A Parent’s Guide to Food Allergy Management At Children’s

Your child must be healthy on the day of the oral food challenge. Please call 404-785-KIDS (5437) to reschedule if your child is sick.

Your child’s asthma, eczema (atopic dermatitis) and allergic rhinitis (runny nose) should be well controlled ahead of testing.

Your child must stop taking antihistamine medicines 7 days before their visit. This includes:

• Benadryl (diphenhydramine).
• Zyrtec (cetirizine).
• Claritin (loratadine).
• Atarax (hydroxyzine).
• Astelin (azelastine).
• Allegra (fexofenadine).

Your visit may last up to four hours.

The clinic has TVs for children to watch, but you may bring other items to entertain your child, like toys, books or homework.

We understand that food challenges may make you or your child feel nervous. Your child may be eating foods they have been told to never eat or foods that caused a reaction in the past. It may also feel boring to spend so much time at the clinic. There are some things you can do to help support your child.

Tell your child about the test ahead of time.

• Explain the test in words they can understand.
• Let them know you will stay with them during the test.

Let them feel comfortable and at ease.

You can allow them to feel comfortable by:

• Asking questions.
• Telling you what they think will happen and how they feel.
• Picking out toys, books, activities or other favorite items to take with them.

Epinephrine device

It is important to bring your child’s epinephrine devices to the visit. This is so you have them for the trip to our clinic and back home.

At Least 2 serving sizes of the food challenge

• Please read food labels to make sure they do not include other things your child cannot eat.
• You can bring something to mix the food into, like a sauce, dip or yogurt if you feel it will help your child eat it.
• You may bring your child’s favorite plate, bowl and utensils if desired.

Food that your child is not allergic to

To consume after their food challenge.

A change of clothes for you and your child

Your child should be hungry when you get to the visit. They should not eat before the test.

A provider will check your child’s health and vital signs before and during the test. They will also talk with you about what to expect, what reactions are possible and what they will do if a reaction happens.

The test:

• Is completed in a room that is open and may have other patients. Each child will have their own chair.
• Starts with a small amount of the challenge food. The team will give a larger amount if there are no symptoms after about 15 minutes. Your child may eat two to six servings of the food.
• Continues until your child eats a meal-sized serving.
• Will be stopped if your child has symptoms. The provider will check your child, talk with you and give medicines if needed.

Most often, your child may go home one to two hours after the test if they did not have symptoms.

Your child may be watched longer if they have allergic symptoms. Antihistamines are given most often for mild symptoms. Treatment may include epinephrine and other medicines if the symptoms are severe.

A food allergy action plan is a document that presents critical information on how to manage your child’s food allergy in the event of an allergic reaction, including allergen(s), how to recognize symptoms and treatment instructions based off their age and weight in an easy-to-follow format.

Keep your plan in a place where others can find it in your home, share it with your child’s school, and make sure you and others understand what to do in case of an emergency.

There are steps parents can take to help protect their child at home.

Read all food labels.

• The United States requires food companies by law to list any common food allergens on their labels.
• Food companies do not always stick to the same recipe. So, even though a food has worked in the past, you will want to keep looking at the labels at the store to make sure no ingredients have changed.

Tell others about your child’s food allergies.

• Include anyone who lives in your house, babysitters and parents of friends your child spends time with.
• Tell them about your child’s food allergens, allergic symptoms and what to do if allergic symptoms happen.
• Train family members and other caregivers of your child on how to use your child’s epinephrine device.

Take care of yourself and ask for help when needed.

• Having a child with food allergies may feel scary and overwhelming. We are here to help. Talk with your child’s allergy team about support for you and your child.

You can partner with your child’s school or day care to help your child stay protected at school.

Talk with the school nurse or teacher about your child's food allergies, their allergy symptoms, and what to do if an allergic reaction happens.

Share a copy of your child’s action plan.

• Make sure your child’s school knows who is responsible for following the plan and how the plan will be communicated to teachers and staff.
• Remember to share a new copy every time their action plan changes.

Provide two epinephrine devices to the school.

• Check that all forms related to giving medicine are filled out and signed.
• Check to make sure the school nurse and your child’s teacher know how to use your child’s epinephrine devices.

