Food Allergy Management Boot Camp

A food allergy results from an abnormal immune response to certain foods, usually to a protein in the food. The most common allergens are milk/dairy, egg, peanut, tree nuts, wheat, soy, fish, shellfish, sesame, but it’s important to note that people can be allergic to many more foods.

Allergic reactions usually occur within a few minutes up to a few hours after exposure to the allergen. Symptoms of allergic reactions can include:

• Skin: hives, swelling, itching, warmth, redness, *scratching, *rubbing
• Respiratory/breathing: shortness of breath or *increased work of breathing, *nasal flaring or *rib pulling, *belly breathing, coughing, wheezing, chest tightness or pain, trouble swallowing, *drooling, hoarse voice or *cry, runny nose, nasal congestion, sneezing
• Gastrointestinal: nausea, vomiting, abdominal pain, *back arching, *knees to chest, diarrhea
• Cardiovascular/heart: dizziness, lightheadedness, skin turning pale or blue color, *mottling, fast heartbeat, fainting
• Neurological/brain: anxiety, sense that something very bad is happening, *sudden behavior change like floppiness, *lethargy, *inconsolability

*Also look for these symptoms and signs in infants and toddlers.

Anaphylaxis is a severe, potentially life-threatening allergic reaction. It may begin as only mild symptoms and may have no skin symptoms (such as hives). The treatment for anaphylaxis is epinephrine.

Effective management of food allergies can improve the quality of children’s lives, so it’s critical for parents and caregivers—such as relatives, family friends, babysitters, nannies, educators, anyone that is responsible for the care of a child with a food allergy—to be educated on preventing and managing allergic reactions.

It is also important to find the balance between allergic reaction prevention and quality of life, while being mindful of minimizing anxiety to the child with allergies (and their caregivers).

Contact with allergens can occur: through the mouth/oral ingestion, breathing it in, or by touching the skin. Rarely, exposure can also occur through the nose and eyes.

• In general, most children need to strictly avoid the allergen.
• Oral ingestion is the most common way to have an allergic reaction to food. Before eating, read labels every time to avoid allergens.
• Inhalation reactions are rare and can occur during active cooking or with the inhalation of small particles of the allergen such as flours or powders.
• Contact with an allergen on a child or caregiver’s skin can cause an allergic reaction if touched to the child’s mouth, eyes, or nose.

Label reading

• Read every label, every time. Ingredients in products can switch without warning. Label reading is the only way to know if a food is safe.
• Anyone serving or preparing food for a child needs to be knowledgeable about the labeling laws and their pitfalls.

Download label reading PDF

Food Allergy Labeling Law

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 for the 9 major allergens, which must be listed in clear, understandable language and stated if in flavorings, colorings or other additives.

FALCPA only applies to the following 9 major allergens:

• 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.)
• Sesame

What products are not covered under FALCPA?

The following items are not regulated by the FDA or FALCPA:

• Fresh meat and poultry products
• Certain egg products
• Most alcoholic beverages
• Non-food items such as lotions, and cosmetics
• Allergens outside of the major 9, such as seeds (except sesame), molluscan shellfish (oysters, clams, mussels, etc.), gluten (except wheat)

How allergens are listed

Only the 9 major allergens are required to be listed clearly on a label. They can be listed in either of two ways:

1. Within the body of the ingredients: Allergens can be written in plain language in the body of a product's ingredient list.
2. In a “contains” statement following the body of the ingredients: companies can choose not to use these statements and include the allergen only within the ingredient list, so it is important to read the full list of ingredients, every time.

Advisory statements (May contain…, Made in a facility that also processes…, Made on shared equipment with…):

• These statements come in many formats and are not regulated by state or federal laws.
• Small studies have shown that word choice was not associated with the amount of detectable allergen.
• Recommendations on how to manage these statements vary by allergen, physician, and family. Discuss the recommendations for your unique circumstance with your allergy team.

Hidden ingredients

Hidden ingredients are non-obvious components of food. They are often known to the person preparing the food, but unknown by the consumer. If an item does not have a label, it is safest to avoid eating it.

