expert roundtables

Pediatric Food Allergy: Patient and Family Education

by Aikaterini Anagnostou, MD, PhD; David M. Fleischer, MD; and Robert A. Wood, MD

Overview

The mainstays of patient and family education with regard to pediatric food allergy include food allergen avoidance and the recognition and treatment of allergic reactions caused by accidental allergen exposure. These core educational areas are foundational and remain relevant when oral immunotherapy (OIT) is pursued.

Q:

What core educational points would you emphasize?

Robert A. Wood, MD

Julie and Neil Reinhard Professor of Pediatric Allergy and Immunology
Professor of Pediatrics and International Health
Director, Eudowood Division of Allergy, Immunology and Rheumatology
Director, Pediatric Clinical Research Unit
Deputy Director, Institute for Clinical and Translational Research
Johns Hopkins University School of Medicine
Baltimore, MD

“Education begins with detailed explanations about not only reading labels but also recognizing the most common scenarios in which these foods are more likely to be hidden, whether due to cross-contamination or a hidden ingredient.”

Robert A. Wood, MD

Most patients do not have a single food allergy, which means that if someone is receiving peanut OIT, there will often be other foods that they need to avoid. Patient and family education on food allergy really begins with food avoidance, which is relevant whether or not OIT is being pursued. Allergen avoidance sounds straightforward, and sometimes it is, but people make mistakes, and this results in allergen avoidance becoming more complicated.

Education begins with detailed explanations about not only reading labels but also recognizing the most common scenarios in which these foods are more likely to be hidden, whether due to cross-contamination or a hidden ingredient. In addition to in-person education, there are fantastic online resources that are available now to help patients and their families. You also want to take care when going out to eat, as it can be difficult to get a safe meal in a restaurant. When traveling with a child who has a severe milk or egg allergy, for example, some families choose to stay in a hotel room with a kitchen or to rent a house where they can cook all of their meals themselves because, as previously stated, it is very difficult to dine out safely. It is even more difficult for children with some of the lesser-known food allergies that are commonly used ingredients in restaurants, such as mustard or garlic.

The second major educational aspect is providing patients and parents with a very clear care plan in the event of an allergic reaction. This includes recognizing what a reaction looks like and understanding details on which medication should be given and when. Having self-injectable epinephrine on hand at all times is something that we emphasize at every single appointment with every family. The discussion gets more detailed when caring for children in their early or late teens, who are starting to take on more responsibility for their self-care, including administering their own medicine.

In short, the following age-old paradigm is important: Do your best to achieve strict avoidance but also be prepared to treat any reaction, however severe, in the event of an accidental exposure.

Aikaterini Anagnostou, MD, PhD

Professor of Pediatrics
Director, Food Immunotherapy Program
Director, Food Challenge Program
Co-Director, Food Allergy Program
Lead, Adolescent Transition for Allergy
Texas Children’s Hospital
Baylor College of Medicine
Houston, TX

“Beyond food labeling, it is important to spend time teaching patients and families how to recognize the symptoms of an allergic reaction. This is a learning process, as it will not necessarily be accomplished in a single visit and may require additional dialogue and information.”

Aikaterini Anagnostou, MD, PhD

There are certain areas, such as food avoidance, where we need to be as detailed as possible, especially for children who are allergic to multiple foods. Reading labels, for example, requires a specific approach, and I find it helpful to involve a dietician in the discussion. The dietician can teach patients and families how to read labels and check for ingredients, as well as inform them about the importance of avoiding foods that have no ingredients listed (eg, in open markets). Parents also need to know how to deal with certain situations, such as traveling, going on an overnight trip outside the home, and informing restaurant staff about the child’s food allergies when dining out.

Beyond food labeling, it is important to spend time teaching patients and families how to recognize the symptoms of an allergic reaction. This is a learning process, as it will not necessarily be accomplished in a single visit and may require additional dialogue and information.

Something else to keep in mind is that food-allergic children may require help beyond what might be initially expected. For instance, research has shown that a significant number of children with tree nut allergies cannot recognize one tree nut from another (eg, cashews vs Brazil nuts). A child might therefore avoid all tree nuts when they are allergic to just 1 or 2. Generally, we cannot assume that patients know everything related to food allergies, and additional information is often helpful.

Wider community education also makes life a lot easier for patients and their families. The awareness and understanding of food allergies and how to manage them used to be very low, but this has improved significantly over time. For example, the majority of school staff are now receiving regular education on food allergies and have become familiar with food allergies and their management.