An epinephrine auto-injector (also known as an epinephrine pen, Epi-Pen or Auvi-Q) is an injectable home medicine used to help treat severe allergic reactions. Make sure two devices are always with your child if the doctor prescribes this medicine.

There are several brands of epinephrine auto-injectors. Each functions in a slightly different way. They all:

• Are handheld devices and contain a dose of medicine, a chamber to hold the medicine, a spring to inject it and a needle.
• Need to be injected into a muscle to work. This is always in the middle, outer thigh (upper leg) muscle. You may inject it through your child’s clothes if needed.

NOTE: Some pen cartons may contain a blank “dummy” pen to use for training. 

• It looks a lot like a real epinephrine pen, except it does NOT contain any medicine or a needle.
• You may use the training pen to practice the steps in case you need to use the real epinephrine pen in the future.
• Children may also use the training pen for practice as they get older.

• An epinephrine nasal spray is a medicine used to help treat severe allergic reactions by spraying the medicine in a nostril.
• Make sure two epinephrine nasal spray devices and an epinephrine auto-injector are always with your child if the doctor prescribes this medicine.

Talk with your child’s care team or pharmacist if you have any questions about how to use your child’s epinephrine device correctly and safely.

Review epinephrine device information to learn how to use the specific device for your child. This could include:

• EpiPen (epinephrine) or EpiPen generic auto-injector.
• Auvi-Q (epinephrine injection, USP).
• Adrenaclick (epinephrine injection, USP auto-injector).
• Neffy (epinephrine nasal spray).

Also read the instructions that come in the device package. Do this as soon as you pick up the device. This helps you learn about using the device before you need to use it in an emergency.

Avoidance is when a child is restricted from eating a food that has been confirmed as an allergy through testing.

An adult caregiver must:

• Be willing to read all food labels and avoid the food allergen.
• Be trained to recognize and treat an allergic reaction.
• Have and be willing to use an epinephrine device in case a reaction happens.

Oral immunotherapy (OIT) helps a child’s immune system build a tolerance to their food allergen. This means it will take more of the food to cause allergic symptoms and may protect them from having a severe reaction. This represents desensitization and is not a cure for food allergies. It may allow for more food freedom.

OIT has been shown to have a higher probability of remission when started in infants, toddlers and preschoolers. Remission is defined as the ability to eat a normal serving size for your child’s age after completing therapy for a year or longer. It is a long-term therapy and may be lifelong.

We offer OIT for peanuts, tree nuts and sesame.

OIT involves:

• Getting a small amount, or dose, of the food allergen every day at home. The allergy team will decide the dose.
• Slowly increasing the dose of the food allergen about every two weeks for about four to six months. This will happen during clinic visits.

A child cannot freely eat their food allergen during this treatment. They must still avoid the allergen outside of dosing at home or during clinic visits.

An adult caregiver must:

• Monitor their child for two hours after their dose on a daily basis.
• Follow all prescribed dosing guidelines given by the allergy team.
• Be willing to read all food labels and avoid the food allergen.
• Be trained to recognize and treat an allergic reaction.
• Have and be willing to use an epinephrine device in case a reaction happens.

A child must be healthy to receive OIT. If a child has a health condition like asthma or allergic rhinitis, their symptoms must be under good control.

Food ladders are a step-by-step way to advance a child’s diet at home. It allows the body to accept the food protein in a broken-down form.

Milk and egg ladders are a kind of dietary plan created to help increase exposure for children with a mild reaction to eggs or milk. The goal is to help your child develop a natural tolerance by introducing the allergen gradually, and increasing the amount of the allergen through different cooking methods. While food ladder advancement may be done at home or in the office, there are specific steps to follow. Do not start your own ladder without a provider’s advice.

A child cannot freely eat their food allergen during this treatment. They must be monitored by a trained caregiver.

An adult caregiver must:

• Be available for frequent check-ins and contact with the allergy team.
• Be trained to recognize and treat an allergic reaction.
• Have and be willing to use an epinephrine device in case a reaction happens.

Ladders are not advised for a child who:

• Has severe or uncontrolled asthma.
• Has had a moderate to severe allergic reaction called anaphylaxis.
• Has needed an epinephrine device after eating or drinking the food allergen.

