NIAID

Guidelines for the Diagnosis 

and Management of Food 

Allergy in the United States 

Summary for Patients, Families, and Caregivers 

National Institute of Allergy and Infectious Diseases 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 

 

 

National Institute of Allergy and Infectious Diseases

Guidelines for the Diagnosis 

and Management of Food 

Allergy in the United States 

Summary for Patients, Families, and Caregivers 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 

National Institute of Allergy and Infectious Diseases 

NIH Publication No. 11-7699 

May 2011 

www.niaid.nih.gov 

 

CONTENTS 

Contents

4 

6 

9 

19 

25	 

29	 

30	 

Introduction 

Food Allergy, Prevalence, and Associated Disorders 

Diagnosis of Food Allergy 

Management of Nonacute Allergic Reactions and 

Prevention of Food Allergy 

Diagnosis and Management of Anaphylaxis 

Caused by Food 

Sample Anaphylaxis Emergency Action Plan 

Glossary* 

* Note: Words in blue throughout the text are defined in the glossary. 

NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

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NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES 

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INTRODUCTION 

 

Introduction

Most of us eat without a thought that something so essential to life might also 

harm us. But for people who are allergic to one or more foods, every mouthful 

can be a worry. Although allergic reactions to food can be mild, they also may 

be severe, leading to a life-threatening allergic reaction called anaphylaxis. 

The Guidelines for the Diagnosis and Management of Food Allergy in the 

United States: Report of the NIAID-Sponsored Expert Panel were written to 

provide healthcare professionals with the most up-to-date clinical advice on 

how to care for their patients with food allergy. 

How	were	the	Guidelines	developed?	 

The Guidelines are the culmination of a 2-year effort in which the 

National Institute of Allergy and Infectious Diseases (NIAID), part of the 

National Institutes of Health, worked with 34 professional organizations, 

federal agencies, and patient advocacy groups. A panel of experts from a 

variety of clinical backgrounds developed the Guidelines based on a review 

and evaluation of recent scientific publications about food allergy. 

The Guidelines are intended to help U.S. healthcare professionals make 

appropriate decisions about patient care; however, it is vital that patients, 

families, and caregivers understand what the Guidelines say about 

managing food allergy. 

What else you should know: The Guidelines are not an official regulatory 

document of any government agency. They are intended as a resource to guide 

clinical practice and to help develop educational materials for patients, their 

families and caregivers, and the public. They do not override your doctor’s 

responsibility to make decisions appropriate to your circumstances. 

If you want to read more about how the Guidelines were developed, visit 

NIAID’s food allergy guidelines Web site at http://www.niaid.nih.gov/topics/ 

foodallergy/clinical. 
NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

5 

INTRODUCTION 

What	do	the	Guidelines	tell	your	doctor?	 

The Guidelines include definitions of food allergy and related disorders, 

recommendations on how to diagnose and manage food allergy, and ways to 

diagnose and manage severe and life-threatening allergic reactions to food. 

What	does	this	booklet	tell	you?	 

This booklet summarizes the most important information from the Guidelines 

and provides a starting point for patient-doctor conversations about food 

allergy. We hope that this information will empower patients, families, and 

caregivers with the knowledge they need to manage the disorder and, in turn, 

experience a better quality of life. 

There are 43 guidelines, and each includes the word “recommends” or 

“suggests.” These words convey the strength of the guideline, defined as 

follows: 

• Recommend is used when the expert panel strongly recommended for 

or against a particular course of action. 

• Suggest is used when the expert panel recommended weakly for or 

against a particular course of action. The reason for this was usually 

the lack of strong evidence to support a recommendation. 

What	the	Guidelines	do	not	do 

The Guidelines do not discuss celiac disease because there are existing 

clinical guidelines for celiac disease. The Guidelines also do not address 

the management of people with food allergy outside of clinical care 

settings (for example, in schools and restaurants) or the related public 

health policy issues (for example, laws about food processing or food 

handling). 
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FOOD ALLERGY, PREVALENCE, AND ASSOCIATED DISORDERS 

Food Allergy, Prevalence, and 

Associated Disorders 

What	is	food	allergy? 

A food allergy is an adverse health effect arising from a specific immune 

response that occurs reproducibly on exposure to a given food. 

Food allergens are the parts of food or ingredients within food (usually 

proteins) that are recognized by immune cells. When an immune cell binds to 

a food allergen, a reaction occurs that causes the symptoms of food allergy. 

What else you should know: Most food allergens cause reactions even after 

they have been cooked or digested. Some allergens, most often from fruits and 

vegetables, cause allergic reactions only when eaten raw. Food oils, such as 

soy, corn, peanut, and sesame, may or may not be allergenic (causing allergy), 

depending on how they are processed. 

