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 may be considered as a treatment option for children ≥4 years of age with clinically diagnosed persistent severe IgE-mediated cow’s milk protein allergy, hen’s egg allergy on the basis of increasing threshold for clinical reactions during treatment
  • Peanut oral immunotherapy is recommended to select children ≥4 years of age with clinically diagnosed severe IgE-mediated peanut allergy under the supervision of a specialist to increase peanut tolerance during therapy
  • Peanut epicutaneous immunotherapy may be considered in select children aged 4-11 years with clinically diagnosed severe IgE-mediated peanut allergy under the supervision of a specialist to increase peanut tolerance during therapy
  • Clinical benefits should outweigh the side effects of oral, sublingual and epicutaneous immunotherapy, 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
  • Indications for allergen immunotherapy (all of the following):
    • History of IgE-mediated systemic allergic reactions after ingestion and/or positive oral food challenge
    • Evidence of allergic sensitization
    • Primary food allergy, as opposed to pollen food allergy syndrome due to cross-reactivity
    • Persistent food allergy with low likelihood of spontaneous resolution
    • Parents, patient and caregivers possess a full understanding of effectiveness, side effects, logistics and the potentially life-long duration of the therapy
    • Parents, patient and caregivers should be motivated, adherent and capable of administering emergency treatment
    • History of severe reactions to food or impaired quality of life due to burden of food allergy
    • Willingness of parents, patient and caregivers to incorporate the food into diet
    • Stability of living and family situation
  • Absolute contraindications include poor adherence, uncontrolled/severe asthma, active malignancy, active systemic autoimmune disorders, systemic immunosuppression therapy, 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, uncontrolled chronic urticaria, beta-blocker or ACE inhibitor therapy, mastocytosis, increased dose of other immunotherapy, chronic undiagnosed gastrointestinal symptoms, inability to ingest study products, psychological problems or possibility of eating disorders

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
  • Etokimab is undergoing clinical trials for its use in peanut allergy

Non-Pharmacological Therapy

Allergen Avoidance

  • Considered first-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
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