wheat 
• Sesame 
• Fish 
• Shellfish 

When considering what foods to give, also keep in mind the foods to avoid:

• Cow’s milk as a drink shouldn’t be introduced until age 1.
• The same goes for honey — none before age 1.
• Loose nuts and seeds can be a choking risk. Wait until around age 5 for these. Also be careful with clumps or chunks of nut butters.
• Avoid high-mercury fish, like swordfish and some types of tuna. Fish like cod, tilapia, salmon, and flounder are better choices.
• Also avoid raw seafood, raw meats, and unpasteurized dairy that can cause foodborne illnesses.
• Limit added salt and sugar. 

Note: It can be hard to tell how much of each allergen your baby is eating and how close they are to the actual goal. The best you can do is aim for reasonable targets and be as consistent as possible. For example…

• Peanut: Around 2 teaspoons, 3 times a week.
• Tree Nuts and Sesame/Tahini: About 2 teaspoons, 2 times a week is a great target.
• Cow’s Milk Products: For plain whole milk yogurt, gradually increase to a goal of 2 ounces (4 tablespoons), at least 2-3 times a week.
• Eggs: Try for 1/3 of a large egg at least twice a week.
• Fish and shellfish: Fish and shellfish can be harder to keep in the diet, so aim for once every couple of weeks. A good serving is the size of your baby’s palm, in baby-friendly forms.

When your baby is trying a food allergen for the first time, it is important to watch them for signs of a food allergy. 

What is a food allergy?

A food allergy is when your body mistakes a certain food for something dangerous or unknown.

When you first start feeding your baby solids, you may be worried about allergic reactions. Severe allergic reactions are not common in babies. In most cases, symptoms will be mild. Your baby can’t tell you what they are feeling with words, but there are some signs that let us know that they may be allergic to a food.

These signs may include:

• A quickly appearing rash, like hives (red, itchy bumps)
• Vomiting
• A change in behavior soon after eating, like suddenly becoming fussy
• Coughing, sneezing, or a sudden increase in drooling can also occur in combination with other symptoms.

If one or more of these signs occur soon after adding a new food, stop feeding your infant, watch them, and if you have any concerns, call your healthcare team.

Babies rarely have a severe reaction. But if they do, it may look something like this: 

• Hives spreading to cover the entire body
• A lot of swelling of the lips, face, or tongue
• Perhaps some difficulty breathing or repetitive vomiting/diarrhea. 
• Repetitive coughing, changes in skin color, sudden tiredness, or going limp.

If you notice any of these more serious signs of an allergic reaction, get immediate medical care. Call 911.

If your baby has already been given an Allergy and Anaphylaxis Emergency Food Allergy Action Plan, follow the steps.

Example: How to Introduce Allergens

Why should I introduce peanut products to my baby so early in life?

Introducing peanut products to your baby early in life can help prevent them from developing a peanut allergy later on.

Peanut butter is not only an easy, go-to food, but it is also an excellent source of protein, fat, and other essential nutrients. Peanut butter is thick and sticky right out of the jar, and by itself can be a choking hazard for a baby. To safely serve smooth peanut butter (not chunky!), simply thin it out by using breast milk, formula, plain water, or a pureed food your baby has already tried and tolerated. Don’t give your baby whole peanuts or pieces of peanuts.

Let’s look at how to thin peanut butter in 3 easy steps:

1. Start by taking 3 teaspoons of pureed fruit and place it into a bowl. 
2. Next, measure 2 leveled teaspoons of peanut butter and add it to the fruit puree.
3. Use a small whisk or fork to blend while mashing the peanut butter against the side of the bowl. Keep in mind that this process can take several minutes until the peanut butter and fruit puree are fully combined.

Once the peanut butter is thinned, it’s time to start eating. Slowly feed your baby a small amount on the tip of a spoon and wait about 10 to 15 minutes for any reaction. If there are no signs of a reaction, and your baby seems to enjoy the food, you can continue feeding. While it can be hard to tell how much allergen your baby is eating, try to aim for around 2 teaspoons a week, 3 times a week. 

You can also use this thinning method for other nut butters, such as almond or cashew, and seed butter or pastes like sesame tahini and sunflower seed butter, which are also full of nutrients.

Timing tips

Set aside at least 2 hours after the first taste to watch your baby for a reaction. Make sure you or another family member can give your baby full attention.

For the very first taste, give a small amount, the tip of a small spoon. Wait 10 minutes between the first and second taste. If your baby does not have any reaction after 10 minutes, give the rest of the peanut butter at his normal eating speed.

Give your baby 2 teaspoons (6 grams) of infant safe peanut products at least 3 times per week. This will help prevent him from developing a peanut allergy later in life.

Tips while your child eats:

• Prepare a full serving of peanut butter from the recipe below.
• Offer the first taste on a small spoon.
• Do not give plain peanut butter to any baby or child under age 4.
• Do not push your baby to eat more than they want.

Options for recipes for babies

Option 1: Peanut butter puree

You will need:

• 2 tsp. smooth, all-natural peanut butter (with no added ingredients)
• 2-3 tbsp. of plain yogurt or pureed (smooth) fruit or vegetable that your baby likes

Mix peanut butter and yogurt or fruit or vegetable puree. Add more water if you want the puree to be thinner.