“Allergy” and “allergic disease” refer to conditions that involve changes to 

your immune system. These immune system changes fall into two categories: 

• Immunoglobulin E (IgE) mediated—the symptoms are the result of 

interaction between the allergen and a type of antibody known as IgE, 

which is thought to play a major role in allergic reactions 

• Non-IgE-mediated—the symptoms are the result of interaction of the 

allergen with the immune system, but the interaction does not involve an 

IgE antibody 

If you are sensitized to a food allergen, it means that your body has made 

a specific IgE (sIgE) antibody to that food allergen, but you may or may not 

have symptoms of food allergy. 

If you can consistently tolerate a food that once caused you to have an allergic 

reaction, you have outgrown the food allergy. 

Food intolerances are adverse health effects caused by foods. They do not 

involve the immune system. For example, if you are lactose intolerant, you 

are missing the enzyme that breaks down lactose, a sugar found in milk. 
NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

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FOOD ALLERGY, PREVALENCE, AND ASSOCIATED DISORDERS 

How	common	is	food	allergy? 

A 2007 survey conducted by the Centers for Disease Control and Prevention 

estimated that food allergy affects 5 percent of children under the age of 5 and 

4 percent of children aged 5 to 17 years and adults in the United States. 

There are eight major food allergens in the United States—milk, egg, peanut, 

tree nuts, soy, wheat, fish, and crustacean shellfish. 

Prevalence rates in the United States for some of these food allergens are 

provided below: 

• Peanut: 0.6 percent 

• Tree nuts: 0.4–0.5 percent 

• Fish: 0.2 percent in children and 0.5 percent in adults 

• Crustacean shellfish (crab, crayfish, lobster, shrimp): 0.5 percent in children 

and 2.5 percent in adults 

• All seafood: 0.6 percent in children and 2.8 percent in adults 

• Milk and egg: no reliable data available from U.S. studies, but based on data 

obtained outside the United States, this rate is likely to be 1–2 percent for 

young children 

Can	food	allergy	be	outgrown? 

Most children eventually outgrow milk, egg, soy, and wheat allergy. Fewer 

children outgrow peanut and tree nuts allergy. Outgrowing a childhood allergy 

may occur as late as the teenage years. 

For many children, sIgE antibodies can be detected within the first 2 years of 

life. A child with a high initial level of sIgE, along with clinical symptoms of 

food allergy, is less likely to outgrow the allergy. A decrease in sIgE antibodies 

is often associated with outgrowing the allergy. 

Food allergy also can begin in adulthood. Late-developing food allergy tends 

to persist. 

What	other	conditions	can	occur	with	food	allergy? 

If someone has food allergy, he or she is more likely to have asthma, eczema, 

eosinophilic esophagitis (EoE), or exercise-induced anaphylaxis. 
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FOOD ALLERGY, PREVALENCE, AND ASSOCIATED DISORDERS 

What	are	risk	factors	for	severe	allergic	reactions	to	foods? 

The severity of allergic reactions to foods is based on many different factors, 

including how much you ate and whether the food was cooked, raw, or 

processed. 

You cannot tell how severe your next allergic reaction will be based on the 

severity of your previous reactions. No available tests can predict how severe 

a future allergic reaction will be. 

You are more likely to have a severe allergic reaction to food if you also 

have asthma. 
NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

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DIAGNOSIS OF FOOD ALLERGY 

Diagnosis of Food Allergy 

When	should	your	healthcare	professional	suspect	food	allergy? 

Guideline 1 recommends that your healthcare professional should consider the 

diagnosis of food allergy 

• If you are experiencing anaphylaxis, a severe allergic reaction to food that 

involves more than one body system (for example, skin and respiratory tract 

and/or gastrointestinal (GI) tract). 

• If you are experiencing a combination of symptoms within minutes to 

hours after eating food and/or after eating a specific food on more than 

one occasion. See table A for a list of allergic symptoms caused by food. 

• If you have been diagnosed with EoE. 

• In an infant or child diagnosed with moderate to severe eczema, EoE, 

enterocolitis, enteropathy, or allergic proctocolitis. 

What else you should know: Food-allergic reactions may be IgE-mediated, 

non-IgE-mediated, or both. Your healthcare professional needs to identify the 

type of reaction so he or she can select the correct diagnostic test(s). 

