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.

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.

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.