Option 2: Peanut butter powder sauce

You will need:

• 2 tsp. powdered peanut butter or peanut flour
• 2-3 tbsp. of warm water, oatmeal, applesauce or mashed banana

Mix peanut butter or peanut flour with the water, oatmeal, applesauce or banana.

Let the mixture cool. Add more water if you want the mixture to be thinner.

Another option is egg. How should I introduce egg, and how much should I introduce? 

Start with well-cooked eggs, such as scrambled. Let cool and mash well using a fork. Mix with breastmilk or prepared formula until smooth.

Try to aim for at least ⅓ of a large egg at least twice a week. 

[STOP PASTE HERE]

Family Resource/Links

This video shares tips for families and caregivers on what to consider during the these months for early allergen introduction. Access the videos here:

What is a Food Allergy and how can families help prevent it

When and how do you introduce solid foods and allergens

Read these resources about early introduction: 

How to Prevent Food Allergies in Infants: A Guide to Early Allergen Introduction

Read this handout about early introduction: 

Introducing your baby to Solids and the Common Food Allergens

9-Month Well-Child Visit

Clinician Instructions: Considerations for discussions with families

• Reinforce dietary diversity and continued ingestion of tolerated allergens
• Keep tolerated allergens in the diet consistently while expanding variety, textures, and quantities.
• Address any barriers and concerns with allergenic foods and identify barriers or reactions.

Source:
Bright Futures Information for Parents (AAP): 9 Month Visit

Consider referrals to agencies and programs such as WIC and SNAP, which can also provide information and assistance with breastfeeding support and other nutrition guidance for nutritious foods during breastfeeding.

After Visit Summary (AVS): Consider copying and pasting into AVS for written instructions

Now that you’re successfully introducing the food allergens, you can focus on keeping them in the diet as part of your baby’s weekly routine as you work towards goal amounts. A great way to do this is to mix the food allergens together with already tolerated foods. Having these foods in the diet over and over again is what will help your baby tolerate them throughout their childhood and as adults.

Keeping all of these foods in your baby’s diet can feel like a lot – especially if you have to do this 2 to 3 times per week. What’s something you can try? Mix and blend these foods into familiar meals, like nut butter in oatmeal or egg in muffins. Or combine already tolerated allergenic foods when possible.

For example:

• Stir peanut powder into yogurt
• Bake muffins made with egg, nut butter, and milk
• Make purees with mashed fish, tofu, and vegetables

Continue to keep in mind the foods to avoid:

• Cow’s milk as a drink shouldn’t be introduced until age 1.
• The same goes for honey — none before age 1.
• Loose nuts and seeds can be a choking risk. Wait until around age 5 for these. Also be careful with clumps or chunks of nut butters.
• Avoid high-mercury fish, like swordfish and some types of tuna. Fish like cod, tilapia, salmon, and flounder are better choices.
• Also avoid raw seafood, raw meats, and unpasteurized dairy that can cause foodborne illnesses.
• Limit added salt and sugar. *

As your baby moves from purées to eating more family meals, it’s important to keep including the allergenic foods they’ve already tried. Some tips for helping with this:

• Add allergenic ingredients into soft, age-appropriate family meals (like egg in pasta or peanut butter in smoothies).
• Watch for choking hazards as textures get more solid – mash, chop, or blend as needed.
• Continue offering these foods a few times per week to support tolerance.
• This phase is a great opportunity to help your child explore new flavors and textures, and keep up allergy prevention as they eat more and more foods. Side benefit: you’re not always making separate meals for your baby!

Continue to look for signs of allergic reactions as you try new foods. In most cases, symptoms will be mild. Your baby can’t tell you what they are feeling with words, but there are some signs that let us know that they may be allergic to a food.

These signs may include:

• A quickly appearing rash, like hives (red, itchy bumps)
• Vomiting
• A change in behavior soon after eating, like suddenly becoming fussy
• Coughing, sneezing, or a sudden increase in drooling can also occur in combination with other symptoms.

If one or more of these signs occur soon after adding a new food, stop feeding your infant, watch them, and if you have any concerns, call your healthcare team.

Babies rarely have a severe reaction. But if they do, it may look something like this: 

• Hives spreading to cover the entire body
• A lot of swelling of the lips, face, or tongue
• Perhaps some difficulty breathing or repetitive vomiting/diarrhea. 
• Repetitive coughing, changes in skin color, sudden tiredness, or going limp.

If you notice any of these more serious signs of an allergic reaction, get immediate medical care. Call 911.

If your baby has already been given an Allergy and Anaphylaxis Emergency Food Allergy Action Plan, follow the steps.

12-Month Well-Child Visit

Clinician Instructions: Considerations for discussions with families

• Address any barriers and concerns with allergenic foods and identify barriers or reactions
• Identify any unnecessary avoidance or difficulty maintaining certain foods in the diet
• Transition towards age-appropriate family foods while continuing tolerated allergens and increasing dietary diversity

Consider referrals to agencies and programs such as WIC and SNAP, which can also provide information and assistance with breastfeeding support and other nutrition guidance for nutritious foods during breastfeeding.

Sources:
Bright Futures Information for Parents (AAP): 12 Month Visit

After Visit Summary (AVS): Consider copying and pasting into AVS for written instructions

Maintain allergenic ingredients in soft, age-appropriate family meals (like egg in pasta or peanut butter in smoothies).