Milk, egg, and peanut account for the vast majority of IgE-mediated reactions 

in young children, whereas peanut, tree nuts, and seafood (fish and crustacean 

shellfish) account for the vast majority of IgE-mediated reactions in teenagers 

and adults. The symptoms of an IgE-mediated food allergy almost always occur 

immediately after eating the food. However, an allergic reaction may not occur 

after exposure if a very small amount of the food is eaten or if the food, such as 

milk or egg, is extensively heated on the stovetop or baked in the oven. 

Reactions that are both IgE-mediated and non-IgE-mediated generally involve 

the GI tract. Disorders caused by these reactions do not get better quickly and 

are not closely associated with eating the food. An example of such a disorder 

is EoE. 
DIAGNOSIS OF FOOD ALLERGY 

TABLE	A.	 Symptoms	of	allergic	reactions	caused	by	food 

NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES 

Affected	part	of	the	body Immediate	symptoms Delayed	symptoms 

Skin Redness Same as immediate symptoms 

Itching plus 

hives 

Measles-like red bumps 

Swelling beneath the skin 

Rash similar to eczema and flushing 

Eyes Itching 

Tearing 

Redness 

Same as immediate symptoms 

Swelling around eyes 

Upper respiratory Nasal congestion 

Itching 

Runny nose 

Sneezing 

Swelling of the voicebox 

hoarseness 

— 

Dry cough 

Lower respiratory Cough Cough 

Chest tightness Shortness of breath 

Shortness of breath Wheezing 

Wheezing 

Visible signs of shortness of 

breath 

GI (oral) Swelling of the lips, tongue, or — 

palate 

Itching in the mouth 

GI (lower) Nausea Same as immediate symptoms 

Colicky abdominal pain plus 

Reflux Bloody stool, irritability, and food 

Vomiting refusal with weight loss (young 

Diarrhea children) 

Cardiovascular Rapid heartbeat (occasionally 

slow heartbeat in anaphylaxis) 

Low blood pressure 

Dizziness 

— 

Fainting 

Loss of consciousness 

Other Uterine contractions 

Sense of “impending doom” — 

GI, gastrointestinal. 

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NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

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DIAGNOSIS OF FOOD ALLERGY 

How	should	your	healthcare	professional	diagnose	IgE-mediated		 

food	allergy?	 

Your healthcare professional should use a medical history, physical 

examination, and appropriate tests to diagnose IgE-mediated food allergy. 

Medical	history	and	physical	examination 

Guideline 2 recommends that your healthcare professional use a medical 

history and physical examination to help in the diagnosis of food allergy; 

however, these alone are not sufficient to diagnose the disorder. 

• A detailed medical history often provides evidence for the type of allergic 

reaction caused by food and suggests which food(s) may be involved. 

• A physical examination may reveal signs that are consistent with an allergic 

reaction or a disorder that is associated with food allergy. 

Your healthcare professional should ask the following questions: 

• What are your symptoms? 

• What food causes your symptoms, and has this food caused these symptoms 

more than once? 

• How much of the food did you eat when the symptoms occurred? 

• Was the food cooked on the stovetop, baked in the oven, or raw? 

• How long after you were exposed to the food did your symptoms occur? 

• Have you ever eaten the food without these symptoms occurring? 

• Were other factors involved, such as exercise, alcohol, or use of aspirin or 

nonsteroidal anti-inflammatory drugs? 

• Have you had these symptoms other than after being exposed to the food? 

• What treatment did you receive, and how long did the symptoms last? 

Guideline 3 recommends that self-reports of presumed food allergy must be 

confirmed by a diagnosis from a healthcare professional. 
	 	 	 	 	 	 	 	 	 	 	 	

DIAGNOSIS OF FOOD ALLERGY 

NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES 

Why this is important: As many as 1 in 3 people think they have food allergy. 

However, when confirmed by a healthcare professional, only about 1 in 28 

people have food allergy (as distinct from food intolerance). Self-reporting of 

food allergy is unreliable and can lead you to avoid foods unnecessarily. This 

can affect your nutrition and quality of life. 

Tests	to	identify	foods	causing	your	allergic	reaction	involving	IgE 

If your healthcare professional suspects that you have an IgE-based food 

allergy, there are blood and skin tests that can identify the foods that may be 

causing your reaction. The results of these tests only show that you produce 

IgE antibodies to food allergens. Blood and skin tests alone cannot be used 

to diagnose food allergy. You do not have food allergy unless you also have 

clinical symptoms. 

Table B summarizes the value of various tests in identifying allergens and 

diagnosing food allergy involving IgE. 

TABLE B. Tests to identify food allergens and diagnose food allergy involving IgE 

Can	it	identify	a		 Can	it	diagnose		 

Test food	allergen? food	allergy? 

