By reading food labels and being careful, many teens with food allergies can go years without having an allergic reaction. However, studies have shown that some will grow complacent about food allergy risks. They may even become lax about carrying their epinephrine. Or some may be needle-phobic and not inclined to use an auto-injector when symptoms warrant it.
Allergic Living editor Gwen Smith checks in with Dr. Michael Pistiner, director of food allergy advocacy, education and prevention for the Mass General Brigham Children’s Food Allergy Center. He offers actionable recommendations for helping the allergic teen grasp why it’s critical to always be ready with epinephrine. He also covers how to reinforce allergy management skills.
If a parent suspects their food allergic teen is not always carrying their epinephrine devices, what’s the best way to instill compliance?
Dr. Pistiner: With adolescents who have been managing a food allergy since they were young children, ideally they will have begun to learn self-management strategies since the time of diagnosis. Such strategies need to be appropriate to the child’s age and stage. As children get older, they can start taking on more responsibility.
Emergency preparedness is one of the pillars of food allergy management and is important at all times and in all circumstances. Key to emergency preparedness is the availability of epinephrine and a person who can recognize a potentially severe allergic reaction and treat promptly.
By the teen years, it’s important to educate and work with them to establish patterns and get comfortable with emergency preparedness. Work with your teen and help them to problem-solve and how to always have their epinephrine available.
Aim for a practical approach, one that they can take ownership of. It’s a good idea to refer to it as “your” emergency plan. The teen needs to own it.
Some teens have told Allergic Living they’ve become resistant to carrying epinephrine since they haven’t had a reaction in years.
Dr. Pistiner: In some cases it may have been a long while since an allergic reaction. For some teens, they may have no recollection of the allergic reaction.
However, this does not necessarily mean that the adolescent or teen has outgrown their food allergy. It would be an ideal time to check in with their allergy team to consider reevaluation and discuss the current food allergy management strategies. This is also a great time for the allergy team to reinforce self-management strategies and emergency preparedness.
What can parents do?
Dr. Pistiner: Have open-ended conversations with the teen to better understand what they perceive as barriers to carrying their epinephrine. This helps parents to “partner” with their teens. Together they can problem-solve to come up with practical solutions that align with the teen’s priorities.
As an adolescent increasingly moves throughout their day without you, their friends and peers can provide additional support. Sharing their feelings and food allergy management strategies with their friends may help to create an allergy “buddy system,” and again help them to take ownership of allergy readiness.
Would you suggest having a teen who’s particularly reluctant to carry epinephrine speak to the allergist?
Dr. Pistiner: When parenting a teenager, the push and pull sometimes is inevitable. Having direct conversations with the allergy team and hearing the clinician’s perspective on allergy management and why epinephrine is effective when used promptly can help. This conversation can also take a bit of the pressure off the parents.
Some teens and tweens expressed fear about the auto-injector’s needle. How do you get through that it’s not really that painful or scary to use?
Dr. Pistiner: I find at our clinic that teens are often surprised to learn that the needle length of an adult dose epinephrine auto-injector is only 3/4 inch, shorter than the width of a dime. The thickness and length of the auto-injector needle is significantly shorter and thinner than the needle that is traditionally used for flu shots, which can cause very little, if any, pain.
For those tweens or teens who still struggle with the idea of self-administering their auto-injector, speak to the allergy team about getting support to address any needle fear, while also considering emerging needle-free alternatives.
Epinephrine is the drug of choice to treat a serious allergic reaction. Ensure they grasp that epinephrine is a safe medicine and it works fast. Prompt treatment may help to keep a reaction from progressing and will also make someone feel better quickly.
When doctors in the past told people to call 911 after treating with epinephrine it wasn’t because epinephrine was given. It was because it was a serious enough reaction to necessitate epinephrine and, if the epinephrine does not take care of the reaction completely, then the ambulance has oxygen IV fluid, likely more epinephrine, other medication and trained personnel.
New guidelines have been released that lay out circumstances when emergency medical services may not need to be contacted. And the guidelines encourage discussions about these circumstances with the healthcare team.
Any considerations with asthma?
Dr. Pistiner: Teens who have asthma in addition to food allergies need to be aware that a food-allergic reaction can cause coughing, wheezing and shortness of breath. If these symptoms are confused for an asthma exacerbation and albuterol is used in place of epinephrine, then anaphylaxis can progress without the appropriate treatment. Epinephrine is needed to treat respiratory symptoms caused by anaphylaxis.
Prior to the availability of albuterol inhalers, epinephrine was used to treat asthma exacerbations. If there is any confusion between a potential food allergic reaction and asthma exacerbation then treating with epinephrine will treat both.
Any last recommendations?
Dr. Pistiner: I find it useful to think and talk about food allergy management like automobile safety. When the children are very little, we teach them the basic safety rules like when you get in a car, put on your seatbelt. As the kids get older, they start increasing responsibility and ultimately will learn to drive alone.
Ideally, the transition into having a responsible and confident driver will be a gradual process over several years. Just like driving, food allergy management will involve collaborative learning between the teens and their parents.
Many of us who have taken our kids to those early drives on the road know that our personalities can sometimes clash. So those early learning experiences could be fraught. We also know there are certain things when we are teaching our kids to drive that we will never compromise on, and they should never compromise on. These include wearing a seat belt, not texting and driving, and following the speed limit. We can also teach our children similar strategies to think about when approaching their food allergy.
Helpful Resources:
American Academy of Allergy, Asthma and Immunology’s Food Allergy Stages Handouts.
In the book Allergies and Adolescents, Transitioning Towards Independent Living, see the chapter “Food Allergies and Teenagers, written by Dr. Pistiner and Dr. Nancy S. Rotter.
Article: Is Your Teen Taking Food Allergy Risks? Includes research on reasons for risk-taking and the influence of peers.
Dr. Michael Pistiner is a pediatric allergist-immunologist and the director of food allergy advocacy, education & prevention at the Mass General Brigham Children Food Allergy Center. He is also an assistant professor of pediatrics at Harvard Medical School. As well, he is the father of a 22-year-old with food allergies.