• Continue to avoid choking hazards as textures get more solid – mash, chop, or blend as needed.
• Continue offering these foods a few times per week to support tolerance.

This phase is a great opportunity to help your child explore new flavors and textures, and keep up allergy prevention as they eat more and more foods. Side benefit: you’re not always making separate meals for your baby!

Continue to look for signs of allergic reactions as you try new foods. In most cases, symptoms will be mild. Your baby can’t tell you what they are feeling with words, but there are some signs that let us know that they may be allergic to a food.

These signs may include:

• A quickly appearing rash, like hives (red, itchy bumps)
• Vomiting
• A change in behavior soon after eating, like suddenly becoming fussy
• Coughing, sneezing, or a sudden increase in drooling can also occur in combination with other symptoms.

If one or more of these signs occur soon after adding a new food, stop feeding your infant, watch them, and if you have any concerns, call your healthcare team.

Babies rarely have a severe reaction. But if they do, it may look something like this: 

• Hives spreading to cover the entire body
• A lot of swelling of the lips, face, or tongue
• Perhaps some difficulty breathing or repetitive vomiting/diarrhea. 
• Repetitive coughing, changes in skin color, sudden tiredness, or going limp.

If you notice any of these more serious signs of an allergic reaction, get immediate medical care. Call 911.

If your baby has already been given an Allergy and Anaphylaxis Emergency Food Allergy Action Plan, follow the steps.

Family Resource/Links

Read this handout for “Feeding Your Child After Their First Birthday”:

Nutrition Education after 12 months

Signs of Developmental Readiness/Early Introduction Guidance

Clinician Instructions: Considerations for discussion with families

• Approach Early Introduction with Shared Decision Making 
• Discuss Mild and Serious Allergic Reactions (also in AVS)
• Following the visit, remind families to bring up any barriers and concerns with allergenic foods and identify barriers or reactions

After Visit Summary (AVS): Consider copying and pasting into AVS for written instructions

Why Early Allergen Introduction Matters

Food allergies are common, but there are steps families can take to help reduce risk. Research shows that giving food allergens to your baby early, around 6 months old, and even as early as 4 to 6 months, and continuing to offer them regularly, can lower the risk of your child getting a food allergy later in life. Following the same thought, waiting to give food allergens until your baby is older may increase their chances of developing a food allergy. 

Visit https://fampitfamily.org/early-allergen-introduction/ for a more extensive guide on early introduction. 

Most babies can begin trying allergenic foods when they are developmentally ready for solids. 

How to know your baby is developmentally ready? 

• Sitting with only a little support
• Controlling their head and neck
• Bringing objects to their mouths
• Opening their mouth when food is offered
• Trying to grasp small objects
• Swallowing food instead of pushing it out with their tongue

Introducing food allergens doesn’t have to be hard. In fact, you can introduce them at the same time you start to offer other solid foods to your baby. These foods together are all called “complementary foods,” because you are giving them while still feeding your baby mainly through breastmilk or formula. In the early days of introducing food allergens, don’t worry if your baby isn’t reaching the goal amount right off the bat. The key here is to add each new allergen one at a time — say, every few days — and keep it in the diet as part of your baby’s weekly routine. 

Common food allergens include:

• Peanut 
• Egg 
• Milk (dairy) 
• Tree nuts 
• Soy 
• Wheat 
• Sesame 
• Fish 
• Shellfish 

When considering what foods to give, also keep in mind the foods to avoid:

• Cow’s milk as a drink shouldn’t be introduced until age 1.
• The same goes for honey — none before age 1.
• Loose nuts and seeds can be a choking risk. Wait until around age 5 for these. Also be careful with clumps or chunks of nut butters.
• Avoid high-mercury fish, like swordfish and some types of tuna. Fish like cod, tilapia, salmon, and flounder are better choices.
• Also avoid raw seafood, raw meats, and unpasteurized dairy that can cause foodborne illnesses.
• Limit added salt and sugar. *

Note: It can be hard to tell how much of each allergen your baby is eating and how close they are to the actual goal. The best you can do is aim for reasonable targets and be as consistent as possible. For example…

• Peanut: Around 2 teaspoons, 3 times a week.
• Tree Nuts and Sesame/Tahini: About 2 teaspoons, 2 times a week is a great target.
• Cow’s Milk Products: For plain whole milk yogurt, gradually increase to a goal of 2 ounces (4 tablespoons), at least 2-3 times a week.
• Eggs: Try for 1/3 of a large egg at least twice a week.
• Fish and shellfish: Fish and shellfish can be harder to keep in the diet, so aim for once every couple of weeks. A good serving is the size of your baby’s palm, in baby-friendly forms.

When your baby is trying a food allergen for the first time, it is important to watch them for signs of a food allergy. 

What is a food allergy?

A food allergy is when your body mistakes a certain food for something dangerous or unknown.

When you first start feeding your baby solids, you may be worried about allergic reactions. Severe allergic reactions are not common in babies. In most cases, symptoms will be mild. Your baby can’t tell you what they are feeling with words, but there are some signs that let us know that they may be allergic to a food.

