What is the management plan for a child with a severe food allergy?

Management of Severe Food Allergies in Children

Immediately prescribe an epinephrine autoinjector with hands-on training for any child with suspected severe food allergy, even before diagnostic confirmation, as this is potentially lifesaving while awaiting allergist evaluation. 1

Immediate Actions in Primary Care

Emergency Medication Prescription

• Prescribe epinephrine autoinjector immediately upon suspicion of severe food allergy, regardless of diagnostic certainty, as children wait an average of 4 months for allergist consultation and remain at risk for life-threatening reactions during this period 1
• Provide hands-on training to caregivers and age-appropriate children on proper epinephrine administration technique 1
• Prescribe antihistamines as adjunctive therapy for managing non-severe allergic symptoms 1
• Epinephrine remains the only medication proven effective for treating acute systemic allergic reactions and anaphylaxis 1

Immediate Dietary Management

• Instruct complete avoidance of the suspected food allergen until allergist evaluation confirms or refutes the diagnosis 1, 2
• Educate families on reading food labels and recognizing hidden sources of allergens 1
• Warn about precautionary labeling (e.g., "may contain traces") and advise strict avoidance of such products due to real contamination risk 1

Comprehensive Family Education

Recognition of Anaphylaxis

Train caregivers to recognize signs and symptoms of anaphylaxis, which may include: 1

• Skin: hives, flushing, angioedema
• Respiratory: wheezing, throat tightness, difficulty breathing
• Gastrointestinal: vomiting, abdominal pain (especially within 2-3 hours of exposure)
• Cardiovascular: dizziness, loss of consciousness

Emergency Action Plan

• Create a written food allergy emergency action plan that specifies when and how to administer epinephrine 1, 2
• Ensure caregivers understand that epinephrine should be given at first sign of systemic reaction, without waiting for symptom progression 1
• Provide school documentation including emergency action plans, Section 504 plans, or individualized education plans (IEPs) as needed 1, 2

Allergist Referral (Essential Component)

Timing and Purpose

• Refer all children with suspected severe food allergy to an allergist for definitive diagnostic testing 1, 2
• The allergist will perform oral food challenges when necessary to verify clinical relevance of positive tests, as the double-blind, placebo-controlled food challenge remains the diagnostic gold standard 1
• Allergist evaluation is critical because positive IgE testing alone has poor positive predictive value and does not confirm true clinical allergy 2, 3

What the Allergist Provides

• Detailed clinical history correlation with test results 2
• Additional diagnostic testing including specific IgE measurements and supervised oral food challenges in controlled settings 2
• Formulation of comprehensive emergency anaphylaxis action plan 1, 2
• Education on cross-reactivity risks (e.g., between peanuts and tree nuts) 1
• Facilitation of dialogue with schools and childcare centers 1

Nutritional Monitoring

Growth and Development

• Arrange nutritional counseling for all children with confirmed food allergies to ensure elimination diets provide adequate nutrients 1, 3
• Monitor growth parameters regularly, as avoidance diets can lead to nutritional deficiencies if not properly managed 1, 3
• Carefully planned allergen-free diets can maintain healthy, active lifestyles when properly supervised 1

Long-Term Follow-Up Strategy

Ongoing Management

• Schedule yearly follow-up for retesting, as many childhood food allergies (particularly milk and egg) resolve over time 2, 3
• Co-manage with the allergist rather than transferring care entirely, maintaining awareness of the child's special needs 1
• Address quality-of-life issues, as food allergy significantly increases anxiety and diminishes quality of life for patients and families 1
• Ensure families regularly check expiration dates on emergency medications and replace as needed 2

Adolescent Transition

• As children transition into adolescence, provide age-appropriate counseling on strategies for avoiding allergens in various social settings 1
• Emphasize increasing personal responsibility for food selection and emergency medication carrying 1

Critical Pitfalls to Avoid

Common Errors

• Never rely solely on positive IgE testing without clinical history, as sensitization does not equal clinical allergy 2, 3
• Do not implement unnecessary dietary restrictions in children without documented food allergy, particularly for managing atopic dermatitis, asthma, or eosinophilic esophagitis 1, 3
• Never delay epinephrine prescription while awaiting allergist consultation, as this leaves children vulnerable to potentially fatal reactions 1
• Avoid using allergy testing to "predict future risk"—testing should only evaluate reactions that have already occurred 3

Special Vaccine Considerations

• MMR vaccine is safe for children with egg allergy, even those with severe reactions 1
• Influenza vaccines are not recommended for patients with history of severe egg reactions (hives, angioedema, allergic asthma, or anaphylaxis to egg proteins) 1
• Yellow fever vaccine should not be administered to patients with severe egg allergy without allergy evaluation and vaccine testing 1

Emerging Therapies (Not Yet Standard Practice)

• Oral immunotherapy (OIT) and sublingual immunotherapy (SLIT) are under investigation for inducing clinical desensitization 1
• These approaches carry risk of severe reactions and are not recommended for routine clinical practice at this time 1
• Allergen-specific immunotherapy with cross-reactive allergens is not recommended for treating IgE-mediated food allergy 1