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




Recognize anaphylaxis

Prevention and Emergency Preparedness Handout
ACT to Prevent Allergic Reactions
  • Anaphylaxis is a severe and life-threatening allergic reaction. It can start with mild symptoms and progress quickly.
  • The longer this reaction goes without treatment, the more dangerous it becomes.
  • People responsible for the child need to know which symptoms suggest a severe allergic reaction and when to use an epinephrine auto-injector.
  • Anaphylaxis emergency care plans are created by a healthcare provider and should be available to help serve as a guide.

Severe Symptoms

If a young child is having an allergic reaction to a food, any of the severe symptom below suggest likely anaphylaxis and that caregivers should treat with epinephrine (1,2):

Severe symptoms that suggest trouble with breathing or swelling involving the airway:

  • Coughing, wheezing or shortness of breath (e.g., belly breathing, fast breathing, nasal flaring, chest or neck “tugging”)
  • Hoarse voice or cry
  • Trouble breathing or swallowing (e.g. drooling, choking, gagging)
  • Swelling of tongue or significant swelling of lips

Severe symptoms that suggest cardiovascular involvement:

  • Skin is blue, grey color or mottled
  • Wobbly, floppy, poor head control; fainting

Severe Skin symptoms (quickly progressing or all over):

  • Many hives or redness over body

Severe Gastrointestinal Symptoms:

  • Significant vomiting or diarrhea

Severe Neurologic Symptoms:

  • Inconsolable crying or lethargic (very difficult to wake up)

Other Symptoms

Other symptoms can also be seen in infants and toddlers, and if they are from more than one system or progress then these can signify anaphylaxis as well and require epinephrine(1,2,):

Skin symptoms:

  • Skin scratching or limited hives

Mucosal or upper airway symptoms:

  • Nose running, rubbing, scratching, or sneezing. Tongue scratching, pulling, thrusting; repetitive licking of lips, hands, or objects. Ear pulling, scratching, or putting fingers in the ears. Eye rubbing, redness, eye scratching

Gastrointestinal Symptoms:

  • Belly pain or discomfort (e.g., knees to chest, back arching); spitting up or hiccups

Neurological Symptoms:

  • Crankiness, withdrawn or clingy, subdued or less active (not caused by other things like hungry, overtired, scared etc.)

Treat all anaphylaxis with epinephrine.

Give epinephrine

  • Epinephrine is the treatment of choice for anaphylaxis. This medication works fast and is safe. Doctors prescribe epinephrine auto-injectors to people with severe allergies.
  • This life saving medicine should be kept close by at all times and someone must know when and how to use it.
  • Two doses should be available, as some children need a second dose.
  • If available, follow the anaphylaxis emergency care plan.

Activate emergency response

  • If someone has a severe allergic reaction, they need to go to the emergency department in an ambulance immediately.
  • Some clinicians have changed their recommendations in regards to calling 911 due to the COVID-19 pandemic, talk to your doctor about these recommendations.

Videos for Parents for Infant Anaphylaxis


  1. Pistiner M, Mendez-Reyes JE, Eftekhari S, Carver M, Lieberman J, Wang J, Camargo CA Jr. Caregiver reported presentation of severe food-induced allergic reactions in infants and toddlers. JACI In-practice. 2020. Nov 18;S2213-2198(20)31224-1. doi: 10.1016/j.jaip.2020.11.005.
  2. Julie Wang, Scott H. Sicherer, AAP SOAI. Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan. Pediatrics. Mar 2017, 139 (3) e20164005; doi: 10.1542/peds.2016-4005.
  3. Dribin TE, et al. Severity grading system for acute allergic reactions: a multidisciplinary Delphi study. Journal of Allergy and Clinical Immunology. 2021 Jan 19. doi: 10.1016/j.jaci.2021.01.003.