Food Allergy Management and Prevention
Support Tool for Infants and Toddlers

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
Tree nuts (almonds, hazelnuts, walnuts, pecans etc.)
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

Be aware that allergens may be written in plain language in the body of a products ingredient list.



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


  • 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.


  • 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.


  • 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



Epinephrine Information and Training

Epinephrine is the first-line treatment for anaphylaxis, with delays in administration associated with increased mortality.(1) Epinephrine autoinjectors provide an effective way for individuals without clinical training to administer epinephrine to themselves or another person.


Recommended dosing is 0.01mg/kg up to 0.5mg IM 1:1000 epinephrine (1mg/ml)

In the US, there are 3 different dosage autoinjectors available:

  1. 0.1 mg (only available in Auvi-Q): approved for patients under 15 kg
    Recommend upsizing to 0.15 mg at 13 kg
  2. 0.15 mg: approved for patients 15 kg to 30 kg
    Recommend upsizing to 0.3 mg at 25 kg
  3. 0.3 mg: approved for patients 30 kg and over

Epinephrine Autoinjectors

If a child has a suspected IgE-mediated food allergy, it is important to prescribe an epinephrine autoinjector. There are currently 4 different epinephrine autoinjector models available in the United States. All autoinjectors come in two-packs, and patients should keep both devices with them at all times. While each autoinjector has similar general administration steps, there are slight differences for each one that should be discussed when training families. A comparison of each autoinjector and resources for training families on administration can be found in the table at the bottom of this page.


  • When teaching families how to administer epinephrine, it is important to train them on the differences in administration of each autoinjector
  • Ensure that parents understand how to hold their child when administering an autoinjector
  • It is important that the family knows what to do after administering their EAI. Prior recommendations have told families to call 911 to be treated in an emergency department. Due to COVID, there has been a change in guidance that recommends for some patients to be watched at home. For more information, see the MGH Food Allergy Center’s page, How to Manage Anaphylaxis During COVID-19.

Important Take-Home Points to Discuss with Families:

  • Delays in administration are associated with increased mortality. (1)
  • If symptoms progress or the child has a poor response, then give another dose after 5 to 15 minutes
    • 10% to 20% of individuals may require more than one dose
  • Availability:
    • Ensure that the family always keeps two autoinjectors readily available with their child
    • Avoid extreme temperatures, and do not store the autoinjector in the car.
    • Ensure the family knows their autoinjector’s expiration date
  • Considerations for children with asthma:
    • If ever any concern that a food allergic reaction has triggered an asthma attack, then treat with epinephrine first, before using asthma rescue medications
  • What about antihistamines?
    • The use of antihistamines as medication to treat anaphylaxis is the most common reason reported for not using epinephrine in the instance of patient anaphylaxis. (2) Using solely antihistamines in place of epinephrine may place a patient at a significantly increased risk for progression toward a life-threatening reaction. If there is any concern about anaphylaxis, epinephrine is the best first response. Please do not wait for antihistamines to begin showing the resolution of symptoms before using epinephrine. 
    • Antihistamines will not stop or prevent anaphylaxis
    • Slow to act, taking about 30-60 minutes
    • Effective as a comfort medication for skin symptoms, such as hives or a rash
  • Common side effects to watch out for:
    • Pallor (100%)Tremor (80%)
    • Anxiety (70%)
    • Tachycardia (50%)
    • Headache (20%)
    • Nausea (20%)
  • Contraindications/Considerations:
    • When treating anaphylaxis, epinephrine has no absolute contraindications
    • Caution with cardiac issues, arrhythmias, uncontrolled hypertension or hyperthyroidism, aortic aneurysm, patients with recent intracranial surgery and patients on sympathomimetics, TCAs, MAO inhibitors
    • Beta-blockers decrease response to epinephrine
Device Doses Trainer included? Other Notes
EpiPen and Authorized Generic by Mylan0.15 mg
0.3 mg
Yes EpiPen and Mylan Savings Cards
Auvi-Q0.1 mg
mg 0.3 mg
Yes0.1 mg dosing is recommended for children under 15 kg (33 lbs) Device includes voice instruction
Teva Epinephrine Auto-Injector 0.15 mg
0.3 mg
Yes Teva Savings Card
Impax Epinephrine Auto-Injector (Generic of Adrenaclick) 0.15 mg
0.3 mg
Order Trainer Online
Impax Savings Card

Video: Anaphylaxis for the Infant

Anaphylaxis for the Infant: Special Considerations for this Growing Population


  1. Simons FE. First-aid treatment of anaphylaxis to food: focus on epinephrine. Journal of Allergy and Clinical Immunology. 2004 May 1;113(5):837-44.
  2. Simons FE, Clark S, Camargo Jr CA. Anaphylaxis in the community: learning from the survivors. Journal of Allergy and Clinical Immunology. 2009 Aug 1;124(2):301-6.