Importance:The incidence and risk (predictive) factors for early life food allergy development remain uncertain. Objective:To estimate the incidence and quantify risk factors for food allergy development. Data Sources:MEDLINE and Embase were systematically searched to January 1, 2025. Data were analyzed from June 1, 2025, to November 25, 2025. Study Selection:Incidence estimates included studies confirming food allergy via food challenge. Risk factor analyses included cohort, case-control, and cross-sectional studies in any language assessing children younger than 6 years using multivariable analyses. Data Extraction and Synthesis:Paired reviewers independently extracted data. Random-effects meta-analyses pooled incidence and adjusted odds ratios (ORs). Risk of bias was assessed using the QUIPS tool, and certainty of evidence assessed using GRADE. Main Outcome and Measure:The primary outcome was food allergy to age 6 years. Results:A total of 190 studies involving 2.8 million participants across 40 countries were analyzed. Among studies using food challenge, overall food allergy incidence was likely 4.7% (moderate certainty). Among 176 studies identifying 342 risk factors with varying certainty, the strongest and most certain factors included prior allergic conditions (eg, atopic dermatitis [eczema] within the first year of life [OR, 3.88; risk difference [RD], 12.0%; 95% CI, 8.8%-15.7%], allergic rhinitis [OR, 3.39; RD, 10.1%; 95% CI, 6.7%-14.4%], and wheeze [OR, 2.11; RD, 5.0%; 95% CI, 2.1%-8.8%]), severity of atopic dermatitis (OR, 1.22; RD, 1.0%; 95% CI, 0.6%-1.6%), increased skin transepidermal water loss (OR, 3.36; RD, 10.0%; 95% CI, 6.3%-14.8%), filaggrin gene sequence variations (OR, 1.93; RD, 4.2%; 95% CI, 2.4%-6.4%), delayed solid food introduction (eg, peanut after age 12 months [OR, 2.55; RD, 6.8%; 95% CI, 1.9%-14.6%]), infant antibiotic use (first month [OR, 4.11; RD, 12.8%; 95% CI, 0.4%-40%], first year [OR, 1.39; RD, 1.8%; 95% CI, 0.8%-3.1%], during pregnancy [OR, 1.32; RD, 1.5%; 95% CI, 0.6%-2.5%]), male sex (OR, 1.24; RD, 1.1%; 95% CI, 0.7%-1.6%), firstborn child (OR, 1.13; RD, 0.6%; 95% CI, 0.3%-1.0%), family history of food allergy (eg, mother [OR, 1.98; RD, 4.4%; 95% CI, 2.5%-6.8%], father [OR, 1.69; RD, 3.2%; 95% CI, 1.3%-5.5%], both parents [OR, 2.07; RD, 4.8%; 95% CI, 1.3%-5.5%], siblings [OR, 2.36; RD, 6.0%; 95% CI, 4.4%-8.0%]), parental migration (OR, 3.28; RD, 9.7%; 95% CI, 4.9%-16.3%), self-identification as Black (vs White [OR, 3.93; RD, 12.1%; 95% CI, 5.2%-22.5%], vs non-Hispanic White [OR, 2.23; RD, 5.5%; 95% CI, 3.0%-8.7%]), and cesarean delivery (OR, 1.16; RD, 1.0%; 95% CI, 0.3%-1.2%). Factors like low birth weight, postterm birth, maternal diet, and stress during pregnancy showed no significant risk difference. Conclusions and Relevance:In this meta-analysis, the most credible risk factors associated with development of childhood food allergy are a combination of major and minor risk factors, including early allergic conditions (atopic march/diathesis), delayed allergen introduction, genetics, antibiotic exposure, demographic factors, and birth-related variables.

