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

Basic Prevention How to Read a Label Avoiding Cross Contact

Avoiding Cross Contact

Cross contact is the presence of unintended food allergen

It is a common cause of allergic reactions.
Allergens can withstand heating and drying.
Even tiny amounts of allergens are enough to cause serious allergic reaction.
If a mistake is made when preparing a food, throw out the item and start over.
Routine training for all caregivers about sources of cross contact is essential.

Common sources of cross contact:

The following are just a few examples of common sources of cross contact. See the table at the end of this page for more examples of cross contact and potential alternatives.

Objects Utensils, cooking surfaces, highchairs, pacifiers, sponges, bib, apron, etc.
Using the same tongs to flip shrimp and a chicken breast. Without properly washing the tongs in-between use, allergens may be transferred to the chicken breast.

Food Steam, splatter, accidental contamination, frying oil
Removing nuts from a salad or scraping cheese off a cheeseburger.

Saliva People, pets, binky, Sophie the Giraffe, musical instrument, etc.
Sucking on another baby’s pacifier after they had a bottle of milk-based formula.

Who needs to know about allergen cross contact?

Any caregiver, including babysitters, siblings, grandparents, extended family, friends, and teachers. Routine teaching of all caregivers about sources of cross contact and prevention of exposure is essential.

Things to Consider with Infants/Toddlers:

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

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.
When grocery shopping, store problematic foods in a separate 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
It is important to remember that allergens cannot be destroyed by cooking, frying or freezing.
Avoid foods prepared on surfaces that cannot be cleaned in-between use, examples include deep fryer, 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.
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.
Do not rely on hand sanitizer products as they do not fully remove food particles.

Objects

Source	Examples	Ways to Avoid
Kitchen Utensils, Serving Spoons	Using a knife to spread peanut butter, not cleaning it properly, and then using it to spread jam. Serving mac and cheese, and then using the same spoon to serve green beans.	Wash utensils and serving spoons in the dishwasher or with soap and water in between each use. Use separate sets of serving spoons during meals for allergen vs non-allergen food items.
Cooking Surfaces, Cutting Boards, Counter Tops	Cooking fish or shellfish on the same grill as steak. Scrambling eggs and then cooking a grilled cheese on same griddle. Cutting cheese and then fresh fruit on the same cutting board.	Clean grill surface with soap and water in between uses. Prepare the allergic child’s food first. Consider having separate cooking surfaces and cutting boards as allergen-safe. Clean counters with soap and water or commercial wipes before and after cooking.
Deep Fryers, Cooking Oils, and Seasoned Wok	French fries that have been fried in the same oil as shrimp. Cooking allergen safe foods in a seasoned wok.	Avoid food cooked in a common deep fryer. Consider simple dished cooked on surfaces that are easily cleaned.
Pots, Pans, Cooling Racks, Small Appliances	Making wheat bread in a bread pan, and then making gluten free bread. Blending a smoothie with cow’s milk, and then one with plant-based milk.	Clean properly in-between uses or designate specific pans and small appliances as allergen-free. Consider cooking the allergy-safe foods first.

Saliva

Source	Examples	Ways to Avoid
Saliva	Kissing your child or cleaning their binky with your mouth after you eat a granola bar with allergens. Sharing toys, teething rings, pacifiers with other infants. Sharing utensils, cups, plates, water bottles, food, or drinks. Pets eat treats with milk and then lick child’s face, or babies eating dog food.	Do not share food, drinks, cups, plates or eating utensils. Wash properly or wipe down toys, pacifiers, teething rings regularly. Keep pet food and treats out of reach of children.

Food

Source	Examples	Ways to Avoid
Airborne	Steam from cooking allergens, such as shellfish in a pot on the stove. Allergic child inhaling wheat, peanut, etc. flour while preparing baked goods.	Consider not cooking allergens that could travel through steam while the allergic child is home, or avoid these allergens in your home. Do not prepare or cook allergens in your home.
Hands	Failing to wash your hands after handling nuts, and then preparing your child’s meal, or setting them up in their highchair. Siblings playing with a toy after eating allergen, and then handing it to allergic child.	Wash hands with warm water and soap before and after preparing each meal and setting up highchair. Regularly wipe down toys to decrease risk of exposure from child to child.
Sponges, Dish Towels, Oven Mitts, Aprons	Used a sponge to clean a mac and cheese baking pan, and then the child’s sippy cup. Wiping hands on apron instead of washing them in between each task.	Considering using disposable wipes, or paper towels, or designating specific cleaning instruments for allergen free cookware, and dinnerware. Wash hands properly in-between tasks.

Avoiding Cross-Contact While Dining Out

When dining out with a child who has food allergies, clear communication is key. Talk to the manager and/or chef, in addition to your server, to ensure that they understand your child’s needs. It’s best to avoid restaurants where there is a language barrier, and clear communication is difficult. If possible, call ahead and discuss your child’s allergy with a manager.

To minimize the risk of cross-contact, avoid ordering combination dishes like stews, soups, and sauces, as they often contain hidden ingredients and may have been prepared before your arrival. Fried foods, salad bars, and buffets are also common sources of cross-contact. Note that certain types of restaurants may be riskier for those with specific allergies (like an ice cream parlor for a child with dairy, peanut, or tree nut allergies), so research beforehand can help mitigate risks.

Finally, never share food that was not prepared specifically for your child with food allergies. The precautions taken in the preparation of your dish may not have been taken for others.