The following hierarchy of service adjustments could be considered:
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1)
Reschedule all food/drug challenges except for the following scenarios:
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a)
Milk, soy, or hydrolysate formula introduction in an infant in whom there is a critical nutritional need for this to be introduced to provide a caloric source, and there is a history prompting safety concerns such that this could not be introduced at home. Examples may include milk or soy FPIES or EoE cases or where either formula is being considered as the alternative source and there is strong parental preference to not change to elemental formula; concern for hydrolysate tolerance in a milk-allergic infant; or cases where there is highly suspected milk/soy allergy misdiagnosis that is resulting in such formula being withheld and there is an urgency for directly supervised reintroduction. Elemental formulas could also be empirically considered.
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b)
Other critical essential grains/nutrients in an infant that have been unnecessarily withheld because of suspected misdiagnosis and there is an urgency for directly supervised reintroduction secondary to nutritional concern.
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c)
Introduction of a common essential nutrient/food in a noninfant with widespread avoidance and there is an urgency for directly supervised reintroduction, such as a G-tube–fed child where a change from an elemental to other nutrient-based food is necessary due to nutritional concern.
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d)
Critical concern that peanut has been withheld unnecessarily in a high-risk infant for the purposes of early introduction, and supervised introduction is needed because of previously identified peanut sensitization.
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e)
Drug allergy patient where there is an urgent or critical need for drug allergy delabeling, challenge, or desensitization.
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f)
Vaccine challenge in any immunocompromised individual.
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g)
This would imply that, until pandemic response measures are removed, the following challenges are considered elective and be deferred (or in some instances considered for telehealth):
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All baked milk or egg challenges.
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Elective early allergen introduction in any non–high-risk infant (consider telehealth).
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Introduction of peanut, tree nut, or seed where the child is sensitized to 1 or more of these items, but has not ever ingested these previously, and testing was motivated by known/suspected allergy to another tree nut or seed and the item was previously withheld or not introduced. This infers that any challenges to confirm tolerance for cross-reactivity will be deferred in the interim.
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Reintroduction of noncritical nutrients in children tested for food allergy secondary to eczema, where the food has been avoided for more than 2 y, starting in infancy (consider telehealth).
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Reintroduction of foods being avoided for EoE (consider telehealth).
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Routine reintroduction to establish tolerance for outgrown IgE-mediated food allergy or FPIES.
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Evaluation of children referred with food sensitization drawn as a panel and/or in the absence of a specific history suggesting symptomatic ingestion, including testing done for the evaluation of atopic dermatitis (consider telehealth).
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Nonemergent drug challenges for the purposes of delabeling where there is no immediate plan for administration in the next 30 d.
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Vaccine challenges in any immunocompetent individual.
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2)
We recommend suspending the routine advice on allergy action plans to seek emergency care/call 911 after epinephrine use, unless symptoms do not immediately resolve without recurrence after a single dose of epinephrine.51
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3)
The following should be strongly considered with regard to routine allergy visits:
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a)
Postpone any return visits where the patient has been seen within the previous 12-18 mo and there has been no interim history of reaction or suspicion of new food allergy (consider telehealth).
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b)
Postpone any new patient visit not involving suspected IgE-mediated allergy to the common 8 foods plus seed or FPIES or any EoE visits for the purposes of dietary elimination testing (could defer to GI guidance about the need for new or routine endoscopic evaluation of possible EoE, but suggest that this be postponed; consider telehealth).
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c)
Postpone any face-to-face new or return patient visit for suspected allergic proctocolitis (consider telehealth).
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d)
Postpone any new or return drug/vaccine reaction visits or evaluations where re-administration is not anticipated in the next 6 mo (consider telehealth).
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e)
Postpone any second opinion or transfer of care where the patient has or has had another allergist, or visits from out-of-region patients (consider telehealth).
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f)
Postpone new-onset, nonrecurrent idiopathic anaphylaxis evaluations (consider telehealth). Recurrent idiopathic anaphylaxis should be prioritized to telehealth or face-to-face evaluation.
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4)
Defer initiation and updosing of any food immunotherapy treatment. All patients should be held at their current dose until normal services resume.
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5)
Defer new and follow-up evaluations for food allergy, anaphylaxis, or EoE study visits, and discontinue all interim research visits (consider telehealth).
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