Oral immunotherapy (OIT) is effective for inducing desensitization to food allergens and continues to be investigated in many clinical trials, either alone or in combination with adjunct therapies. However, adverse events (AEs) such as gastrointestinal (GI) symptoms are common during OIT. These symptoms can pose a considerable management challenge for investigators adhering to clinical trial protocols with strict study windows where extended dosing interruptions are not feasible. GI symptom management practices in the previous clinical trials have usually been left to the discretion of each study site, resulting in a wide heterogeneity of management practices that could lead to substantial variability between sites. In the Omalizumab as a Monotherapy and as Adjunct Therapy to Multi-Allergen Oral Immunotherapy (OIT) in Food Allergic Children and Adults (OUtMATCH) randomized controlled clinical trial (NCT03881696) assessing omalizumab and multiallergen OIT, a critical need for a unified approach for managing GI AEs was identified. To address this need, a subcommittee comprising investigators, both allergists and gastroenterologists, within and outside of the Consortium of Food Allergy Research, developed a working definition for persistent GI AEs during OIT along with a management plan to be used within the ongoing OUtMATCH trial. We present here the definition and management plan, along with illustrative case-based scenarios encountered during the trial. Implementing a management plan for GI AEs during OIT clinical trials has the potential to create standardization, enhance symptom monitoring, improve outcome classification, allow for stratification of AEs related to GI symptoms, and improve safety outcomes for study participants.

Background: Self-injectable epinephrine (SIE) is the first line of defense against anaphylaxis, a potentially life-threatening allergic reaction commonly triggered by food. Internal medicine residents play a crucial role in managing food allergy and anaphylaxis, but knowledge and comfort in doing so may vary. Objective: The purpose of the study was to assess the efficacy of a brief educational intervention on improving internal residents’ preparedness to manage food allergies, specifically focusing on prescribing and counseling patients regarding SIE use. Methods: A survey assessing residents’ understanding and comfort was administered, followed by a presentation of a brief educational module and subsequent completion of a postintervention survey. Results: Thirty-four residents completed both the preintervention and postintervention surveys. Almost all participants reported improvement in their comfort levels for both prescribing and counseling patients on the use of SIE (P < .05). Pre-post knowledge improved from 83% to 97% (P = .02) regarding the correct location of epinephrine injection, and from 37% to 65% (P = .01) regarding appropriate scenarios for prescribing SIE. Ninety-four percent of participants rated the intervention as helpful. Conclusions: A brief educational module for internal medicine residents showed strong efficacy and participant satisfaction.