Skin prick/puncture test Yes No 

Intradermal testing Yes No 

(but test poses risk of adverse reactions) 

Total serum IgE No No 

Allergen-specific IgE in the Yes No 

serum 

Atopy patch test No No 

Combination of skin prick/ Yes No 

puncture test, sIgE test, and (but no advantage over 

atopy patch test skin prick/puncture test alone) 

Food elimination diet Yes Probably 

Oral food challenge Yes Yes 

(but test poses risk of adverse reactions) 

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NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

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DIAGNOSIS OF FOOD ALLERGY 

 

 

 

Skin prick/puncture test 

Guideline 4 recommends that your healthcare professional use a skin prick/ 

puncture test (SPT) to identify the food(s) that may be causing the IgEmediated food allergy. 

With an SPT, your healthcare professional uses a needle to place a tiny amount 

of food extract just below the surface of the skin on your lower arm or back. 

What else you should know: 

• SPTs are safe. 

• SPTs can identify foods against which you have made IgE antibodies. 

• The results of an SPT usually appear within 30 minutes. 

• A positive SPT result is a raised bump with redness around it, called a wheal 

and flare. This occurs when a food allergen reacts with its IgE antibody. 

• A positive SPT result does not mean that you are allergic to the food. A 

positive result shows that you have made IgE antibodies to the food. 

• Occasionally, even when the food allergy involves IgE, negative SPT results 

do occur. 

Intradermal test 

Guideline 5 recommends that your healthcare professional not use intradermal 

testing to diagnose food allergy. 

An intradermal test is performed by injecting a small amount of allergen into 

the skin. 

Why not use it? There is not enough clinical evidence to show that intradermal 

testing is more useful than an SPT to diagnose food allergy. You also are more 

likely to have an adverse reaction to an intradermal test, compared with an SPT. 

Total serum IgE 

Guideline 6 recommends that your healthcare professional not make a 

diagnosis based on the total amount of IgE antibodies in the serum (from a 

blood sample). 

Why not use it? There is not enough clinical evidence to show that measuring 

total serum IgE levels is sensitive or specific enough to diagnose food allergy. 
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DIAGNOSIS OF FOOD ALLERGY 

Allergen-specific IgE in the serum 

Guideline 7 recommends that your healthcare professional test for sIgE in the 

serum (from a blood sample) to identify foods that may be responsible for the 

food allergy. However, these tests by themselves do not diagnose food allergy. 

What else you should know: 

• Measuring sIgE levels can be useful in identifying possible food allergens. 

• Serum testing can be especially useful if SPTs cannot be done. For example, 

SPTs cannot be done when you have extensive dermatitis (inflammation of 

the skin) or when you need to take antihistamines. 

• The results of sIgE testing and SPTs do not always match up. 

• Undetectable sIgE levels occasionally occur in people with food allergy 

involving IgE. 

Atopy patch test 

Guideline 8 suggests that your healthcare professional not use an atopy patch 

test (APT) to assess noncontact food allergy. 

An APT is performed by placing a sticky patch on the skin of the upper back 

that releases a small amount of food allergen into the tissues beneath the skin. 

Why not use it? There is not enough clinical evidence to show that APTs are 

useful in determining whether you have noncontact food allergy. 

Use of skin prick/puncture tests, sIgE tests, and atopy patch tests in combination 

Guideline 9 suggests that your healthcare professional not use the combination 

of SPTs, sIgE tests, and APTs to diagnose food allergy. 

Why not use it? There is not enough clinical evidence to show that using 

SPTs, sIgE tests, and APTs in combination is better than using SPTs or sIgE 

tests alone. 

Food elimination diet 

Guideline 10 suggests that your healthcare professional eliminate specific foods 

from your diet to help diagnose food allergy. Food elimination may identify 

foods responsible for some non-IgE-mediated and some mixed IgE- and nonIgE-mediated food allergy disorders. 
NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

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DIAGNOSIS OF FOOD ALLERGY 

 

 

 

What else you should know: If your symptoms disappear when you 

eliminate a food from your diet, you may have food allergy. Your healthcare 

professional should perform additional tests to confirm the diagnosis. 

For non-IgE-mediated food allergy disorders, your medical history and the 

results of a food elimination diet may provide a diagnosis. 

Oral food challenge test 

Guideline 11 recommends that your healthcare professional use the oral 

food challenge test to diagnose food allergy. 

Note: Because an oral food challenge test always carries a risk, it must be 

performed by a healthcare professional trained in how to conduct this test 

and at a medical facility that has appropriate medicines and devices to 

treat potential severe allergic reactions. 