These signs may include:

• A quickly appearing rash, like hives (red, itchy bumps)
• Vomiting
• A change in behavior soon after eating, like suddenly becoming fussy
• Coughing, sneezing, or a sudden increase in drooling can also occur in combination with other symptoms.

If one or more of these signs occur soon after adding a new food, stop feeding your infant, watch them, and if you have any concerns, call your healthcare team.

Babies rarely have a severe reaction. But if they do, it may look something like this: 

• Hives spreading to cover the entire body
• A lot of swelling of the lips, face, or tongue
• Perhaps some difficulty breathing or repetitive vomiting/diarrhea. 
• Repetitive coughing, changes in skin color, sudden tiredness, or going limp.

If you notice any of these more serious signs of an allergic reaction, get immediate medical care. Call 911.

If your baby has already been given an Allergy and Anaphylaxis Emergency Food Allergy Action Plan, follow the steps.

Example: How to Introduce Allergens

Peanut Introduction as per NIAID/LEAP

Why should I introduce peanut products to my baby so early in life?

Introducing peanut products to your baby early in life can help prevent them from developing a peanut allergy later on. Ask your provider when it is right to introduce peanut products for the first time.

Peanut butter is not only an easy, go-to food, but it is also an excellent source of protein, fat, and other essential nutrients. Peanut butter is thick and sticky right out of the jar, and by itself can be a choking hazard for a baby. To safely serve smooth peanut butter (not chunky!), simply thin it out by using breast milk, formula, plain water, or a pureed food your baby has already tried and tolerated. Don’t give your baby whole peanuts or pieces of peanuts.

Let’s look at how to thin peanut butter in 3 easy steps:

1. Start by taking 3 teaspoons of pureed fruit and place it into a bowl. 
2. Next, measure 2 leveled teaspoons of peanut butter and add it to the fruit puree.
3. Use a small whisk or fork to blend while mashing the peanut butter against the side of the bowl. Keep in mind that this process can take several minutes until the peanut butter and fruit puree are fully combined.

Once the peanut butter is thinned, it’s time to start eating. Slowly feed your baby a small amount on the tip of a spoon and wait about 10 to 15 minutes for any reaction. If there are no signs of a reaction, and your baby seems to enjoy the food, you can continue feeding. While it can be hard to tell how much allergen your baby is eating, try to aim for around 2 teaspoons a week, 3 times a week. 

You can also use this thinning method for other nut butters, such as almond or cashew, and seed butter or pastes like sesame tahini and sunflower seed butter, which are also full of nutrients.

Timing tips

Set aside at least 2 hours after the first taste to watch your baby for a reaction. Make sure you or another family member can give your baby full attention.

For the very first taste, give a small amount, the tip of a small spoon. Wait 10 minutes between the first and second taste. If your baby does not have any reaction after 10 minutes, give the rest of the peanut butter at his normal eating speed.

Give your baby 2 teaspoons (6 grams) of infant safe peanut products at least 3 times per week. This will help prevent him from developing a peanut allergy later in life.

Tips while your child eats:

• Prepare a full serving of peanut butter from the recipe below.
• Offer the first taste on a small spoon.
• Do not give plain peanut butter to any baby or child under age 4.
• Do not push your baby to eat more than they want.

Options for recipes for babies

Option 1: Peanut butter puree

You will need:

• 2 tsp. smooth, all-natural peanut butter (with no added ingredients)
• 2-3 tbsp. of plain yogurt or pureed (smooth) fruit or vegetable that your baby likes

Mix peanut butter and yogurt or fruit or vegetable puree. Add more water if you want the puree to be thinner.

Option 2: Peanut butter powder sauce

You will need:

• 2 tsp. powdered peanut butter or peanut flour
• 2-3 tbsp. of warm water, oatmeal, applesauce or mashed banana

Mix peanut butter or peanut flour with the water, oatmeal, applesauce or banana.

Let the mixture cool. Add more water if you want the mixture to be thinner.

Another option is egg. How should I introduce egg, and how much should I introduce? 

Start with well-cooked eggs, such as scrambled. Let cool and mash well using a fork. Mix with breastmilk or prepared formula until smooth.

Try to aim for at least ⅓ of a large egg at least twice a week.

Family Resources/Links

These videos share tips for families and caregivers on how to approach early introduction of solids and allergens. Access the videos here:

What is a Food Allergy and how can families help prevent it

When and how do you introduce solid foods and allergens

Read these resources about early introduction: 

How to Prevent Food Allergies in Infants: A Guide to Early Allergen Introduction

Read this handout about early introduction: 

Introducing your baby to Solids and the Common Food Allergens

Maintenance of Allergens for Early Introduction Guidance

Clinician Instructions: Considerations for discussion with families

• Discuss Mild and Serious Allergic Reactions (also in AVS)
• Following the visit, remind families to bring up any barriers and concerns with allergenic foods and identify barriers or reactions
• Discuss switching to family foods

After Visit Summary (AVS): Consider copying and pasting into AVS for written instructions

Maintenance Guidance

Now that you’re successfully introducing the food allergens, you can focus on keeping them in the diet as part of your baby’s weekly routine as you work towards goal amounts. A great way to do this is to mix the food allergens together with already tolerated foods. Having these foods in the diet over and over again is what will help your baby tolerate them throughout their childhood and as adults.