Xolair is a medicine that reduces sensitivity to a food allergen and may protect a child from having anaphylaxis, a severe allergic reaction that can be life-threatening.

• It is designed to target and bind to immunoglobulin E (IgE) in the body, minimizing the allergic reaction.
• The drug neutralizes the IgE in the blood so fewer allergic antibodies end up on allergy cells.
• By binding to IgE, it is prevented from arming the immune cells that are otherwise triggered to cause the symptoms of anaphylaxis in allergic individuals.

Xolair is not available to all children with food allergies.

• They must be at least 1 year of age with a confirmed food allergy and have blood tests that qualify them for this treatment.
• There may be other factors that affect whether a child can receive Xolair.

Xolair is given as one or more injections (shots) at least one to two times every month for the rest of a child’s life.

• The first three shots are given in the Children’s food allergy clinic so the team can watch for signs of allergic reaction. Then you will be trained to give the shots at home.
• It takes 16 weeks of shots to protect against accidental ingestion.
• The most common side effect is a reaction at the injection site. Other possible side effects include joint pain, rash and increased chance of parasitic infection in at-risk populations.

A child cannot freely eat their food allergen while on Xolair. They must be monitored by a trained caregiver.

An adult caregiver must:

• Be willing to read all food labels and avoid the food allergen in most cases.
• Be trained to recognize and treat an allergic reaction.
• Have and be willing to use an epinephrine device in case a reaction happens.

Ongoing research leads to new therapies for managing food allergies. While there are no cures for food allergies, Children’s offers new treatments through clinical trials or routine care as the new treatments become available. These treatments are not available to all children with food allergies. They may require:

• Very specific history, taking into consideration details like a child’s allergens, allergic reaction history, blood test results and other health history.
• Frequent clinic visits, blood tests and other testing.

Information about current clinical trials, including trial descriptions and eligibility criteria, can be found on our research webpage. You may also call 404-785-6448 or email CADRE@choa.org to learn more.

Most clinical trials are available at no cost to participants.

Oral immunotherapy (OIT) helps your child’s immune system build a tolerance to peanuts, sesame or tree nuts. This means it will take more peanuts, sesame or tree nuts to cause allergic symptoms.

Your child will:

• Get a small amount, or dose, of peanuts, sesame or tree nuts every day at home. The allergy team will decide the dose.
• Slowly increase the dose of peanuts, sesame or tree nuts about every two weeks. The allergy team will do this during a clinic visit.

Your child may have the following types of visits with the allergy team:

• Consultation visit to check your child’s food allergy history and care plan.
• Oral food challenge based on their history and test results.
• Up-dosing visits when your child gets a higher dose of peanut, sesame or tree nut. These visits happen about every two weeks for the first four to six months of therapy.
• Maintenance dose visits every three to 12 months when the up-dosing phase is done.

Our team will talk with you about:

• How to give the dose to your child at home.
• The signs and symptoms of an allergic reaction.
• When and how to use an epinephrine device.
• Why it is important to have epinephrine ready to use at all times.

Remember to bring your child’s:

• Choice of food, such as applesauce, pudding or yogurt, to mix with the dose during your visit.
• Two epinephrine devices.

Your child must:

• Be healthy and not have symptoms of being sick like fever (temperature of 100.4°F or higher), cough, congestion, vomiting (throwing up) or diarrhea (loose stools).
• Arrive to the clinic with a full stomach after a meal. A meal that is high in carbohydrates, such as rice, pasta, bread, cereal or oatmeal, is preferred.
• Stay at the clinic for at least one hour after getting the dose.
• Get checked by an allergy provider before going home.

One of our providers will meet with you and your child. They will:

• Check your child’s vital signs (temperature, heart and breathing rates, blood pressure and oxygen level).
• Talk with you about your child’s health history and symptoms.
• Ask about any allergic reactions and whether your child has needed epinephrine for any reason since their last visit.
• Do a physical exam.
• Do an asthma assessment if needed.
• Address your questions and concerns.

Your child will receive the new dose if they:

• Are healthy and free from illness.
• Ate a meal before their visit.
• Have two epinephrine devices with them.

After your child takes the dose, the allergy team will:

• Closely watch your child for at least one hour to make sure they do not have any allergic reactions.
• Check your child right before going home.
• Review instructions about how to give the dose to your child at home.
• Schedule a follow-up visit.