An oral food challenge test includes the following steps: 

• You are given doses of various foods, some of which are suspected of 

triggering an allergic reaction. 

• Initially, the dose of food is very small, but the amount is gradually 

increased during the challenge. 

• You swallow each dose. 

• You are watched to see whether a reaction occurs. 

There are three types of oral food challenge tests: 

• A double-blind placebo-controlled food challenge (DBPCFC) test is 

considered the best one. In this test, the patient receives increasing 

doses of the suspected food allergen or a harmless substance (placebo). 

Neither the patient nor the healthcare professional knows which one 

the patient receives. 

• A single-blind food challenge is the next best option. In this test, the 

healthcare professional knows what the patient is receiving, but the 

patient does not. 

• An open-food challenge test may be sufficient to diagnose food allergy 

under certain circumstances. In this test, both the patient and the 

healthcare professional know whether a food allergen is received. 
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DIAGNOSIS OF FOOD ALLERGY 

 

 

 

If an oral food challenge test results in no symptoms, then food allergy can 

be ruled out. If the challenge results in symptoms and these symptoms are 

consistent with your medical history and laboratory tests, then a diagnosis of 

food allergy is confirmed. 

What else you should know: The DBPCFC is the most specific test for diagnosing 

food allergy, but it can be expensive and inconvenient. Your healthcare 

professional may consider using a single-blind or open-food challenge as an 

alternative. 

Nonstandardized and unproven tests 

Guideline 12 recommends that your healthcare professional avoid using tests 

not recommended in the Guidelines to diagnose food allergy involving IgE. 

See the full Guidelines at http://www.niaid.nih.gov/topics/foodallergy/clinical 

for a list of these tests. 

How	should	your	healthcare	professional	diagnose	non-IgE-mediated		 

food	allergy? 

The diagnosis of non-IgE-mediated food allergy can be challenging. A medical 

history and physical examination alone may not help your doctor distinguish 

between a food allergy that involves IgE and one that does not. 

The following are examples of disorders associated with food allergy that do 

not involve IgE: 

• Eosinophilic GI diseases (EGIDs), but one exception is EoE, which can be a 

mixture of IgE- and non-IgE-mediated 

• Food protein-induced enterocolitis syndrome (FPIES) 

• Food protein-induced allergic proctocolitis (AP) 

• Allergic contact dermatitis (ACD) 

• Systemic contact dermatitis 

Table C lists tests that your healthcare professional should use to evaluate food 

allergy that does not involve IgE. 
 

 

 

 

DIAGNOSIS OF FOOD ALLERGY 

TABLE	C.	Tests	to	diagnose	non-IgE-mediated	food	allergy 

Disorder	associated	with	 Can	the	test	diagnose	 

food	allergy Test food	allergy? 

Eosinophilic esophagitis Skin prick/puncture test No 

(an EGID that is a mixture sIgE test No 

of IgE and non-IgE) Atopy patch test No 

Food protein-induced enterocolitis Oral food challenge Yes 

syndrome Food elimination Yes 

Food protein-induced allergic Oral food challenge Yes 

proctocolitis Food elimination Yes 

Allergic contact dermatitis Atopy patch test Yes 

Food elimination Yes 

Systemic contact dermatitis Atopy patch test Yes 

Food elimination Yes 

EGID, eosinophilic gastrointestinal disease; sIgE, specific IgE. 

Eosinophilic	gastrointestinal	diseases 

Guideline 13 suggests that your healthcare professional consider using SPTs, 

sIgE tests, and APTs to identify foods associated with EoE. The role of these 

tests in the diagnosis of other EGIDs has not been established. 

What else you should know: Usually, a healthcare professional makes a 

diagnosis of an EGID after finding high levels of immune cells called eosinophils 

in a biopsy from the GI tract. The symptoms of these disorders depend on which 

part of the GI tract is involved and whether the accumulation of eosinophils is 

localized or widespread. EoE is one type of EGID. 

Food	protein-induced	enterocolitis	syndrome 

Guideline 14 recommends that your healthcare professional use a medical 

history and an oral food challenge test to diagnose FPIES. However, if the 

patient is an infant or child and the medical history includes episodes of 

low blood pressure or multiple reactions to the same food, the absence of 

symptoms while avoiding the food can confirm diagnosis. 

What else you should know: FPIES often lasts only a few years. A patient 

should be retested to confirm that FPIES has been outgrown. 

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DIAGNOSIS OF FOOD ALLERGY 

Food	protein-induced	allergic	proctocolitis 

Guideline 15 recommends that your healthcare professional use a medical 

history, the absence of symptoms while avoiding the causative food, and 

recurrence of symptoms following an oral food challenge to diagnose AP. 