Keeping all of these foods in your baby’s diet can feel like a lot – especially if you have to do this 2 to 3 times per week. What’s something you can try? Mix and blend these foods into familiar meals, like nut butter in oatmeal or egg in muffins. Or combine already tolerated allergenic foods when possible.

For example:

• Stir peanut powder into yogurt
• Bake muffins made with egg, nut butter, and milk
• Make purees with mashed fish, tofu, and vegetables

Continue to look out for the signs of a food allergy. 

Again, most symptoms will be mild. Your baby can’t tell you what they are feeling with words, but there are some signs that let us know that they may be allergic to a food.

These signs may include:

• A quickly appearing rash, like hives (red, itchy bumps)
• Vomiting
• A change in behavior soon after eating, like suddenly becoming fussy
• Coughing, sneezing, or a sudden increase in drooling can also occur in combination with other symptoms.

If one or more of these signs occur soon after adding a new food, stop feeding your infant, watch them, and if you have any concerns, call your healthcare team.

Babies rarely have a severe reaction. But if they do, it may look something like this: 

• Hives spreading to cover the entire body
• A lot of swelling of the lips, face, or tongue
• Perhaps some difficulty breathing or repetitive vomiting/diarrhea. 
• Repetitive coughing, changes in skin color, sudden tiredness, or going limp.

If you notice any of these more serious signs of an allergic reaction, get immediate medical care. Call 911.

If your baby has already been given an Allergy and Anaphylaxis Emergency Food Allergy Action Plan, follow the steps.

Family Resources/Links

These videos share tips for families and caregivers on how to approach early introduction of solids and allergens. Access the videos here:

What is a Food Allergy and how can families help prevent it

When and how do you introduce solid foods and allergens

Read these resources about early introduction: 

How to Prevent Food Allergies in Infants: A Guide to Early Allergen Introduction

Read this handout about early introduction: 

Introducing your baby to Solids and the Common Food Allergens

Eczema Guidance

Clinician Instructions: Considerations for discussion with families

• Discuss Eczema Management and Treatments
• If the patient has not begun common food allergens and solids, discuss the dual exposure hypothesis and the importance of maintaining a barrier to the common food allergens
• Consider referral to dermatology, if available, for treatment of severe symptoms

After Visit Summary (AVS): Consider copying and pasting into AVS for written instructions

General Skincare:

Apply moisturizer at least daily, especially within 3 minutes after bathing to lock in the moisture. Waiting too long after bathing can dry out your child’s skin. Make sure to wash your hands before applying the moisturizer, as you want to avoid trapping any allergens or germs that may be on your hands against your child’s skin. Use moisturizers that are fragrance-free and dye-free, as they will be less irritating on your child’s skin.

[PASTE] IF YOUR BABY HAS NOT STARTED THE COMMON ALLERGENS AND SOLIDS

It is important to pay attention to your baby’s skin. While your baby is not yet getting introduced to new foods to eat, they may still be coming into direct contact with specific food allergens on their skin. If this happens regularly, it may increase their chances of developing an allergy to that particular food. This is especially important for babies with inflamed or irritated skin, like with eczema. Studies show that while eating an allergen early can protect your baby from that food allergy, routine contact with the skin puts them at higher risk. 

So what can you do to help protect your baby’s skin? 

Wash hands after:

• Eating, especially if the food eaten is a common allergen
• Or before handling your baby’s skin, such as during diaper changes and when applying lotions and creams. 

If developmentally ready, begin introducing your baby to food allergens when you start other solids, around when they’re 4 to 6 months old. Introducing food allergens early can help lower the risk of food allergy and offers that protection from skin exposure. Talk to your healthcare team about early introduction at this time. 

[STOP PASTE HERE]

Management:

Soak and Seal Method

Give your child a bath in lukewarm water with gentle cleansers. After getting out of the bath, gently pat (do not rub) off water using a towel and leave the skin slightly damp. Apply any topical steroids or treatment to the skin. Apply moisturizer all over the body, within 3 minutes, and wait for the moisturizer to absorb into the skin before putting on clothes.

Steroid Use:

Topical steroids are effective in the treatment of eczema. If topical steroids are needed, apply 1-2 times a day for 7 days on active lesions and continue application for 2-3 days after eczema lesions have resolved. Make sure to use less strong steroids on the face.

Wet Wraps:

Wet wrap therapy can be useful for tougher-to-manage eczema. After getting out of the bath and applying moisturizers, moisten clean cloth/gauze and wrap the affected areas. Cover the wet wraps with dry covers and leave overnight.

Family Resources/Links

This video shares tips for families and caregivers on what to consider during the first several months related to early allergen introduction, especially if your baby has eczema. Access the video here:

What you and your family can do in the first several months

Read these resources about eczema: 

Understanding Eczema and How It Can Relate to Food Allergies

Managing Eczema with Everyday Skincare

Managing Eczema by Treating Flare-ups

Eczema and How the Healthcare Team Can Help

Food Reaction Guidance

Clinician Instructions: Considerations for discussion with families

• Review steps of diagnosing food allergy
  • Delays in referral, testing, etc.
• Guidance about Specific Food and Diet with Allergens
• Review and assess referral to Food Allergy Specialist

After Visit Summary (AVS): Consider copying and pasting into AVS for written instructions

What happens after an allergic reaction? 

