For 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.

IgE Mediated

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.

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
Eggs
Peanuts
Tree nuts (almonds, hazelnuts, walnuts, pecans etc.)
Soy
Wheat
Fish (cod, bass, salmon, tuna etc.)
Crustacean shellfish (lobster, shrimp, crab, etc.)

Note: While the 8 major allergens are responsible for the majority of allergic reactions, ALL allergens must be taken seriously.

The Food and Drug Administration (FDA) enforces the Food Allergen Labeling and Consumer Protection Act (FALCPA) labeling law. FALCPA applies to all domestic and imported packaged foods and the 8 major allergens, which must be written in clear, plain language and labeled when in flavorings, colorings or other additives.

Note: FALCPA only applies to the 8 major allergens!

The allergens below are not included in the major 8 allergens and therefore are not included in the labeling law:

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.

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.

Videos for Parents for Anaphylaxis for the Infant

Anaphylaxis for the Infant: Special Considerations for this Growing Population
https://www.youtube.com/watch?v=Ah8r70DOJ-0&ab_channel=breatherville
Ask the Allergist: Anaphylaxis and Food Allergies
https://www.youtube.com/watch?v=4rmCBD_xDVs

Early Food Introduction

Skincare and Eczema Management

IgE Mediated Food Allergy

Non-IgE MediatedFood Allergy

EMR
Documentation

Patient
Instructions

Preventing an Allergic Reaction Emergency Preparation Placing a Referral for an Allergist

REAct Epinephrine Information and Training Anaphylaxis Action Plan

Anaphylaxis Action Plan

For patients who have a suspected or confirmed IgE-mediated food allergy, it is important to provide the family with an anaphylaxis action plan. An action plan provides families and caregivers with information on common signs and symptoms of an allergic reaction and when to give epinephrine.

We suggest using the American Academy of Pediatrics (AAP) anaphylaxis action plan. For current information from the AAP on how to fill out an action plan and current action plan, see Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan.

Anaphylaxis in infants and toddlers can look different than in older children and adults. Additionally, infants are unable to verbalize their symptoms, so it is important that parents and caregivers can recognize signs that may be indicative of an allergic reaction. We have included below a breakdown of the symptoms included and how they may present differently in infants and toddlers, as well as important take home points for discussing with families.

Important take home points for families:

When in doubt, give epinephrine!
Infants and toddlers having an allergic reaction may look different than older children or adults experiencing anaphylaxis because these younger children cannot dictate how they are feeling.
Look for new, abnormal changes in the child’s appearance and/or behavior.
If more than one body system is involved, administer epinephrine.

Understanding and Explaining Severe Symptoms:

