Patient Instructions

The sections below contain the same information as in the PDF handouts throughout each topic, but are formatted for easier placement within EMR systems to place in after visit patient handouts.

Early Food Introduction

Helpful Tips and Tricks for Allergy Prevention

The dual exposure hypothesis is a belief that the ability to eat a food without a reaction (tolerance) is developed by having the GI tract see the food, whereas the potential for food allergy is developed by skin exposure to the food, which can be worsened by eczema or skin breakdown. It is important to try to prevent repeated skin exposure to foods that your child has not eaten yet. To try to limit skin exposure it is best to avoid eating allergenic foods in your child’s play area and restrict eating to the table. It is important to clean surfaces where food is prepared or eaten to help reduce your child’s environmental exposure to any food allergens. Limit snacking throughout the house to reduce the amount of food dust/particles that get on rugs, carpets, etc. It is best to wash your hands before applying lotions and creams and after handling foods.

Peanut Introduction as per NIAID/LEAP

Why should I introduce peanut products to my baby so early in life?

Introducing peanut products to your baby early in life can help prevent him from developing a peanut allergy later on. Ask your doctor when it is right to introduce peanut products for the first time.

What should I do before giving my baby peanut products for the first time?

Talk with your baby’s doctor about whether he is ready to try peanut products.

If your baby has other known food allergies or very bad eczema (dry, scaly patches of skin), ask your doctor if your baby should have an allergy test or see a pediatric allergist (allergy doctor).

How do I introduce peanut products?

Safety tips

Give the first taste when your baby is healthy. Do not give the first taste if he has a cold, fever, diarrhea or other illness.

Give your baby his first taste of peanut products at home. Do not give the first taste at daycare or in a restaurant.

Timing tips

Set aside at least 2 hours after the first taste to watch your baby for a reaction. Make sure you or another family member can give full attention to your baby.

For the very first taste, give a small amount, the tip of a small spoon. Wait 10 minutes between the first and second taste. If your baby does not have any reaction after 10 minutes, give the rest of the peanut butter at his normal eating speed.

Give your baby 2 teaspoons (6 grams) of peanut products at least 3 times per week. This will help prevent him from developing a peanut allergy later in life.

Tips while your child eats:

Prepare a full serving of peanut butter from the recipe below.

Offer the first taste on a small spoon.

For babies and children under age 4, mix peanut butter with 1 safe food at a time. Do not give plain peanut butter to any baby or child under age 4.

Do not push your baby to eat more than he wants.

Peanut recipes for babies

Option 1: Peanut butter puree

You will need:

2 tsp. smooth, all-natural peanut butter (with no added ingredients)

2-3 tbsp. of plain yogurt or pureed (smooth) fruit or vegetable that your baby likes

Mix peanut butter and yogurt or fruit or vegetable puree. Add more water if you want the puree to be thinner.

Option 2: Peanut butter powder sauce

You will need:

2 tsp. powdered peanut butter or peanut flour

2-3 tbsp. of warm water, oatmeal, applesauce or mashed banana

Mix peanut butter or peanut flour with the water, oatmeal, applesauce or banana.

Let the mixture cool.

Add more water if you want the mixture to be thinner.

Option 3: Bamba® peanut butter puffs

You will need:

21 Bamba® peanut butter puffs

For babies aged 7 months and under, soften puffs in 4-6 tbsp. of water. Feed your baby one puff at a time.

For babies older than 7 months or who can eat dissolvable solids, feed puffs one at a time as normal.

A note about choking

Only give your baby smooth peanut butter.

Never give your baby chunky or crunchy peanut butter. Your baby can choke on the small peanut pieces.

Never give your baby whole peanuts or pieces of peanuts.

A note about food allergies

When your baby is trying a peanut product for the first time, it is important to watch him for signs of a food allergy. An allergic reaction can happen up to two (2) hours after trying a new food.

What is a food allergy?

A food allergy is when your body mistakes a certain food for something dangerous or unknown.

