How do you manage a food allergy?

Management of Food Allergy

The cornerstone of food allergy management is strict avoidance of the specific allergen, prompt recognition of allergic reactions, and immediate treatment with epinephrine for severe reactions. 1

Diagnosis and Initial Evaluation

• Refer patients with suspected food allergy to an allergist for comprehensive evaluation including skin prick tests and/or serum-specific IgE tests to identify potential food allergens 1, 2
• A positive test result alone is insufficient for diagnosis - clinical correlation with history is required 2
• In some cases, oral food challenges may be necessary to confirm the diagnosis under medical supervision 1

Primary Management Strategy

Allergen Avoidance

• Complete avoidance of the identified allergen is the first-line treatment for food allergy 1, 2
• Educate patients and caregivers on:
  • Reading and interpreting food labels to identify allergens 1
  • Recognizing alternative names for allergens 1
  • Avoiding products with precautionary labeling (e.g., "may contain") due to risk of cross-contamination 1
  • Strategies for avoiding allergens in various settings (home, school, restaurants) 1, 3

Nutritional Considerations

• Provide nutritional counseling and regular growth monitoring, especially for children with food allergies 1, 2
• When eliminating major food groups, ensure adequate nutritional intake through appropriate substitutions 2
• For infants with food allergies who are exclusively breastfed, the allergen may need to be eliminated from the mother's diet 4

Emergency Management

Medications and Action Plan

• Prescribe epinephrine autoinjectors for all patients with IgE-mediated food allergy, especially those with:
  • Previous systemic allergic reaction
  • Food allergy and asthma
  • Known allergy to peanut, tree nuts, fish, or crustacean shellfish 1, 5
• Epinephrine dosing:
  • Adults and children ≥30 kg: 0.3 to 0.5 mg IM in anterolateral thigh
  • Children <30 kg: 0.01 mg/kg IM in anterolateral thigh (maximum 0.3 mg) 5
• Antihistamines are appropriate for managing mild, non-severe allergic reactions 1
• Create and provide a written emergency action plan that includes:
  • Recognition of symptoms of allergic reactions
  • Instructions for epinephrine administration
  • Emergency contact information 1

Management of Anaphylaxis

• Administer epinephrine immediately for anaphylaxis - delayed administration has been implicated in fatalities 1, 5
• Epinephrine doses may need to be repeated every 5-15 minutes if symptoms persist 1
• After treatment for anaphylaxis, patients should:
  • Be observed for 4-6 hours in a medical facility
  • Be discharged with two doses of epinephrine
  • Have a follow-up plan for further evaluation 1

Patient Education and Quality of Life

• Provide age-appropriate education on:
  • Allergen avoidance strategies
  • Recognition of allergic symptoms
  • Proper use of epinephrine autoinjectors 1
• Address quality of life concerns, as food allergy can increase anxiety for patients and families 1
• For adolescents and young adults (high-risk group for fatal anaphylaxis), provide specific counseling on risk-taking behaviors and transition of responsibility 1
• Consider referral to support resources such as the Food Allergy and Anaphylaxis Network (www.foodallergy.org) 1

Special Considerations

Schools and Community Settings

• Provide documentation for schools (e.g., food allergy emergency action plan, Section 504 plans) 1
• Educate school staff on recognition and management of allergic reactions 1
• Ensure epinephrine is available and that staff are trained in its use 1

Vaccines

• MMR and MMRV vaccines are safe for children with egg allergy, even those with severe reactions 1
• Most patients with egg allergy can receive influenza vaccines under appropriate supervision 1

Follow-up Care

• Regular follow-up with an allergist is recommended to:
  • Reassess the allergy status, as some food allergies (especially milk, egg) may resolve over time
  • Update emergency action plans
  • Reinforce education on avoidance and emergency management 1, 2

Emerging Treatments

• While promising, oral immunotherapy, sublingual immunotherapy, and epicutaneous immunotherapy are still considered investigational and not recommended for routine clinical practice 1, 6
• These approaches carry the risk of severe reactions and should only be considered in specialized centers 1

Common Pitfalls to Avoid

• Failing to distinguish between true food allergy and food intolerance, leading to unnecessary dietary restrictions 2
• Neglecting nutritional needs when implementing elimination diets 2
• Underutilization of epinephrine - it is vastly underprescribed and underused by healthcare providers and patients 1
• Relying solely on antihistamines for treatment of anaphylaxis instead of epinephrine 1
• Implementing overly restrictive diets based solely on sensitization (positive test) without clinical symptoms 1