Diagnosing a food allergy is often a step-by-step process, and there isn’t a single test that gives all the answers. Sometimes, a test may come back positive even if your baby doesn’t actually have a food allergy. To make the most accurate diagnosis, your child’s doctor will look at the whole picture: your observations, your baby’s medical history, and carefully chosen tests.

Why do you see a Food Allergy Specialist?

While the conversation about your child’s food allergies will often start with a pediatrician, there may come a time when you want your child’s healthcare team to include a specialist. 

Allergy specialists are experts in treating food allergies. They can be physicians (MD/DO), who are board-certified in allergy and immunology, Nurse Practitioners, or Physician Assistants/Associates. Many allergy specialists are trained to care for infants, young children, and even teens. Check with the office to confirm if your allergy specialist sees infants and toddlers. Allergy specialists are trained to:

• Figure out what your child is reacting to and make a diagnosis.
• Do allergy testing (like a skin test or blood tests).
• Decide if your child needs a supervised oral food challenge.
• Create a care plan to help your child stay safe and feel better.
• Help decide if treatments like oral immunotherapy or biologics may be needed.
• Work with you on whether an elimination diet is appropriate.
• Decide if you have to remove specific foods from your child’s diet.
• Prescribe epinephrine.
• Create an anaphylaxis action plan.

They can also help when it’s unclear what’s causing your child’s reactions or when allergies affect daily life.

Family Resources/Links

This resource shares tips for families and caregivers on what to consider and understand when your infant or toddler is being diagnosed with a food allergy. Access the resource here: 

Understanding and Diagnosing Food Allergies in Infants & Toddlers

Preventing Food Allergy Reactions

Emergency Preparedness – Allergic Reactions and Anaphylaxis

Food Allergy Guidance

Clinician Instructions: Considerations for discussion with families

• Review Pillars of Food Allergy Management
  • Management (Cross-Contact) and (Label Reading)
  • Emergency Preparedness (Epinephrine and  Anaphylaxis Emergency Action Plan)
• Practice Shared Decision Making for Discussion about Treatments and Therapies
  • If applicable, review and assess referrals to Food Allergy Specialist

After Visit Summary (AVS): Consider copying and pasting into AVS for written instructions

What is a Food Allergy?

Your child’s immune system is still developing and learning what is safe. Sometimes, when babies try a new food, their immune system mistakes it for something harmful and reacts. This is called a food allergy.

Many food allergies fall under the category of IgE-mediated food allergies. (Non-IgE-mediated food allergies are another type). IgE is a protein made by the immune system. In people with food allergies, IgE reacts to certain foods and causes the body to release chemicals that lead to allergic symptoms.

Reactions usually happen quickly—within minutes to a few hours after eating. Serious reactions (called anaphylaxis) are uncommon in babies but can be life-threatening and need emergency treatment right away.

How to Avoid a Food Allergy Reaction

Once your child is diagnosed with a food allergy, there is a lot to learn. It’s normal to feel overwhelmed at first. The good news is that focusing on a few key basics can make a big difference. 

Label Reading

Oral ingestion is the most common way to have an allergic reaction to food. Before eating, read labels to avoid allergens. Ingredients change without notice, so read labels every time.

Check these three places for allergens: 

1) Ingredients List – An ingredients list is usually found on the back or side of the package. This is where you will find everything used to make the product. Allergens may appear by their common name (like “milk”) or under another name (like “casein”).

2) Contains Statement – Contains statements are often printed in bold after the ingredients list. Example: Contains: Milk, Egg, Wheat. Not all products include this statement, so it should never replace reading the ingredients list.

3) Advisory statements – These are not required to be included on packaging and vary by brand. You may see:

 “May contain…” 

“Made in a facility that also processes…”

“Processed on shared equipment with…” 

Advisory statements should never replace the ingredient lists. 

Under U.S. food labeling laws, most packaged foods regulated by the FDA must clearly identify the 9 major food allergens when they are used as ingredients.

Cross Contact

If your child has a food allergy, ingredients are not the only thing you need to pay attention to. You also need to be mindful of how foods are made and handled. Even if a food does not contain your child’s allergen as an ingredient, it may still cause a reaction if it touches that allergen. This is called “cross-contact.” While this can feel overwhelming, there is good news. Once you understand how cross-contact happens and where it is most likely to occur, there are simple steps you can take to help prevent it.

Cross-contact occurs when a food allergen comes into contact with a food that is supposed to be safe and allergen-free. The part of food that causes allergic reactions (called proteins) can be so small that you cannot see it. Your child’s immune system can notice even tiny amounts of these proteins and start an allergic reaction. Cross-contact usually doesn’t happen because someone is careless. It often happens because people don’t realize what to watch for when cooking, serving, eating, or cleaning up after a meal.

There are three main ways cross-contact can happen:

1. Food-to-Food Contact

Food-to-food contact happens when an allergen touches another food. This can occur during storage, cooking, plating, or serving. It may happen directly when two foods come into contact, such as foods touching on the same plate or sharing a container. It can also happen indirectly, when allergen proteins get onto utensils, plates, or pans that are then used to prepare a food that is supposed to be safe.