Examples of hidden ingredient sources by allergen:

• Milk: bread, butter on steak, caramel, cheese alternatives, canned tuna, hotdogs, deli meat, non-dairy creamer, guacamole. Also in finger paints, shaving cream
• Peanut/tree nut: desserts, Asian foods, sunflower seeds, packaged popcorn, ice cream, egg rolls, sauce, pesto, Mexican foods, barbeque sauce. Also in bean bags/furniture, bird seed.
• Egg: baked goods, egg alternatives, froth on drinks, soft pretzel glaze, pasta, ice cream
• Soy: soups and sauces, meat alternatives, canned tuna, cereal, bread, peanut butter, crackers
• Wheat: meat substitutes, ice cream, soy sauce, salad dressing, processed meat. Also in pastes, play dough
• Fish and shellfish: Asian foods, Worcestershire sauce, barbeque sauce

Avoiding cross contact

Cross contact is the presence of unintended food allergen, often transferred to other foods, surfaces, or saliva. It is a common cause of allergic reactions. Even tiny amounts of allergens can be enough to cause a serious allergic reaction. Routine training for all caregivers (parents, grandparents, teachers, babysitters, anyone who prepares or serves food for your child) about sources of cross contact is essential.

Common sources of cross contact (please see the “Cross Contact” attachment for additional examples with specific avoidance techniques):

• Objects: Utensils, kitchen slicers, oven mitts, aprons, cooking surfaces, highchairs, car seats, pacifiers, bibs, sponges, hands, etc. (ex: using the same tongs to flip shrimp and a chicken breast)
• Food: Steam, splatter, accidental contamination, buffets, frying oil, garnishes, etc. (ex: removing nuts from a salad or scraping cheese off a cheeseburger)
• Saliva: People, pets (licking, pet food), binky, toys, musical instruments, water bottles, etc. (ex: sucking on another baby’s pacifier after they had a bottle of milk-based formula)

Infants/Toddlers:

• Because younger children are more likely to put their hands or objects in their mouths and noses, caregivers should have increased awareness and wash their children’s hands after potential exposure to allergen. Avoid sharing of food, utensils, water bottles, pacifiers, and anything else that may go in their mouth.

Preventing cross contact

• Preparation: Wash your hands with soap and water or wet wipes after encountering any allergens. Hand sanitizers do not remove allergens effectively. Commercial cleaners and wipes are effective at cleaning surfaces of allergens.
• Keep allergen-free foods away from other foods in storage and when grocery shopping.
• Do not allow children with a food allergy to share food, drinks, plates, cups, utensils, or other objects that may contact their mouth.
• Avoid foods in bulk bins, the deli counter, hot and cold salad bars, buffets, and anywhere else that foods commonly come into contact with other foods.
• When dining out, talk to your server, the manager, and/or chef to ensure that they understand your child’s needs. If possible, call ahead to discuss your child’s allergy with a manager. Do not 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.

Cooking

• Prepare allergen-free foods first and then prepare food for the rest of the family.
• Use separate utensils and serving spoons.
• Avoid foods prepared on surfaces that cannot be cleaned in-between use, such as a deep fryer, deli slicer, seasoned wok, or common grill surface.
• Avoid foods with combined and hidden ingredients, such as soups, stews, and sauces.
• For most food allergies, cooking or freezing the food does NOT reduce or eliminate the chances of a food allergy reaction. Some children with milk/dairy or egg allergies are able to tolerate the cooked form of the allergen. Your allergist can provide guidance for your child’s individual situation.

Cleaning

• Carefully wash contacted items with soap and water or in the dishwasher.
• Wipe down tables, highchairs, toys, pacifiers, menus, salt/pepper shakers and any other item your child could touch with their hands or put in their mouths.

Download cross contact PDF

All caregivers need to know about the allergy and know which allergens need to be avoided. This includes home, school, restaurants, parties and play dates, and secondary caregivers (babysitters, grandparents, etc.)

• Educate any caregivers responsible for the infant or toddler in avoidance strategies and emergency preparedness.
• Anyone responsible for serving or preparing their food must know how to read a label and how to prevent cross contact.
• It may be helpful to give each of your child’s caregivers a copy of their Anaphylaxis Action Plan from your healthcare provider.

It is important to teach your child age-appropriate information about their food allergy, as uncertainties often lead to answers scarier than reality and increased fear. Develop routines and rules, such as washing hands and avoiding sharing.