What else you should know: AP usually ends between ages 1 and 2 years. 

A child should be retested to confirm that AP has been outgrown. 

Allergic	contact	dermatitis	 

Guideline 16 recommends that your healthcare professional use a medical 

history, the absence of symptoms while avoiding the causative food, and 

positive APTs to diagnose ACD. 

What else you should know: Positive APT reactions indicate the presence of 

sIgE antibodies, but there must be other clinical signs to support the diagnosis. 

Systemic	contact	dermatitis 

Guideline 17 suggests that your healthcare professional use a medical history, 

the absence of symptoms while avoiding the causative food, and positive APTs 

to diagnose systemic (whole-body) contact dermatitis. 

How	should	your	healthcare	professional	diagnose	contact	urticaria? 

Contact urticaria is a disease that comes in two forms, one that involves IgE 

and one that does not. 

Guideline 18 suggests that your healthcare professional use a medical history, 

the absence of symptoms while avoiding the causative food, positive sIgE 

tests or SPTs, and positive immediate responses to APTs to diagnose contact 

urticaria caused by food and involving IgE. 
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MANAGEMENT OF NONACUTE ALLERGIC REACTIONS AND PREVENTION OF FOOD ALLERGY 

 

Management of Nonacute Allergic Reactions 

and Prevention of Food Allergy 

How	should	food	allergy	be	managed? 

Guidelines 19 through 21 recommend that if you have been diagnosed with 

IgE-mediated food allergy, non-IgE-mediated food allergy, or food allergy 

in combination with eczema, asthma, or EoE, you should avoid the 

allergenic food. 

What else you should know: Not eating the allergenic food is currently the 

safest way to manage food allergy and prevent symptoms. Your healthcare 

professional should work with you to decide whether certain related foods 

also should be avoided. 

Guideline 22 recommends that if you have eczema, asthma, or EoE and you 

have not been diagnosed with food allergy, you should not avoid foods that 

may be allergenic as a way to manage your eczema, asthma, or EoE. 

What else you should know: There is no evidence that avoiding allergenic foods 

reduces the severity of eczema, asthma, or EoE if you do not have food allergy. 

Guideline 23 recommends that children diagnosed with food allergy receive 

nutritional counseling and regular growth monitoring. 

Guideline 24 suggests that if you have food allergy, you should receive training 

on how to understand ingredient lists on food labels and avoid products with 

warning labels such as “this product may contain trace amounts of allergen” or 

“made in a facility where allergen-containing products are made.” 

What else you should know: The U.S. Food Allergen Labeling and Consumer 

Protection Act of 2004 requires food labels to list which of the eight major 

food allergens (milk, egg, peanut, tree nuts, soy, wheat, fish, and crustacean 

shellfish) are present as ingredients in prepared foods. 

However, the law does not require or suggest wording for warning labels, such 

as “may contain trace amounts of nuts” or “may be prepared in a facility that 

also uses nuts.” The inclusion of these warning labels is voluntary. 
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MANAGEMENT OF NONACUTE ALLERGIC REACTIONS AND PREVENTION OF FOOD ALLERGY 

Guideline 25 suggests that individuals with food allergy should receive 

follow-up testing. 

What else you should know: Some children outgrow their food allergies. 

Follow-up testing can help you and your healthcare professional decide 

whether it is safe to introduce certain foods into the child’s diet. 

Are	medications	available	to	prevent	and	treat	allergic	reactions		 

caused	by	foods? 

Guidelines 26 and 27 state that there are no medications available to prevent 

IgE- or non-IgE-mediated food allergy. 

What else you should know: Drugs are available that may prevent or decrease 

allergic reactions to foods. However, they have side effects and in some cases 

can increase your risk of infection. 

Guidelines 28 and 29 recommend that your healthcare professional not 

use allergen-specific immunotherapy or immunotherapy with cross-reactive 

allergens to treat food allergy involving IgE. 

Why not use them? The safety of immunotherapy is uncertain. Early studies 

of allergen-specific immunotherapy have had promising results, but the 

therapeutic effect and duration of benefit have not been proven. There has 

been little study of immunotherapy with cross-reactive allergens. 

If you would like to participate in clinical trials of immunotherapy, you can 

find more information at http://www.clinicaltrials.gov. 

Guideline 30 recommends that you should receive education and information 

on how to avoid food allergens and how to develop an emergency management 

plan that is age and culturally appropriate. 

What	are	the	recommendations	for	vaccines	for	patients	with	egg	allergy? 