David M. Fleischer, MD

Section Head, Allergy and Immunology
Professor of Pediatrics
Director, Allergy and Immunology Center
Children’s Hospital Colorado
University of Colorado Denver School of Medicine
Aurora, CO

“When a reaction does occur, it is always good to discuss with the patient what happened with that episode and its sequence of events, whether by telemedicine or in person.”

David M. Fleischer, MD

I agree with my colleagues and would add to the observation that the transition from being a child to becoming an independent, young adult can be a particularly important time. It is the difference between being cared for and starting to take responsibility for self-care, and this occurs at a time when risk-taking behaviors can become heightened in adolescents and young adults. This prompts an interest in OIT among some parents for their child as they get older, especially before they go away to college. However, being compliant with a daily therapy such as OIT can become problematic for adolescents and young adults, so ongoing avoidance without a food allergy treatment may be best until other nondaily, nonoral treatments become available in the future. We educate parents when their children are young, and we continue to educate children as they get older. But there are some unique opportunities in early adolescence, so it may be helpful for patients in this age group to meet with a dietician, who can review with them what they were not taught when they were younger.

The key educational issues are about avoidance and being prepared for a reaction, and these points are relevant whether or not the patient is on OIT. When establishing a food allergy action plan, we include information on how to respond to reactions and when to give which medicine and for which symptoms. Obviously, there are some reactions that should be treated with epinephrine immediately, after which you can give an antihistamine, but antihistamines take longer to work. If the patient is coughing and wheezing, an antihistamine will not work quickly enough. The patient needs epinephrine first and then an antihistamine. This information should be included in the action plan, and it needs to be reviewed every time the patient has an appointment. When a reaction does occur, it is always good to discuss with the patient what happened with that episode and its sequence of events, whether by telemedicine or in person.

References

Anagnostou A. Weighing the benefits and risks of oral immunotherapy in clinical practice. Allergy Asthma Proc. 2021;42(2):118-123. doi:10.2500/aap.2021.42.200107

Boyce JA, Assa’ad A, Burks AW, et al; NIAID-Sponsored Expert Panel. Guidelines for the diagnosis and management of food allergy in the United States: summary of the NIAID-sponsored expert panel report. J Allergy Clin Immunol. 2010;126(6):1105-1118. doi:10.1016/j.jaci.2010.10.008

Cherkaoui S, Ben-Shoshan M, Alizadehfar R, et al. Accidental exposures to peanut in a large cohort of Canadian children with peanut allergy. Clin Transl Allergy. 2015;5:16. doi:10.1186/s13601-015-0055-x

Lieberman P, Decker W, Camargo CA Jr, O’Connor R, Oppenheimer J, Simons FE. SAFE: a multidisciplinary approach to anaphylaxis education in the emergency department. Ann Allergy Asthma Immunol. 2007;98(6):519-523. doi:10.1016/s1081-1206(10)60729-6

More in Pediatric Food Allergies

Thumb

Pediatric Food Allergies

Expert Perspectives in Pediatric Food Allergies to Cover Key Topics in Pediatric Food Allergy Treatment

Expert Perspectives

Expert Perspectives delivers health care providers with insights from key thought leaders on the latest advancements and current practices in medic...READ MORE

Thumb

Pediatric Food Allergies

Oral Immunotherapy: Goals, Expectations, and Future Prospects

Patient Care Perspectives by Aikaterini Anagnostou, MD, PhD

Oral immunotherapy (OIT) is an exciting novel intervention that desensitizes the majority of patients to food allergens and can greatly mitigate th...READ MORE

Thumb

Pediatric Food Allergies

Recognizing and Responding to Anaphylactic Food Reactions

Clinical Topic Updates by Aikaterini Anagnostou, MD, PhD

One of the most important aspects of anaphylaxis is its rapid progression. Knowledge of the potential symptoms of anaphylactic food reactions and f...READ MORE

More In Allergy & Immunology

Pediatric Food Allergies

Reducing The Risks Of Accidental Food Allergen Exposure

Expert Roundtables by Aikaterini Anagnostou, MD, PhD; David M. Fleischer, MD; and Robert A. Wood, MD

Pediatric Food Allergies

To Outgrow Or To Treat: Egg, Milk, And Peanut Allergies

Expert Roundtables by Aikaterini Anagnostou, MD, PhD; David M. Fleischer, MD; and Robert A. Wood, MD

Pediatric Food Allergies

Challenges And Opportunities In The Management Of Pediatric Food Allergy

Patient Care Perspectives by David M. Fleischer, MD