QuestionWhat are the risk factors associated with the development of food allergy in children?FindingsThis systematic review and meta-analysis of 2.8 million participants in 190 studies identified the following largest and most certain risk factors associated with the development of food allergies in children: prior allergic conditions (atopic march/diathesis), atopic dermatitis, increased skin transepidermal water loss, filaggrin gene sequence variations, delayed solid food introduction, infant and intrapartum antibiotic exposure, male sex, being first born, family history of allergy, parental migration, self-identification as Black, and cesarean delivery.MeaningThis systematic review and meta-analysis clarifies the major and minor risk factors associated with developing early-onset food allergy to inform optimal prevention clinical practice, policy, and research. ImportanceThe incidence and risk (predictive) factors for early life food allergy development remain uncertain.ObjectiveTo estimate the incidence and quantify risk factors for food allergy development.Data SourcesMEDLINE and Embase were systematically searched to January 1, 2025. Data were analyzed from June 1, 2025, to November 25, 2025.Study SelectionIncidence estimates included studies confirming food allergy via food challenge. Risk factor analyses included cohort, case-control, and cross-sectional studies in any language assessing children younger than 6 years using multivariable analyses.Data Extraction and SynthesisPaired reviewers independently extracted data. Random-effects meta-analyses pooled incidence and adjusted odds ratios (ORs). Risk of bias was assessed using the QUIPS tool, and certainty of evidence assessed using GRADE.Main Outcome and MeasureThe primary outcome was food allergy to age 6 years.ResultsA total of 190 studies involving 2.8 million participants across 40 countries were analyzed. Among studies using food challenge, overall food allergy incidence was likely 4.7% (moderate certainty). Among 176 studies identifying 342 risk factors with varying certainty, the strongest and most certain factors included prior allergic conditions (eg, atopic dermatitis [eczema] within the first year of life [OR, 3.88; risk difference [RD], 12.0%; 95% CI, 8.8%-15.7%], allergic rhinitis [OR, 3.39; RD, 10.1%; 95% CI, 6.7%-14.4%], and wheeze [OR, 2.11; RD, 5.0%; 95% CI, 2.1%-8.8%]), severity of atopic dermatitis (OR, 1.22; RD, 1.0%; 95% CI, 0.6%-1.6%), increased skin transepidermal water loss (OR, 3.36; RD, 10.0%; 95% CI, 6.3%-14.8%), filaggrin gene sequence variations (OR, 1.93; RD, 4.2%; 95% CI, 2.4%-6.4%), delayed solid food introduction (eg, peanut after age 12 months [OR, 2.55; RD, 6.8%; 95% CI, 1.9%-14.6%]), infant antibiotic use (first month [OR, 4.11; RD, 12.8%; 95% CI, 0.4%-40%], first year [OR, 1.39; RD, 1.8%; 95% CI, 0.8%-3.1%], during pregnancy [OR, 1.32; RD, 1.5%; 95% CI, 0.6%-2.5%]), male sex (OR, 1.24; RD, 1.1%; 95% CI, 0.7%-1.6%), firstborn child (OR, 1.13; RD, 0.6%; 95% CI, 0.3%-1.0%), family history of food allergy (eg, mother [OR, 1.98; RD, 4.4%; 95% CI, 2.5%-6.8%], father [OR, 1.69; RD, 3.2%; 95% CI, 1.3%-5.5%], both parents [OR, 2.07; RD, 4.8%; 95% CI, 1.3%-5.5%], siblings [OR, 2.36; RD, 6.0%; 95% CI, 4.4%-8.0%]), parental migration (OR, 3.28; RD, 9.7%; 95% CI, 4.9%-16.3%), self-identification as Black (vs White [OR, 3.93; RD, 12.1%; 95% CI, 5.2%-22.5%], vs non-Hispanic White [OR, 2.23; RD, 5.5%; 95% CI, 3.0%-8.7%]), and cesarean delivery (OR, 1.16; RD, 1.0%; 95% CI, 0.3%-1.2%). Factors like low birth weight, postterm birth, maternal diet, and stress during pregnancy showed no significant risk difference.Conclusions and RelevanceIn this meta-analysis, the most credible risk factors associated with development of childhood food allergy are a combination of major and minor risk factors, including early allergic conditions (atopic march/diathesis), delayed allergen introduction, genetics, antibiotic exposure, demographic factors, and birth-related variables. This systematic review and meta-analysis estimates the incidence of and quantifies risk factors for food allergy development in children.

Atopic dermatitis (AD) and food allergies are 2 atopic conditions that tend to develop early in life. Their interrelationship has been a topic of controversy and many studies. The presence of atopic dermatitis in infancy and early childhood, particularly if severe, is a risk factor for the development of immunoglobulin E (IgE) -mediated food allergies. While it is common for children with AD to demonstrate extensive sensitization to foods, serum IgE testing is not always indicative of clinical allergy.

BACKGROUND:Food allergy (FA)-related bullying is common, yet little is known about risk factors for FA-related bullying or the relationship between FA-related bullying and psychosocial wellbeing. This study aimed to (1) identify sociodemographic and clinical factors associated with risk of FA-related bullying in children with FA, and (2) evaluate the psychosocial functioning of children and parents reporting FA-related bullying. METHODS:This was a cross-sectional survey study of children ages 5-17 years with immunoglobulin E (IgE)-mediated FA and their parents, recruited from Boston Children's Hospital (BCH) and through social media outlets. Children and parents with versus without a history of FA-related bullying were compared on sociodemographic and clinical characteristics and FA-related psychosocial outcomes using validated instruments. RESULTS:In this cohort of 295 child-parent dyads, the median child age was 8.0 years, 53.2% of children were male, and parent respondents were primarily mothers (96.6%). Reported lifetime prevalence of FA-related bullying was 36.6%. FA-related bullying was associated with certain child characteristics, including coming from a household at risk of food insecurity (FI) (12.0% of bullied children v. 2.2% of not bullied children were from food insecure households, p < .001), having coexisting atopic and mental health conditions-particularly anxiety (30.6% of bullied children v. 8.6% of not bullied children carried an anxiety disorder diagnosis, p < .001)-and having a history of more severe FA reactions. FA-related bullying was associated with elevated concerns in child and parental FA-related psychosocial functioning domains. CONCLUSION:Pediatricians and allergists should screen for FA-related bullying and offer families appropriate guidance around management of FA-related bullying.