Large spills or crumbs are easier to notice, but small amounts of allergens can spread to other foods or surfaces without anyone realizing it. Common ways this can happen include:

• Steam or splatter from cooking on the stove landing on nearby foods.
• Small crumbs being left behind in dips or spreads such as butter, jelly, or cream cheese.
• Using the same knife, spoon, tongs, or other utensil for multiple foods without washing it in between.

It is important to know that once foods have touched, removing the visible allergen does not make the food safe. For example, if a slice of cheese is placed on a burger and then taken off, it may remove what you can see, but tiny amounts of dairy protein can still be on the burger and cause an allergic reaction.

2. Surfaces and Objects

Allergens can get left behind on surfaces and objects after food touches them. When your little one grabs that surface, the allergen can end up on their hands and sometimes into their mouth. Children may also put toys or surfaces directly into their mouths. This is especially common for babies and toddlers, who love to taste-test everything they see and cannot wash their hands as adults can.

3. Saliva 

After eating, small amounts of allergen protein can stay in the saliva for a while. These proteins can be passed to your child if they share cups, utensils, or pacifiers with others, or if they receive kisses on or near the mouth. Pets can also spread allergens if they have recently eaten a food containing your child’s allergen and then lick your child or their toys.

To lower the risk, avoid sharing cups, utensils, or saliva (such as kissing near the mouth) for a few hours after eating a food containing your child’s allergen. Brushing teeth and eating an allergen-free meal may help lower the amount of allergen in the mouth, but they do not get rid of it completely.  

Note: You may also hear the word cross-contamination. This sounds similar but actually means something different:

• Cross-contact: Allergen protein from one food gets on another food. This may cause an allergic reaction.
• Cross-contamination: Bacteria or germs from one food get on another food. This may cause food poisoning.

Emergency Preparedness and Anaphylaxis for Food Allergies

IgE-mediated allergic reactions do not all look the same. Some are mild and stay in one part of the body. Others are more serious and involve more than one body system or affect breathing or circulation. Sometimes it can be easy to mistake an allergic reaction for normal behavior. Knowing what to look out for helps guide us on what to do next.

What are the signs and symptoms of a mild allergic reaction?

Mild reactions are usually limited to one body area and do not spread or get worse quickly. In this case, stop feeding your baby the food, watch for changes, and talk with your healthcare team about next steps.

What is anaphylaxis? 

A serious allergic reaction is called anaphylaxis. It can happen when your baby or toddler eats a food they are allergic to. (Anaphylaxis can also occur with other types of allergens, like stinging insects and medications.) It can look something like:

• Your child has mild symptoms but in more than one body area. For example, a small area of hives by itself is a mild symptom, and limited vomiting by itself is a mild symptom, but both hives and vomiting together can be considered early anaphylaxis. Or…
• Your child has severe symptoms in one or more areas of the body. These severe symptoms can happen in different areas of the body, including the skin, stomach, breathing, and circulation. Or…
• Your child starts with one mild symptom, but it gets worse as time passes, becoming a severe symptom, aka anaphylaxis. Or…
• Your child starts with one mild symptom, but one or more new mild symptoms appear, which is then early anaphylaxis.

The first-line treatment for anaphylaxis is epinephrine.

What are the signs and symptoms of a serious allergic reaction – anaphylaxis?

This chart goes over the severe symptoms your baby may have if they are having a serious allergic reaction. These symptoms are grouped by the area of the body they can happen in. Remember, a reaction can also be considered anaphylaxis if the symptoms are mild (described in the mild symptoms chart above) but in more than one area of the body.

If your baby is having severe symptoms and they are diagnosed with a food allergy and have epinephrine, give epinephrine and follow your baby’s Anaphylaxis Emergency Action Plan. An easy way to remember what to do is to follow the REAct steps outlined below.

R – Recognize Anaphylaxis

Watch for serious symptoms like trouble breathing, vomiting, sudden sleepiness, swelling, or symptoms affecting two or more body systems. Use the above chart to see what symptoms might look like specifically in infants and toddlers.

E – Epinephrine 

If your baby or toddler is experiencing some symptoms and you’re not sure it’s anaphylaxis, the best approach is to still give epinephrine. Early treatment can keep a reaction from getting worse and make your baby or toddler feel better quickly. 

Position your baby after epinephrine. After giving epinephrine, position your baby based on their symptoms:

If there’s trouble breathing or coughing:

• Hold your baby upright against your chest.
• Support their head and make sure their legs aren’t dangling.

If the baby’s head and body are limp and floppy, or if they’re hard to wake up:

• Lay your baby flat on their back with legs slightly raised.
• Do not pick your baby up suddenly or let your baby move around too much.

If there’s vomiting:

• Lay your baby on their side to prevent choking.

Give a second dose of epinephrine if:

• Symptoms do not get better in about 5 minutes after the first dose, or
• Symptoms come back or get worse

If you give a second dose of epinephrine, call 911.

Reminder: Keep two doses of epinephrine available at all times. Don’t forget to refill the prescription.

Act – Activate emergency plan

These days, guidelines allow a bit more flexibility on what happens after epinephrine is given for anaphylaxis. If your child’s anaphylaxis is treated early and symptoms quickly get better after a first dose of epinephrine, you may not need to call 911. Your healthcare team will discuss with you whether this is an option for your child.