• Anaphylaxis is a severe, potentially life-threatening allergic reaction. It can start with mild symptoms but can then progress quickly. It’s also important to know that in some cases there may be no skin symptoms (such as hives).
• The longer this reaction goes without treatment, the more severe it can become and the more difficult it can be to treat.
• All caregivers need to know which symptoms suggest a severe allergic reaction and when to use an epinephrine auto-injector.

Symptoms

• Children may have a hard time describing their symptoms and may complain of funny feelings in their mouth, such as being “unable to get the taste out”.

Key points

• Infants and toddlers having an allergic reaction may look different than older children or adults experiencing anaphylaxis because they cannot communicate as clearly how they are feeling. Learn more about anaphylaxis in babies.
• Look for new, abnormal changes in the child’s appearance and/or behavior.
• If more than one body system is involved, give epinephrine.

Anaphylaxis Action Plans/anaphylaxis emergency care plan: this is a guide created by your healthcare provider that should clearly show which allergens need to be avoided and which symptoms require the epinephrine auto-injector.

• Everyone responsible for the care of your child with food allergies should have access to a copy of the plan.
• Without knowledge of your child’s allergy and emergency care plan, some schools may be unable to give treatment for allergic reactions.
• Your Anaphylaxis Action Plan helps to determine when a reaction requires epinephrine. It can help differentiate a mild reaction from a reaction that may be anaphylaxis and thus requires epinephrine.
• Examples of symptoms that may be considered mild can include hives in the area of food contact or itchiness of the tongue or mouth or mild stomach pain or nausea.
• Antihistamines take 30-60 minutes to work and will NOT stop or prevent a severe allergic reaction. If you have any concern for anaphylaxis, you should give your child epinephrine. When in doubt, give epinephrine.
• In some states and in some schools, non-school nurses are unable to give antihistamines and can only give epinephrine when trained.

Download Anaphylaxis Action Plan PDF

• Epinephrine is the first-line, treatment of choice for anaphylaxis. This medication works fast and is safe. Doctors prescribe epinephrine to people with potentially severe allergies. Not giving epinephrine early in a severe allergic reaction is associated with an increased risk of death, an increased need for hospitalization and an increased risk of a second phase of the reaction called a bi-phasic reaction.
• Epinephrine comes in different forms. Ensure all of your child’s caregivers are confident in their ability to use your child’s form of epinephrine. Be mindful of your epinephrine’s expiration date and ask for a new prescription if it is expired.
• This life-saving medicine should be always kept close by and someone with the child must know when and how to use it. Avoid storing epinephrine at extreme temperatures (keep at 59-86°F), and do not store it in the car.
• Two doses should always be with the child because some children need a second dose to treat anaphylaxis.
• A few minutes after giving the first dose of epinephrine, if your child does not look better, their symptoms worsen, or they develop new symptoms, then give another dose of epinephrine.
• 10% to 20% of children with anaphylaxis may require more than one dose to treat a severe allergic reaction.
• Common side effects of epinephrine: paleness, shakiness, and feeling anxious. Some can also feel a fast heart rate, headache, and nausea.
• Everyone should receive epinephrine during a suspected anaphylactic reaction. During a severe allergic reaction, it is always safer to give epinephrine than to wait, and there is no reason not to give epinephrine.

Tips for giving epinephrine

• Avoid giving the epinephrine over pockets, buttons, or seams on your child’s pants.
• Be prepared for your child to be fearful. Many children believe auto-injector needles are as long as the device, but the needle is actually shorter than the diameter of a dime.
• Practice with an epinephrine trainer.

If someone has a severe allergic reaction, they may need to go to the emergency department in an ambulance immediately. First you should get control of the reaction with immediate epinephrine and then consider calling 911 even after giving epinephrine. Keep in mind that new guidance in the last few years has given healthcare teams some flexibility in what they are recommending to their patients’ families regarding the need to call 911 and go to the emergency department.

Epinephrine is short-acting, and some allergic reactions may require more epinephrine as well as additional medical treatment like oxygen or IV fluid. In the case of a severe reaction, it may also be important to go to the hospital by ambulance instead of a car so that your child can be carefully monitored by healthcare professionals in case additional care is needed in route. It is especially important to go to the emergency department even after receiving the epinephrine if any of the symptoms were severe in the first place, if the epinephrine didn’t immediately and didn’t completely work, if only the one epinephrine dose was available or if there was any additional worry or concern.