What are common signs of a food allergy?

Rash or hives (swollen red bumps) around the mouth or on the face or body

Swollen lips, tongue, or face

Itching

Vomiting

Coughing

Change in skin color (blue or pale)

Wheezing (whistling sound when you breathe in)

Trouble breathing

Suddenly feeling tired or drowsy

Feeling like your body is going limp

What to do if your baby has an allergic reaction

Call 911 or take your baby to the emergency room right away.

If your baby’s allergist (allergy doctor) has created a Food Allergy Action Plan, follow the steps.

Food Introduction (OTHER THAN PEANUT)

It is best to introduce new foods to your child in an age-appropriate and culturally appropriate manner. The foods should be free of choking hazards, such as whole nuts, and thinned by mixing them with formula, breastmilk, or pureed fruits or vegetables. There is no reason to delay the introduction of foods that are considered “allergenic” like tree nuts, eggs, dairy, soy, wheat, sesame, fish, and shellfish beyond 4-6 months of age. We recommend that you start with a tip of a teaspoon and double this every 10 to 20 minutes until your child has reached about 2 grams of the allergen protein. The amount of protein can be found on the nutrition label. For example, about 2 teaspoons for nut butters, and sesame tahini) and about 1/3rd of a large egg has 2 grams of those specific proteins.

This initial food introduction can also be done more slowly if you or your provider have any concerns. It is important to be aware of the signs of an allergic reaction or anaphylaxis. These symptoms include hives, swelling, wheezing, cough, shortness of breath, nausea, vomiting, difficulty breathing, or loss of consciousness. If you have any concerns it is important to call 911. Please let your provider know if there are any signs of a reaction because a referral to an allergist will be made. If foods are tolerated it is important to keep them in the diet at regular intervals.

Skincare and Eczema Management

General Skincare:

Apply moisturizer at least daily, especially within 3 minutes after bathing to lock in the moisture. Waiting too long after bathing can dry out your child’s skin. Make sure to wash your hands before applying the moisturizer, as you want to avoid trapping any allergens or germs that may be on your hands against your child’s skin. Use moisturizers that are fragrance-free and dye-free, as they will be less irritating on your child’s skin.

Eczema Management:

Soak and Seal Method

Give your child a bath in lukewarm water with gentle cleansers. After getting out of the bath, gently pat (do not rub) off water using a towel and leave the skin slightly damp. Apply any topical steroids or treatment to the skin. Apply moisturizer all over the body, within 3 minutes, and wait for the moisturizer to absorb into the skin before putting on clothes.

Steroid Use

Topical steroids are effective in the treatment of eczema. If topical steroids are needed, apply 1-2 times a day for 7 days on active lesions and continue application for 2-3 days after eczema lesions have resolved. Make sure to use less strong steroids on the face.

Wet Wraps

Wet wrap therapy can be useful for tougher to manage eczema. After getting out of the bath and applying moisturizers, moisten clean cloth/gauze and wrap the affected areas. Cover the wet wraps with dry covers and leave overnight.

IgE Mediated Food Allergy

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
Egg
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 Ways

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.

Non-IgE Mediated Food Allergy

Pediatric Gastroenterologist

We have put in a referral for a pediatric gastroenterologist. A pediatric gastroenterologist is a medical doctor who specializes in managing issues related to the GI tract, including the esophagus, stomach, small and large intestine, liver as well as the pancreas. Gastroenterologists perform many procedures like endoscopy and colonoscopy and treat many diseases, such as Crohns disease, celiac disease, ulcerative colitis, irritable bowel syndrome to name a select few. Non IgE mediated food allergies, such as eosinophilic esophagitis and food protein enterocolitis, are often co-managed by the gastroenterologist with the allergist for optimal results. In addition to this they work closely with a patient’s pediatrician in order to create the best care plan for a patient’s needs.

To find a pediatric gastroenterologist in your area you can use this search engine found at the North American Society for Pediatric Gastroenterologist, Hepatology, and Nutrition.

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