Several vaccines are made using chicken eggs. These vaccines contain varying 

amounts of egg protein. Although these egg-based vaccines contain very low 

amounts of egg protein, people with a medical history of anaphylaxis to egg 

may be at risk if injected with these vaccines. People without a history of 

anaphylaxis should talk with their healthcare professional to discuss whether 

they can safely receive egg-based vaccines.1 

1 This information differs slightly from the Guidelines and reflects more up-to-date guidance about egg-based vaccines. 
	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	

MANAGEMENT OF NONACUTE ALLERGIC REACTIONS AND PREVENTION OF FOOD ALLERGY 

The Advisory Committee on Immunization Practices (ACIP), the American 

Academy of Pediatrics (AAP) Red Book, and vaccine manufacturer’s package 

inserts (PIs) provide recommendations for giving vaccines to patients with 

egg allergy (summarized in table D). The recommendations are based on 

the amount of egg protein in the vaccine and the patient’s history of allergic 

reactions. 

TABLE D. 2010 ACIP and AAP Red Book recommendations and PI information	 

for administering vaccines to patients with egg allergy 

Vaccine ACIP AAP	Red	Book PI 

Measles, mumps, May be used May be used May be used with 

rubella/measles, caution 

mumps, rubella, 

and varicella 

Influenza Consult a physician Contraindicated Contraindicated 

Rabies Use caution No specific May be used with 

recommendation caution 

Yellow fever Contraindicated, but Contraindicated, but Skin testing and 

desensitization protocols desensitization protocols desensitization protocols 

may be used to give the may be used to give the provided in the PI 

vaccine if necessary vaccine if necessary 

AAP, American Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices; PI, package insert. 

In some cases, your healthcare professional may choose to use a desensitization 

protocol, a method that involves administering a single dose of vaccine in two 

or more portions to reduce the potential risk of an allergic reaction. 

Guideline 31 recommends that children with egg allergy, even those with a 

history of severe reactions, receive vaccines for measles, mumps, and rubella 

(MMR) and for MMR with varicella (MMRV). 

What else you should know: MMR and MMRV vaccines are safe because the 

egg protein content of these vaccines is very low. 

NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

21 
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MANAGEMENT OF NONACUTE ALLERGIC REACTIONS AND PREVENTION OF FOOD ALLERGY 

Influenza	vaccine 

Currently, there is not enough clinical evidence to recommend that a patient 

with a history of severe allergic reactions to egg protein receive the influenza 

vaccine. Severe allergic reactions include a history of hives, angioedema, 

asthma, or anaphylaxis. 

This statement applies to influenza vaccines that are inactivated (made from 

viruses that are dead so they cannot cause disease) or live-attenuated (made 

from viruses that are alive but weakened so they cannot cause disease). 

You should talk with your healthcare professional if you have egg allergy and 

are thinking about getting the influenza vaccine. 

Rabies	and	yellow	fever	vaccines 

The Guidelines recommend against receiving yellow fever or rabies vaccines if 

you have a history of severe allergic reactions to egg proteins, unless you first 

undergo allergy evaluation and testing with the vaccine. The ACIP and AAP 

recommend this approach, which also is approved by the vaccine manufacturer. 

What else you should know: The Imovax rabies vaccine does not contain egg 

protein and is safe for people with egg allergy. No data are available on the 

amount of egg protein in other rabies vaccines or the yellow fever vaccine. The 

concentration may not be low enough to be safe for patients with egg allergy. 

Your healthcare professional can evaluate you to see whether you are allergic 

to the vaccine. Based on the results, you and your healthcare professional can 

decide whether it is safe to receive the vaccine. 

Can	avoiding	nonfood	allergens	and	cross-reactive	food	allergens	prevent		 

food	allergy	from	developing? 

Guidelines 32 and 33 suggest that if you are at risk for developing food 

allergy, you should not limit exposure to nonfood allergens (for example, dust 

mites, pollen, or pet dander) or to foods that may be cross-reactive with the 

eight major food allergens (milk, egg, peanut, tree nuts, soy, wheat, fish, and 

crustacean shellfish). 

What else you should know: A person at risk for developing food allergy has 

a biological parent or sibling with existing hay fever, asthma, eczema, or food 

allergy, or a history of any of these. There is not enough evidence to suggest 

that avoiding nonfood allergens has any effect on the development of food 
NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

23 

MANAGEMENT OF NONACUTE ALLERGIC REACTIONS AND PREVENTION OF FOOD ALLERGY 

allergy or that foods that cross-react with the major allergenic foods will 

cause allergic symptoms. Avoiding foods unnecessarily could put you at risk 

for inadequate nutrition. 

