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 9 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.)
Sesame

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

Early Introduction of Complementary Foods

How do you know an infant is ready for solid foods:

Good head and neck control
- Ability to sit on their own with minimal support
- Opens mouth and leans forward when offered food
- Able to grasp larger objects and brings them up to the mouth

Some infants may show developmental signs of readiness before age 6 months, but introducing complementary foods before age 4 months – or waiting until after 6 months – is not recommended (1). Chapter 2 of the USDA Dietary Guidelines for Americans 2020-2025 encourage the introduction of potentially allergenic foods along with other complementary foods. In addition to peanuts, the Dietary Guidelines for Americans 2025 recommend eggs, cow milk products, tree nuts, wheat, crustacean shellfish, and soy be introduced when other complementary foods are introduced.

The American Academy of Pediatrics states that: “There is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4 to 6 months prevents atopic disease.”

Which foods should my patient eat, and how much?

When counseling families on food introduction, it is important to discuss how to tell when an infant is ready for solid food and what foods are developmentally appropriate. If serving purees, families should aim for a smooth, even texture for the baby’s first few foods. First finger foods given to an infant should be very soft and easy to smash between the thumb and forefinger. For thicker foods, such as nut butters, it is best to thin them out with warm water or mix them into something smoother, such as applesauce. Some signs that a baby is ready to try solid foods are:

Good head and neck control
Ability to sit on their own with minimal support
Opens mouth and leans forward when offered food
Able to grasp larger objects and bring them up to the mouth

Some infants may show developmental signs of readiness before age 6 months, but introducing complementary foods before age 4 months — or waiting until after 6 months— is not recommended (1). Chapter 2 of the USDA Dietary Guidelines for Americans 2020-2025 encourage the introduction of potentially allergenic foods along with other complementary foods. In addition to peanuts, the Dietary Guidelines for Americans 2025 recommend eggs, cow milk products, tree nuts, wheat, crustacean shellfish, and soy be introduced when other complementary foods are introduced. Although only peanut has guideline-based recommendations for quantity and frequency (2 grams of peanut protein, 3x a week), there are currently no guideline recommendations for quantity or frequency of other allergenic foods. Looking at available studies, including the LEAP study (1), EAT study (2), and others, 2 grams of allergen protein twice a week may be a reasonable target. For foods like egg, dairy, wheat, and soy, more frequently may make sense, as these foods are ubiquitous in our diets. In the case of fish and shellfish, slightly less frequently (e.g., once a week) may equally be reasonable based on family and household consumption and accessibility.

One may determine the grams of protein by using the specification on the nutrition label of the grams of protein in a particular serving size of the food, and utilizing this measurement to calculate the goal dose of 2 grams. For the case of nut butters and sesame tahini, a little more than 2 teaspoons may be the target. In the case of egg, about 1/3 of a large egg may be the target. For fish and shellfish, in general, the serving size is about the size of the palm of a child’s hand; however, 2 grams is also the goal.

There are many factors to take into account when deciding what foods parents should introduce to their children, and when each food should be introduced. Because there are no official guidelines for most foods, it is important to utilize a shared decision-making process with the family and take into account preferences they may have. This allows for the personalized application of recommendations based on the most current and promising research. See Shared Decision Making for the Allergist for the full study (3).

Gut vs. Skin: The Dual-Exposure Hypothesis

An important aspect to consider when deciding what foods to introduce is to consider what foods the family eats regularly, as environmental exposures to allergenic foods may be a risk factor in developing allergies. It is also important to consider what foods fit with a family’s preference, taste, and culture.

Under the dual-exposure hypothesis, if a child avoids oral exposure of an allergenic food (e.g. peanuts), but experiences frequent environmental exposures through their skin, they may be more likely to develop a sensitivity or allergy to peanut. When a child is exposed to a food allergen via the skin (e.g. food touches the skin), the immune cells of the skin are more likely to cause sensitization to that food. This is especially true if the skin is inflamed or irritated, as is the case with eczema. However, when a child is exposed to a specific food via the oral route (e.g. food is consumed), the immune cells in the digestive system create a tolerance to that food. (4,5)

Dual Exposure Hypothesis

Under the dual-exposure hypothesis, if a child does not already have an allergy and is routinely exposed to the allergen (e.g. peanut) orally, through the gut this may lead to induction of tolerance to that allergen. T-regulatory cells within mesenteric lymph nodes may play a role (lack).

Nutrition Guidance for Families

References:

Du Toit, G., Roberts, G., Sayre, P.H., Bahnson, H.T., Radulovic, S., Santos, A.F. et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015; 372: 803–813.
Perkin, M.R., Logan, K., Tseng, A., Raji, B., Ayis, S., Peacock, J. et al. Randomized trial of introduction of allergenic foods in breast-fed infants. N Engl J Med. 2016; 374: 1733–1743
Blaiss MS, Steven GC, Bender B, Bukstein DA, Meltzer EO, Winders T. Shared decision making for the allergist. Annals of Allergy, Asthma & Immunology. 2019 May 1;122(5):463-70.
Du Toit G, Sampson HA, Plaut M, Burks AW, Akdis CA, Lack G. Food allergy: Update on prevention and tolerance. Journal of Allergy and Clinical Immunology. 2018 Jan 1;141(1):30-40.
Lack G. Update on risk factors for food allergy. Journal of Allergy and Clinical Immunology. 2012 May 1;129(5):1187-97.
U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov.
Greer, F. R., Sicherer, S. H., Burks, A. W., COMMITTEE ON NUTRITION, & SECTION ON ALLERGY AND IMMUNOLOGY (2019). The Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Hydrolyzed Formulas, and Timing of Introduction of Allergenic Complementary Foods. Pediatrics, 143(4), e20190281. https://doi.org/10.1542/peds.2019-0281
National Institute for Allergy and Infectious Disease. Addendum Guidelines for the Prevention of Peanut Allergy in the United States.; 2017. doi:10.1097/01.JAA.0000512231.15808.66

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