Managing Allergic Conditions Pediatric

Required Documents

• Prior allergy test results (specific IgE levels, skin prick test records)
• Current dietary restriction list with rationale for each
• Anaphylaxis action plan (if exists)
• Medication list (antihistamines, epinephrine, inhalers)
• Growth chart (to assess impact of dietary restrictions)

Step 1 — Allergic Condition Classification

IgE-Mediated (Immediate) Reactions

• Onset: minutes to 2 hours after exposure
• Symptoms: urticaria, angioedema, vomiting, wheezing, hypotension, anaphylaxis
• Conditions: food allergy (IgE-mediated), allergic rhinitis, acute urticaria, anaphylaxis, drug allergy (Type I), venom allergy

Non-IgE-Mediated (Delayed) Reactions

• Onset: hours to days after exposure
• Symptoms: eczema flare, chronic diarrhea, bloody stools, failure to thrive
• Conditions: food protein-induced enterocolitis syndrome (FPIES), food protein-induced proctocolitis, eosinophilic esophagitis (EoE)
• Testing: specific IgE and skin prick are NEGATIVE in non-IgE-mediated conditions; diagnosis is clinical

Mixed IgE/Non-IgE

• Atopic dermatitis (eczema): both IgE and non-IgE mechanisms; food triggers in ~30% of moderate-severe eczema in young children

Step 2 — Allergy Testing and Interpretation

Skin Prick Testing (SPT)

• Wheal ≥ 3 mm greater than negative control = positive
• Positive SPT = sensitization, NOT necessarily clinical allergy
• Positive predictive value is poor (~50%); negative predictive value is excellent (> 95%)
• Antihistamines must be withheld: cetirizine/loratadine ≥ 3-7 days; diphenhydramine ≥ 3 days before testing

Specific IgE (sIgE) Blood Testing

• ImmunoCAP is the standard platform
• Results reported in kU/L; higher levels correlate with higher (but not certain) likelihood of clinical reactivity
• 95% predictive decision points (Sampson criteria) for common foods:

  Allergen	sIgE Level (≥ 95% PPV)	For Children < 2y
  Egg white	≥ 7 kU/L	≥ 2 kU/L
  Milk	≥ 15 kU/L	≥ 5 kU/L
  Peanut	≥ 14 kU/L	—
  Tree nuts	Varies by nut	—
  Fish	≥ 20 kU/L	—

Component-Resolved Diagnostics (CRD)

• Measures IgE to specific allergenic proteins within a food
• Peanut: Ara h 2 is the strongest predictor of clinical allergy (> 0.35 kU/L highly associated)
• Milk: Cas (casein) IgE predicts persistent allergy; Bos d 8 correlates with reactivity to baked and unheated milk
• Egg: Gal d 1 (ovomucoid) predicts reactivity to baked egg; Gal d 2 and Gal d 4 may indicate tolerance to baked egg
• CRD helps avoid unnecessary avoidance and guides oral food challenge decisions

Oral Food Challenge (OFC)

• Gold standard for food allergy diagnosis
• Indications: equivocal test results, suspected tolerance development, confirm or exclude clinical reactivity
• Must be performed in supervised medical setting with resuscitation equipment
• Graded doses administered every 15-30 minutes over 2-4 hours; observation for 2 hours after final dose
• Positive challenge: objective symptoms (urticaria, vomiting, wheezing, hypotension)
• Negative challenge: food can be reintroduced into diet

Step 3 — Food Allergy Management

Allergen Avoidance

• Written dietary avoidance plan with specific allergen names, cross-reactive foods, and label-reading guidance
• Educate on FALCPA (Food Allergen Labeling and Consumer Protection Act): top 9 allergens must be declared; precautionary labels ("may contain") are voluntary and unregulated
• Dietitian referral to ensure nutritional adequacy when major food groups are eliminated (especially milk, egg, wheat, soy)

Epinephrine Action Plan (Anaphylaxis Emergency Plan)

Every child with IgE-mediated food allergy must have:

• Epinephrine auto-injector prescribed (EpiPen Jr 0.15 mg for 7.5-25 kg; EpiPen 0.30 mg for > 25 kg)
• Written anaphylaxis action plan with:
  • Allergen(s) identified
  • Signs/symptoms of anaphylaxis (two or more organ systems involved)
  • Instructions: administer epinephrine FIRST, then call 911; antihistamines are adjunctive, NOT a substitute for epinephrine
  • Biphasic reaction warning: observe for 4-6 hours after anaphylaxis (late phase in ~20% of cases)
• Auto-injector training for patient, family, and school nurse
• Two auto-injectors available at all times (school + home/carried)

