What is the recommended management for a patient with a severe food allergy?

Management of Severe Food Allergy

All patients with severe food allergy must be prescribed two epinephrine autoinjectors (0.15 mg for 10-25 kg, 0.3 mg for ≥25 kg), receive strict allergen avoidance counseling, have a written emergency action plan, and undergo nutritional counseling with regular follow-up. 1, 2

Immediate Epinephrine Prescription and Dosing

Epinephrine is the only first-line treatment for anaphylaxis and must be prescribed to all patients with severe food allergy. 1

Specific Indications for Epinephrine Auto-Injectors

• Any patient with a previous systemic allergic reaction to food 1, 2
• All patients with food allergy and coexisting asthma (which confers a four-fold higher risk of severe reactions) 1, 2
• Patients allergic to peanut, tree nuts, fish, or crustacean shellfish 1, 2
• Strong consideration for all patients with documented IgE-mediated food allergy 1

Dosing Protocol

• Children 10-25 kg: 0.15 mg epinephrine autoinjector administered intramuscularly to the anterolateral thigh 1, 2
• Individuals ≥25 kg: 0.3 mg epinephrine autoinjector administered intramuscularly to the anterolateral thigh 1, 2
• Alternative dosing: 1:1000 epinephrine solution at 0.01 mg/kg per dose (maximum 0.5 mg) 1
• Two autoinjectors must always be prescribed because repeat dosing may be required every 5-15 minutes if symptoms persist or recur 1, 2

Critical Safety Considerations

• Delayed epinephrine administration is the primary factor contributing to food allergy fatalities 1, 2
• Epinephrine remains vastly underprescribed and underused despite being life-saving 2
• Autoinjectors are temperature-sensitive and must be stored at room temperature 1
• Establish a system to monitor expiration dates and ensure timely replacement 1, 2

Strict Allergen Avoidance Strategy

Complete avoidance of the identified allergen is the cornerstone of management and the only proven preventive measure for IgE-mediated reactions. 1, 2

Education Requirements

• Comprehensive training on reading food labels and recognizing hidden allergen ingredients in processed foods 1, 2
• Products with precautionary labeling (e.g., "may contain trace amounts") must be avoided due to significant contamination risk 1, 2
• Training on cross-contamination prevention in food preparation and dining environments 1, 2
• Schools, childcare providers, and supervising adults must be educated on reaction recognition and emergency treatment 2

Written Emergency Action Plan

Every patient must receive a written, individualized emergency action plan that defines anaphylaxis and provides step-by-step instructions. 1, 2

Plan Components

• Clear definition of anaphylaxis: skin/mucosal involvement plus respiratory compromise or hypotension 2
• Step-by-step instructions for intramuscular epinephrine administration to the anterolateral thigh 2
• Directive to call emergency services (911) immediately after epinephrine administration 1, 2
• Instructions to self-administer epinephrine at the first sign of recurrence and immediately seek emergency care 1

Post-Reaction Management

• All patients who receive epinephrine must proceed to an emergency facility for observation 1
• Minimum observation period of 4-6 hours; longer observation required for severe or refractory reactions 1, 2
• Biphasic reactions occur in 1-20% of cases, typically around 8 hours but can appear up to 72 hours after the initial event 1, 2

Adjunctive Medications for Acute Reactions

While epinephrine is the only first-line treatment, adjunctive medications play a supportive role. 1

Antihistamines

• Diphenhydramine: 1-2 mg/kg per dose (maximum 50 mg) orally or intravenously for adjunctive symptom control 1
• Oral liquid formulations are absorbed more rapidly than tablets 1
• Second-generation antihistamines are acceptable alternatives for non-severe reactions 1
• Critical caveat: Antihistamines are appropriate for mild, non-systemic symptoms but must never replace epinephrine for anaphylaxis 1, 2

Bronchodilators and Supportive Care

• Albuterol: 4-8 puffs (children) or 8 puffs (adults) via metered-dose inhaler, or nebulized solution (1.5 mL for children, 3 mL for adults) every 20 minutes for bronchospasm 1
• Supplemental oxygen therapy as needed 1
• Large-volume intravenous fluids for orthostasis, hypotension, or incomplete response to epinephrine 1
• Place patient in recumbent position with lower extremities elevated if tolerated 1

Post-Discharge Adjunctive Treatment

• H1 antihistamine: Diphenhydramine every 6 hours for 2-3 days, or non-sedating second-generation antihistamine 1
• H2 antihistamine: Ranitidine twice daily for 2-3 days 1
• Corticosteroid: Prednisone daily for 2-3 days (though evidence for preventing biphasic reactions is limited) 1

Mandatory Nutritional Counseling and Monitoring

Nutritional counseling is required for all food-allergic patients, especially when major food groups are eliminated. 1, 2

Rationale and Implementation

• Approximately 30% of children have multiple food allergies requiring careful nutritional oversight 2
• Regular growth monitoring is essential to detect potential growth impairment 1, 2
• Adequate nutrient intake must be achieved through appropriate allergen-free food substitutions 2
• Failure to address nutritional needs can lead to growth impairment and nutrient deficiencies 2

Follow-Up and Specialist Referral

Follow-up with primary care within 1-2 weeks after anaphylaxis, with referral to an allergist/immunologist for comprehensive evaluation. 1

Follow-Up Protocol

• Direct communication between treating physician and primary care professional is recommended 1
• Allergen identification through history and follow-up testing before discharge 1
• Emphasis on subsequent testing to determine and verify the trigger for successful future avoidance 1
• Regular follow-up with both primary care providers and allergists 2
• Periodic re-testing for allergens commonly outgrown (milk, egg, soy, wheat) 2

High-Risk Populations Requiring Intensified Management

Adolescents, young adults, and patients with asthma have the highest risk of fatal anaphylaxis. 1, 2

Specific Risk Factors

• Adolescents and young adults due to risk-taking behaviors 1, 2
• Patients with asthma, especially poorly controlled (four-fold increased risk) 1, 2
• Individuals with prior anaphylaxis episode 1, 2
• Peanuts and tree nuts cause the majority of fatalities from food-induced anaphylaxis 1

Critical Pitfalls to Avoid

The most common fatal error is delayed or absent epinephrine administration. 1, 2

Common Management Failures

• Only 39.7% of food-allergic children at summer camps brought an epinephrine autoinjector 2
• Approximately 6.6% of patients receive inadequate epinephrine doses due to prescribing errors 2
• Antihistamines alone must never be relied upon for systemic reactions—they are adjunctive only 1, 2
• Overly restrictive diets based solely on positive testing without clinical symptoms should be avoided 2
• Do not confuse food allergy with food intolerance 2

Non-Recommended Interventions

No medications are currently approved to prevent IgE-mediated food allergic reactions. 1, 2

• Oral, sublingual, and epicutaneous immunotherapy are not recommended for routine clinical practice and should be limited to research settings 1, 2
• Maternal dietary restriction during pregnancy or lactation is not recommended as a prevention strategy 2
• Immunotherapy with cross-reactive allergens is not recommended for treating IgE-mediated food allergy 1

Emerging Therapy: Omalizumab

Omalizumab is FDA-approved for IgE-mediated food allergy in patients ≥1 year of age, dosed at 75-600 mg subcutaneously every 2-4 weeks based on serum IgE level and body weight. 3

• Dosing is not dependent on serum IgE level or body weight for chronic spontaneous urticaria, but is for food allergy 3
• The appropriate duration of therapy has not been established; periodically reassess need for continued therapy 3
• Patients should receive at least 3 doses under healthcare provider guidance before considering self-administration 3