Background Approved therapeutics for peanut allergy are not designed for the many patients with allergic reactions to more than one peanut. Methods We randomly assigned (1:1) participants 4 to 14 years of age reacting to a challenge of between 443 mg and 5043 mg of peanut protein to peanut oral immunotherapy (P-OIT) using home-measured peanut butter versus peanut avoidance. The primary end point was the difference between groups in the proportion tolerating a two-dose-level increase or 9043 mg of peanut protein. For ingestion participants tolerating 9043 mg, sustained unresponsiveness (tolerance off treatment) was tested after 16 weeks of ad lib ingestion followed by 8 weeks of abstinence. Results Of 73 participants, 38 were randomly assigned to P-OIT and 35 to avoidance. Thirty-two of 38 participants in the ingestion group (84.2%) and 30 of 35 in the avoidance group (85.7%) underwent the primary outcome food challenge. The primary analysis with prespecified multiple imputation for missing values showed 100% success for ingestion versus 21.0% for avoidance (between-group difference, 79.0 percentage points; 95% confidence interval [CI], 64.6 to 93.5; P<0.001). All 32 treated and 3 out of 30 avoiders (10%) tolerated 9043 mg. In the intention-to-treat analysis, sustained unresponsiveness occurred in 68.4% (26/38) on P-OIT versus 8.6% (3/35) tolerating 9043 mg among those avoiding (between-group difference, 59.9 percentage points; 95% CI, 42.4 to 77.3). No dosing reactions were greater than grade 1 severity, and no serious adverse events were reported. Conclusions In this trial of P-OIT using store-bought, home-measured peanut versus peanut avoidance in high-threshold peanut allergy, those treated achieved significantly higher rates of desensitization with a durable response off treatment. (Funded by the National Center for Advancing Translational Sciences [UL1TR004419] and the National Institute of Allergy and Infectious [U19AI136053]; ClinicalTrials.gov number, NCT03907397.)

Clinical Implications Oral immunotherapy to sesame with crushed sesame seeds and tahini can be a safe and effective way to manage patients with sesame allergy. Our results suggest that it may help these patients achieve sustained unresponsiveness.

This clinical report updates and replaces a 2010 clinical report from the American Academy of Pediatrics that addressed food allergy management in schools. Food allergy affects up to 10% of children, and anaphylaxis is estimated to occur in 1 in 15 schools per year. School food allergy management requires strategies to reduce the risk of ingestion of the allergen as well as procedures to recognize and treat allergic reactions and anaphylaxis. The role of the pediatrician or pediatric primary care clinician may include diagnosing and documenting a potentially life-threatening food allergy; prescribing self-administered epinephrine to individual patients or for general use in a school (stock/unassigned epinephrine); educating children, parents, and school personnel on prevention, recognition, and management of allergic reactions to food; and working with schools in developing plans to reduce the risk of anaphylaxis and to implement emergency treatment in the event of a reaction. This clinical report highlights the role of the pediatrician and primary care clinician in managing students with food allergies.

Omalizumab was recently approved by the US Food and Drug Administration for treatment of any single food allergy or multiple food allergies in children aged 1 year and older and adults. There is currently no formal guidance regarding recommended best practices for omalizumab use in food allergy, including patient selection, anticipated goals and outcomes of therapy, procedure for monitoring patients who elect to start omalizumab therapy, and ways in which omalizumab can be incorporated into the landscape of food allergy management and daily clinical practice. This work group report was developed by the food allergy therapies subcommittee of the Adverse Reactions to Foods Committee within the American Academy of Allergy, Asthma & Immunology. Consensus, evidence-based guidance regarding experts’ recommendations for using omalizumab to treat children and adults with food allergy was developed by using modified Delphi methodology. In iterative fashion, a total of 8 statements regarding how to use omalizumab to treat patients with food allergy were developed by 16 clinical experts. This guidance provides the clinician with a suggested approach to patient selection, initiation of therapy, monitoring of efficacy, and long-term follow-up care. The role of preference-sensitive care is emphasized, with most statements offering care recommendations relevant to the culture and values of a particular practice setting.