What is the treatment for an allergic reaction to saliva?

Treatment of Allergic Reactions to Saliva

For immediate allergic reactions to saliva exposure (such as from kissing or shared utensils), treat with intramuscular epinephrine for severe symptoms including respiratory involvement, diffuse hives, or circulatory symptoms, and use oral antihistamines for mild localized reactions. 1, 2

Acute Management Based on Severity

Severe Reactions (Anaphylaxis)

• Administer intramuscular epinephrine immediately for any of the following: diffuse hives, shortness of breath, any respiratory symptoms, obstructive swelling of tongue/lips interfering with breathing, or circulatory symptoms 1, 2
• Epinephrine can be dosed every 5-15 minutes if symptoms are not responding; patients should carry 2 epinephrine autoinjectors 1
• Place patient in recumbent position with elevated lower extremities if hypotension is present 1
• Administer intravenous fluids (10-20 mL/kg bolus) for hypotension and/or repetitive emesis 1
• Provide supplemental oxygen if hypoxia is present 1

Adjunctive Treatment for Severe Reactions

• H1 antihistamines (diphenhydramine) can be given intramuscularly or intravenously in addition to epinephrine 1
• H2 antihistamines (ranitidine) should be administered in combination with H1 antihistamines, never alone, due to slower onset of action 1
• Systemic corticosteroids may be given for severe reactions to prevent late-phase biphasic reactions, though evidence for benefit is limited 1
• Bronchodilators for bronchospasm, atropine for bradycardia, and glucagon (1-5 mg IV over 5 minutes in adults; 20-30 mcg/kg up to 1 mg in children) for epinephrine-unresponsive reactions 1

Mild Reactions

• Oral antihistamines are appropriate for mild symptoms such as a few hives, mild nausea, or localized itching 1
• Antihistamines should never be used in place of epinephrine for severe symptoms 1

Prevention Strategies

Allergen Avoidance from Saliva

The most critical aspect is counseling patients about saliva allergen persistence and transmission:

• Peanut allergen (Ara h 1) can persist in saliva at levels capable of causing reactions immediately after ingestion (up to 40 mcg/mL) 3
• 87% of individuals have undetectable peanut allergen levels by 1 hour after ingestion with no interventions, and none had detectable levels several hours after a peanut-free meal 3
• Simple interventions (brushing teeth, rinsing, chewing gum) reduce salivary allergen by >95% but allergen remains detectable in ~40% of samples 3

Specific Avoidance Recommendations

• Most effective strategy: Wait several hours PLUS consume a peanut-free meal before intimate contact or sharing utensils 3
• Immediate interventions (brushing, rinsing, gum) are less reliable than waiting with a peanut-free meal 3
• Patients with food allergies require explicit counseling that partners brushing teeth or chewing gum alone does not eliminate risk 3

Monitoring and Follow-up

• Observe patients for 1-2 hours after resolution of immediate-type reactions before discharge 1
• Longer observation periods (4 hours) may be necessary for certain reaction types 1
• Repeat vital signs and physical examination every 15 minutes during active reactions, then every 30-60 minutes after resolution until discharge 1

Common Pitfalls

• Do not rely on antihistamines alone for respiratory or systemic symptoms - this delays life-saving epinephrine administration 1
• Do not assume simple mouth-cleaning interventions eliminate allergen exposure risk - waiting several hours with a peanut-free meal is more effective 3
• Do not discharge patients immediately after symptom resolution - biphasic reactions can occur, requiring observation period 1