Symptoms	Infant/Toddler Specific Terms	Lay-Terms	Discussion points for parents/caregivers
“Shortness of breath, wheezing, or coughing”	Nasal flaring Grunting Exaggerated abdominal breathing Retractions (suprasternal and intercostal) Tripoding Wheezing Coughing	Widening of the nostrils to allow greater airflow Low-pitched groan indicating distress or difficulty breathing Larger than normal expansion of the infant’s tummy when breathing in Sucking in of skin around the chest and ribs Child leans forward with arched back and hands on legs, a position that allows increased airflow High-pitched squeaking sound when breathing in and/or out	Signs of shortness of breath in the infant/toddler, in layperson terms Identification of new or abnormal sounds and behaviors in the infant/toddler that may indicate difficulty breathing
“Skin color is pale or has a bluish color”	Perioral cyanosis Cyanosis of nailbeds/ Delayed capillary refill Mottling Pallor	Blueish color of/around the lips White/blue fingertips with slow (>3 seconds) return of pink color to nailbeds after pressure is applied Red, lacy, speckled appearance of the skin, particularly the arms and legs Pale/white appearance of the face	Identification of new or abnormal skin color in the infant/toddler Cyanosis identification
“Weak pulse; Fainting or dizziness”	Loss of consciousness Lethargy Sudden/abnormal onset of cold hands and feet	Child becomes unresponsive/passes out Child is very slow moving and takes longer than usual to respond to you; seems “out of it” Hands and/or feet feel very cold (typically accompanied by white/blue coloring)	Signs of cardiovascular compromise in the infant/toddler, in layperson terms Limited value of hypotension assessment in early anaphylaxis, with heart rate detection important for the healthcare provider
“Tight or hoarse throat; Trouble breathing or swallowing”	Change in pitch/tone of voice and cry Stridor Snoring Nasal congestion Excessive drooling/ protrusion of tongue Wheezing, grunting, nasal flaring	Sound of voice/ cry is different/ strained/ raspy High pitched crowing sound when breathing in Sound as if the infant is snoring when breathing in More drooling than normal with the infant repetitively sticking tongue out Sounds indicating trouble breathing as previously described	Signs the infant/toddler may be experiencing throat constriction or trouble breathing or swallowing, in layperson terms
“Swelling of lips or tongue that bother breathing”	Bilateral lip swelling with difficulty breathing Swelling that is expanding Tongue obstructing airway Inability to visualize posterior pharynx Air hunger	Both lips are noticeably larger than usual Lips/mouth is puffy and keeps getting bigger Tongue is noticeably larger than usual and taking up most of the room in the mouth You cannot see the back of the throat with the child’s mouth wide open Child sounds like he/she is choking or gasping for air	Signs of compromised breathing that warrant epinephrine administration, in layperson terms How the extent of swelling may correlate with level of concern for true anaphylactic reaction
“Vomiting or diarrhea (that is severe or combined with other symptoms)”	Persistent vomiting Vomiting resulting in dehydration Vomiting uncharacteristic for the child Vomiting similar to that of previous allergic reaction	Vomiting that doesn’t stop once the child eats the food Vomiting so much that the child appears dehydrated (sunken eyes; flat, sunken fontanelle (soft spot on top of infant’s head); vomiting bile/ liquid after clearing food from stomach) -Vomiting that is different from the child’s usual “spit up” or vomiting Vomiting like the last time the child had an allergic reaction	Vomiting/diarrhea characteristics likely associated with anaphylaxis Identification of new or abnormal vomiting/diarrhea in the infant/toddler
“Many hives or redness over body”	Hives spreading to trunk Hives in areas of the body not in contact with the food	Round, raised, red blotches on the child’s chest, stomach, and/or back Round, raised, red blotches on the skin that the food did not touch	Significance of localized vs. full body hives in context of contact vs. systemic reactions
“Feeling of ‘doom’, confusion, altered consciousness, or agitation”	Excessive crying Increased irritability Lethargic Inconsolable	Crying relentlessly Abnormally angry, having a temper tantrum Abnormally sleepy or slow moving -Cannot be calmed or consoled by ways of soothing that usually work	Such ominous or ambiguous signs in the infant/ toddler that may be indicative of anaphylaxis, in layperson terms

For Mild to Moderate Symptoms:

These symptoms may be the first signs of anaphylaxis. Therefore, it is important the child is monitored for progression of mild to severe symptoms. If the child has any of these symptoms in addition to any symptoms described previously, epinephrine should be administered. If the infant or toddler has symptoms that involve two or more body symptoms, epinephrine administration is warranted. Caution caregivers that change in behavior is only relevant if attributable to an allergic reaction.

Understanding and explaining mild and moderate symptoms:

Symptoms	Infant/ Toddler Specific Terms	Lay-Terms	Discussion points for parents/caregivers
“Itchy nose, sneezing, itchy mouth”	Nasal/perioral itching Repetitive protrusion of tongue Appearing in distress	Child scratching or rubbing nose and/or mouth Child keeps sticking out tongue as if he/she has a bad taste in the mouth Signs of discomfort as described previously, such as inconsolable crying, irritability/ agitation, appearing uncomfortable	Signs of itchy nose/mouth, in layperson terms Identification of new or abnormal signs of irritation in the infant/toddler
“A few hives”	Progressive vs. localized hives Contact hives	Round, raised, red blotches that do not spread and appear in one area Round, raised, red blotches only on the area(s) of skin that the food touched	Description of appearance of hives Possibility for hive progression over time and need for monitoring of infant/toddler Reiteration of significance of localized vs. widely-distributed hive development
“Mild stomach nausea or discomfort”	Borborygmi Gagging, retching, dry heaving Excessive crying or irritability	Hiccup-like sounds with sucking in of stomach; gagging without vomiting Child will not stop crying and you cannot see any visible injury or sign of discomfort	Signs of nausea or stomach upset in the infant/toddler, in layperson terms

References

Wang, J., & Sicherer, S. H. (2017). Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics, 139(3).
Dosanjh, A. (2013). Infant anaphylaxis: The importance of early recognition. Journal of Asthma and Allergy, 6, 103-107.
Greenhawt, M., Gupta, R. S., Meadows, J. A., Pistiner, M., Spergel, J. M., Camargo, C. A., Simons, F. E. R., & Lieberman, P. L. (2019). Guiding principles for the recognition, diagnosis, and management of infants with anaphylaxis: An expert panel consensus. Journal of Allergy and Clinical Immunology, 7(4), 1148-1156.