In these cases…

• there needs to be more than one dose of epinephrine available
• your baby cannot have severe or life-threatening symptoms
• another person is present
• you’re comfortable managing the situation
• symptoms largely get better after treatment, and
• the healthcare team previously approved this for your child

Call 911 if…

• you don’t have a second dose of epinephrine
• symptoms return or worsen after the first dose of epinephrine
• symptoms do not go away quickly or completely after the first dose of epinephrine
• a second dose of epinephrine is needed

Follow the Anaphylaxis Action Plan from your Healthcare Team

Building habits to avoid food allergens is a great way to keep your baby safe — and at the end of the day, it’s enough. You may choose to take additional steps and discuss the different food allergy treatments with your healthcare team. Your primary care team will help you feel comfortable managing food allergies, and when appropriate, an allergy specialist can provide testing, determine the right treatment for your child, and guide you through the process.

Below, learn more about the different treatments and medications that may come up during your child’s food allergy journey. 

Types of food allergy treatments

Some young children with food allergies have very strong reactions to even tiny amounts of certain foods. For these children, new treatments called biologics may help. Omalizumab (Xolair®) is an FDA-approved biologic medication for the treatment of food allergies. It is for children 1 year of age and older at risk for severe symptoms.

What is omalizumab?

• Omalizumab is given as an injection to treat a child’s food allergy.
• It works by blocking a substance in the body called IgE. IgE plays a major role in allergic reactions.
• By lowering IgE, omalizumab can help calm the immune system and reduce allergic responses in case of an accidental exposure.
• Omalizumab does not cure food allergies. Your child will still need to avoid their allergens and carry epinephrine for emergencies.

Before a visit with your allergy specialist, consider and gather information about the following regarding your child’s food allergies when discussing Omalizumab as a treatment option:

• Your history of accidental exposures to your food allergens (number of times epinephrine was used, number of emergency room visits, and intensive care admissions as a result of anaphylaxis) and what happened during those reactions.
• Whether avoiding your food allergens has been difficult or not been enough to stop accidental exposures. 
• Whether your attempts to avoid allergens are affecting your quality of life. 
• Whether the severity of your allergic reactions has changed over time.
• Whether you are willing and able to follow the recommended at-home dosing schedule for omalizumab.

Food allergy oral immunotherapy is a long word (often called OIT) for a type of treatment that helps build tolerance to common food allergens. In other words, it helps your baby slowly get used to the allergen. The goal is to make the immune system less likely to cause a severe allergic reaction if accidentally exposed to the allergen (such as your child unknowingly taking a bite of something that had cross-contact with their allergen).

OIT works by giving a tiny amount of the known food allergen to your child to start, then gradually giving larger amounts until a maintenance dose is reached. Eating this maintenance dose regularly can give most children protection from accidental exposures, even if the accidental exposure is to an amount larger than the maintenance dose.

Food allergy OIT must always be done with a trained healthcare provider. Do not attempt it on your own! OIT is a relatively newer treatment, and not all doctors offer it. It is usually done at special allergy centers that have experience with this therapy.

Things to know when considering OIT:

• Some allergy practices offer OIT for common food allergens, such as peanut, egg, or tree nuts. Some offer OIT for many more things. The process for each allergen is largely the same: your child is given small, increasing amounts of the food allergen until a maintenance dose is reached.
• Side effects can occur.
• Some children may lose their allergy while on OIT, and OIT may be what helps that happen, or it may help it happen faster. But this has not been 100% proven, so be cautious of groups that discuss OIT as a cure. Each child is different. Many do very well with OIT, and some eventually (often over many months to years) gain the ability to eat their allergen like any other food.

Baked milk or egg for building tolerance

Some children with milk or egg allergies can safely eat baked foods like muffins or cookies that contain these ingredients. This is great news for many families, as these are often highly asked for pantry items! Baking at high heat changes the proteins in milk and egg. This can make the milk and egg products less likely to cause an allergic reaction.

Food allergy research shows that:

• Children with a confirmed milk or egg allergy may become more tolerant if they eat baked forms regularly.
• The immune system may learn to accept these foods over time.
• Some children may even outgrow the allergy completely.

Baked milk or egg introductions are not the same as oral immunotherapy (OIT). Baked food is not given in a set daily dose. It uses real, baked food like home-baked goods. Discuss the baked milk/egg process with an allergy specialist to find out whether your child can have it. Your child may need to have allergy testing (skin test/blood test or oral food challenge) before adding baked forms of milk or eggs.

Your allergy team can guide you on when and how to start including baked-in egg or milk, and how to continue adding additional forms of egg or milk as time goes on. This is often called a “baked egg or milk ladder.” This ladder is a plan to guide families on slowly introducing new forms of egg and milk to their baby’s diet one step at a time.

Family Resources/Links

More information on FAMP-IT Family, which is a tool to help you navigate the early years of your baby’s food allergy with confidence and ease: 

Preventing Food Allergy Reactions

How to Read Food Labels

Cross-Contact and Food Allergies in Infants and Toddlers

Emergency Preparedness – Allergic Reactions and Anaphylaxis

Videos for Parents on Infant Anaphylaxis

• Anaphylaxis for the Infant: Special Considerations for this Growing Population
• Ask the Allergist: Anaphylaxis and Food Allergies