Treatment Guideline Chart
Food allergy is an adverse reaction due to a specific immune response occurring reproducibly upon exposure to certain foods. It occurs minutes to hours after food consumption.
Immunological mechanisms can be IgE mediated, non-IgE mediated or mixed IgE and non-IgE mediated.
It may be life-threatening and is the most common cause of anaphylaxis in children.
It should be differentiated from food intolerance in which adverse reactions from exposure to food arise from non-immunological mechanisms.

Food%20allergy%20(pediatric) Treatment


Food-induced Anaphylaxis


  • In life-threatening anaphylaxis, self injectable intramuscular (IM) Epinephrine (0.01 mg/kg) is the only first-line of treatment; all other treatments are adjunctive
    • IM route provides faster increase in plasma and tissue concentrations of Epinephrine compared to subcutaneous (SC) route
    • At least 2 auto-injections should be prescribed and carried at all times by patients at risk for food-induced anaphylaxis
  • Intravenous (IV) Epinephrine is recommended for patients who do not respond to repeated IM Epinephrine injections and fluid resuscitation
  • May be given every 5-15 minutes as needed to maintain blood pressure and control symptoms

Bronchodilators (Inhaled)

  • Eg Albuterol
  • Adjunctive treatment for bronchospasm not responsive to IM Epinephrine
  • Nebulized therapy, if available, is considered more practical than metered-dose inhalers


  • Eg Dopamine
  • Used in cases of persistent hypotension in anaphylaxis despite administration of Epinephrine and IV fluids
  • Continuous monitoring of vital signs should be done


  • May be used for refractory hypotension and bradycardia in patients who are taking beta-blockers since vasopressor effects of Epinephrine may be decreased in these patients

Antihistamines (H1 and H2-receptor Antagonists)

  • Limited evidence to support their use in emergency treatment of anaphylaxis
  • Useful only for relief of urticaria and itching


  • May be considered for patients with bradycardia 

Non-acute Food-induced Allergic Reactions 

Antihistamines (H1 and H2-receptor Antagonists)

  • Remain the mainstay in managing symptoms of non-severe food-induced allergic reactions
    • Used mainly for cutaneous reactions (eg itching and urticaria) but not as first-line medication during anaphylaxis
  • May also be used in cases where allergen avoidance is difficult or when it results in nutritional deficiencies
  • Oral antihistamines used for first aid treatment of allergic reactions should be in chewable or liquid preparation to facilitate faster absorption
  • Not recommended for prevention of food-induced allergic reaction


  • Although not used in the treatment of acute anaphylaxis due to its slow onset of action, its empiric use is supported by healthcare professionals
  • Anti-inflammatory properties of corticosteroids provide benefit in allergic diseases
  • Help prevent recurrence of symptoms and biphasic or protracted reactions


  • Treatment option for patients with confirmed IgE-mediated FA in whom avoidance measures are ineffective, not tolerated and affect patient’s quality of life
  • Oral immunotherapy is recommended as a treatment option for children 4-5 years of age with persistent cow’s milk protein allergy, hen’s egg allergy or peanut allergy on the basis of increasing threshold for clinical reactions during treatment
  • Several clinical trials show that oral, sublingual and epicutaneous immunotherapy have the potential to be used for FA, but clinical benefits should outweigh its side effects, and the inconclusive evidence that they are able to induce long-term tolerance to the target foods should be considered
    • Oral immunotherapy is more effective in inducing desensitization but may produce more adverse effects compared to sublingual and epicutaneous immunotherapy
  • Absolute contraindications include poor adherence, uncontrolled/severe asthma, active malignancy, active systemic autoimmune disorders, active eosinophilic esophagitis, other gastrointestinal eosinophilic disorders, pregnancy
  • Relative contraindications include severe systemic illness, severe medical conditions eg cardiovascular diseases, systemic autoimmune disorders in remission, uncontrolled active atopic dermatitis, chronic urticaria, betablockers, ACE inhibitors, mastocytosis

Monoclonal Antibodies

  • Eg Dupilumab, Omalizumab
  • Omalizumab, a monoclonal anti-IgE antibody, has been granted breakthrough therapy designation by the United States Food and Drug Authority for the prevention of severe allergic reactions following accidental exposure to ≥1 foods in people with allergies
    • Clinical trials showed that Omalizumab has the potential to induce desensitization in patients with food allergy
    • Omalizumab may also be given as an adjunct to oral immunotherapy
  • Studies showed that Dupilumab may reduce food allergy reactions by inhibiting IL-4 and IL-3 receptors that are associated with increased risk of food allergies

Non-Pharmacological Therapy

Allergen Avoidance

  • Considered 1st-line treatment in patients with documented and confirmed food allergies
  • Patients should be advised regarding cross-reacting allergens in other foods, hidden food allergens (eg casein and whey for cow’s milk, ovalbumin for chicken’s egg) and high risk situations like anaphylaxis
  • Elimination diet is advised only based on a positive history confirmed by skin prick test (SPT) or specific IgE test
    • Ensure that nutritional requirements of patients are met to avoid nutritional deficiencies
    • Ensure that the patient is clinically allergic to a particular food before removing it from their diet; may be pertinent to the patient’s growth and development
  • Individuals without documented or confirmed food allergy (FA) are not recommended to avoid potentially allergenic foods as part of managing asthma, atopic dermatitis or eosinophilic esophagitis
  • Allergen avoidance during pregnancy to prevent allergy in the offspring is not recommended due to risk in maternal and/or fetal nutrition, and lack of evidence to support its implementation
Editor's Recommendations
Special Reports