Your child should take their dose every day so that they maintain their tolerance level. It is very important that your child:

• Continues to avoid peanuts, sesame or tree nuts except for the therapy dose.
• Takes all doses after a meal or heavy snack. A meal that is high in carbohydrates, such as rice, pasta, bread, cereal or oatmeal is preferred.
• Takes the dose around the same time each day.
• Takes the dose at least one hour before bedtime.

Your child should not do things that increase body temperature and heart rate for 30 minutes before and at least two hours after getting the dose. Things to avoid include:

• Exercise and sports.
• Baths, showers, hot tubs, saunas and swimming.
• Going outside on a hot day.

Your child should not get the dose if they have symptoms of being sick, such as:

• Fever (temperature of 100.4°F or higher).
• Runny nose or congestion.
• Cough.
• Vomiting or diarrhea.
• Asthma flare-up.

The parent or caregiver giving the peanut, sesame or tree nut dose should:

• Know the symptoms of severe allergic reaction or anaphylaxis.
• Know how to treat symptoms and give medicines such as epinephrine.
• Have two epinephrine devices in case of anaphylaxis after your child gets their dose.

When you give the dose:

• Make sure your child eats the entire dose.
• You and your child should wash your hands immediately after handling the mixture.
• Closely watch your child for two hours to make sure they do not have any allergic reactions.

There is a chance of allergic symptoms, including severe symptoms or anaphylaxis. Most often, allergic symptoms during oral immunotherapy are mild to moderate. These symptoms may include:

• Itching of the lips and mouth.
• Stomach (belly) pain.
• Vomiting. 
• Hives.
• Inflammation in the tube that connects the mouth and stomach. This is called eosinophilic esophagitis.

Your child is more likely to have allergic symptoms at certain times. The provider may tell you to stop giving doses if your child:

• Is sick with symptoms like fever (temperature of 100.4°F or higher), cough, vomiting or diarrhea.
• Is fasting or not eating well.
• Is not sleeping well.
• Is taking nonsteroidal anti-inflammatory drugs like ibuprofen (Motrin, Advil or store brand).
• Has a medical or dental procedure. 
• Has asthma that is not well-controlled.

If your child misses more than three doses in a row, you MUST contact the food allergy team by calling 404-785-KIDS (5437) or sending a message on MyChart. Your child may need a clinic visit to be monitored during repeat dosing.

If your child has an allergic reaction—whether related to the immunotherapy dose or for any other reason—follow their food allergy action plan.

Call 911 right away if your child is having a severe allergic reaction after receiving epinephrine.

Signs of severe allergic reaction may include:

• Shortness of breath, wheezing or repeated coughing.
• Pale or blue skin color.
• Feeling faint, weak or dizzy.
• Hoarseness or trouble swallowing.
• Very bad swelling to the tongue or lips.
• Repeated vomiting.
• Severe diarrhea.
• Feeling something bad is about to happen.
• Feeling very nervous or anxious.
• Confusion.
• A mix of symptoms from different body areas.

Clinical trials are research studies that explore whether a medicine, treatment or device is safe and helpful. People who join clinical trials help researchers answer important questions that can lead to new cures and treatments.

Our clinical trials focus on the major food allergens, including peanuts, milk, eggs and tree nuts. All food allergens are important, and we hope to include more food allergens in future studies.

Information about current clinical trials, including trial descriptions and eligibility criteria, can be found on our research webpage. You may also call 404-785-6448 or email CADRE@choa.org to learn more.

Visit our research webpage. We will update it as new trials become available.

We encourage anyone with a food allergy to contact us by calling 404-785-6448 or emailing CADRE@choa.org. This helps us know our community’s needs when we are approached about a potential study.

Most clinical trials do not allow a child to be in more than one trial at once. However, your child might be able to join other kinds of studies like questionnaire or lab-only studies. The study team can explain what is allowed.

Most clinical trials are available at no cost to participants. The company running the study most often provides the study medicine for free. They may also cover the cost of some medical care during the trial.

You may have other costs, such as the cost of travel or time away from work.

If you have questions, talk with the study team or email us at foodallergyresearch@choa.org.