Peanut Allergy: Early Introduction (LEAP/LEAP-ON)

• Per AAP/NIAID 2017 Addendum Guidelines:
  • High-risk infants (severe eczema ± egg allergy): introduce peanut-containing foods at 4-6 months after evaluation (SPT or sIgE)
  • Moderate-risk (mild-moderate eczema): introduce around 6 months
  • Low-risk: introduce freely with other complementary foods
• Early introduction reduces peanut allergy risk by up to 80% in high-risk infants (LEAP trial)

Oral Immunotherapy (OIT) and Biologics

• Peanut OIT (Palforzia): FDA-approved for ages 4-17; daily escalating doses under medical supervision; reduces severity of reactions but does not cure allergy; must continue daily maintenance
• Omalizumab (Xolair): anti-IgE monoclonal; FDA-approved as adjunct for food allergy ages 1+; enables tolerance of larger accidental exposures
• Both require allergist management; not for primary care initiation

Step 4 — Allergic Rhinitis Management

Diagnosis

• Symptoms: sneezing, nasal congestion, rhinorrhea (clear), nasal pruritus, postnasal drip
• Allergic shiners, allergic salute, Dennie-Morgan lines, nasal crease
• Confirm with SPT or sIgE to aeroallergens

Stepwise Therapy

Allergen Immunotherapy

• SCIT: weekly injections for build-up (3-6 months), then monthly maintenance (3-5 years)
• SLIT: sublingual tablets (grass, ragweed, dust mite) for ages 5+; daily at home after first dose observed
• Both modify disease course: reduce new sensitizations and reduce asthma development risk in children with allergic rhinitis

Step 5 — Atopic Dermatitis and Drug Allergy

Atopic Dermatitis (Eczema) — See Also Dermatology Skill

• Food allergy testing in eczema: only test for clinically suspected triggers; do NOT "panel test" broadly
• Emollient-first approach: apply moisturizer (ointment > cream > lotion) immediately after bathing
• Topical corticosteroids: low potency (face, skin folds), medium (body), use for flares
• Dupilumab: FDA-approved for moderate-severe atopic dermatitis ages ≥ 6 months

Drug Allergy Evaluation

• Most reported "penicillin allergies" in children are NOT true allergy (< 5% confirmed on testing)
• Penicillin allergy evaluation: skin testing + graded oral challenge can de-label > 90% of patients
• Benefits of de-labeling: avoids unnecessary use of broader-spectrum antibiotics, reduces C. difficile risk, reduces cost

Checkpoint B — Allergy Management Review

• Allergic condition classified (IgE-mediated vs. non-IgE vs. mixed)
• Detailed exposure and reaction history documented
• Appropriate testing ordered and interpreted in clinical context (not in isolation)
• Dietary restrictions evidence-based (not based on sensitization alone)
• Epinephrine auto-injector prescribed with written action plan
• Auto-injector training documented for family and school
• Dietitian referral made if major food groups eliminated
• Early allergen introduction counseled (peanut per LEAP guidelines)
• Allergic rhinitis managed per stepwise approach
• Growth monitored if dietary restrictions are in place
• Immunotherapy discussed if appropriate (refractory rhinitis, venom allergy)
• All [VERIFY] flags resolved or escalated

Quality Audit

Guidelines

• Follow NIAID 2010 Guidelines for Diagnosis and Management of Food Allergy (updated with 2017 Addendum for peanut)
• Apply LEAP trial evidence for early peanut introduction in high-risk infants
• Use Sampson criteria for 95% predictive decision points in sIgE interpretation
• Follow PRACTALL consensus for atopic dermatitis management in children
• Follow AAP/ACAAI/JCAAI guidelines for allergic rhinitis stepwise therapy
• Montelukast: FDA black box warning for neuropsychiatric events — discuss risk/benefit
• Palforzia (peanut OIT): FDA-approved ages 4-17; requires REMS program enrollment
• Omalizumab: FDA-approved for food allergy ages 1+ as of 2024
• Epinephrine is FIRST-LINE for anaphylaxis — antihistamines are adjunct only
• Component-resolved diagnostics (Ara h 2, Gal d 1, etc.): use to refine risk assessment when available
• Do not order "allergy panels" without clinical indication — panels generate false positives that lead to unnecessary restrictions
• This skill produces clinical documentation; it does not replace clinical judgment