Should	a	child	at	high	risk	for	food	allergy	be	tested	prior	to	introducing	 

highly	allergenic	foods	into	the	diet?	 

The Guidelines state that there is not enough evidence to recommend routine 

food allergy testing before introducing highly allergenic foods (such as milk, 

egg, and peanut) to children who are at a high risk of reacting to these foods. 

Children at high risk are those who already have severe allergic disease or a 

family history of food allergy. 

Should	a	child	with	no	preexisting	severe	allergic	disease	and	no	family	 

history	of	food	allergy	be	tested	prior	to	introducing	highly	allergenic	foods	 

into	the	diet?	 

Guideline 34 suggests that a child with no preexisting severe allergic disease 

and no family history of food allergy should not be tested for food allergy 

before highly allergenic foods are introduced into the diet. 

Why not? There is insufficient evidence to suggest any benefit to testing for 

food allergy in children who have no symptoms or risk factors. 

Should	a	child	with	eczema	be	tested	for	food	allergy? 

Guideline 35 suggests that a healthcare professional should consider evaluating 

a child for milk, egg, peanut, wheat, and soy allergy if the child is younger 

than 5 years old and has eczema that does not go away with treatment, or has 

eczema and a history of allergic reactions to a specific food. 

What else you should know: Children with moderate to severe eczema are 

at risk for developing food allergy, especially allergy to milk, egg, and peanut. 

These children may benefit from a food allergy evaluation. 

Can	food	allergy	be	prevented? 

Guideline 36 recommends that a mother not restrict her diet during 

pregnancy or when breastfeeding as a way to prevent food allergy from 

developing in her child. 
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MANAGEMENT OF NONACUTE ALLERGIC REACTIONS AND PREVENTION OF FOOD ALLERGY 

 

 

 

What else you should know: There is no evidence to suggest that restricting a 

mother’s diet while she is pregnant or breastfeeding prevents the development 

of food allergy in her child. 

Guideline 37 recommends that a mother exclusively breastfeed her infant until 

age 4 to 6 months, unless breastfeeding is not advised for medical reasons. 

What else you should know: There is no strong evidence that breastfeeding 

increases the likelihood that an infant will develop food allergy. 

Guideline 38 does not recommend giving an infant at risk for food allergy 

soy milk formula instead of cow’s milk formula to prevent food allergy from 

developing. 

What else you should know: There is neither long-term harm nor significant 

benefit in giving an infant soy milk formula. 

Guideline 39 suggests that parents and caregivers should consider using 

hydrolyzed infant formulas instead of cow’s milk formula to prevent food 

allergy from developing in children at risk for food allergy and who are not 

exclusively breast-fed. 

What else you should know: Only a limited number of studies, with varying 

results, have examined whether the use of hydrolyzed infant formulas can 

prevent food allergy. 

Guideline 40 suggests that you should not delay introducing solid foods, 

including potentially allergenic foods, to an infant beyond 4 to 6 months 

of age. 

What else you should know: There is no evidence that supports delaying 

the introduction of solid foods to an infant beyond 4 to 6 months of age to 

prevent allergic diseases from developing. This includes giving an infant a 

food containing milk, eggs, peanut, tree nuts, soy, or wheat.2 

2 healthcare professionals generally advise that no infant or young child should be given whole or pieces of peanuts or tree nuts 

because of the risk of choking. This is an important safety consideration. This information is not found in the Guidelines and 

was not considered by the expert panel. Please check with your healthcare professional for specific guidance. 
NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

25 

DIAGNOSIS AND MANAGEMENT OF ANAPhYLAxIS CAUSED BY FOOD 

Diagnosis and Management of Anaphylaxis 

Caused by Food 

What	should	your	healthcare	professional	understand	when	diagnosing	 

anaphylaxis	caused	by	food? 

Guideline 41 recommends that a healthcare professional diagnosing a patient 

with anaphylaxis should understand the following: 

• Signs and symptoms of anaphylaxis 

• Timing of symptoms in relation to exposure to the allergenic food 

• Conditions such as asthma that may be associated with food allergy 

and how these conditions may affect treatment 

• The limited value of laboratory tests during an anaphylactic episode 

What else you should know: If you are experiencing symptoms of anaphylaxis, 

seek immediate treatment and tell your healthcare professional if you have a 

history of allergic reactions to food or have been previously diagnosed with 

food allergy. 

The	symptoms	of	anaphylaxis 

The symptoms of anaphylaxis vary and can be difficult to recognize. If you 

experience any one of the following three conditions, you may be experiencing 

an anaphylactic episode: 

• Your symptoms appear within minutes to several hours and involve skin, 

mucosal tissue (moist lining of the body cavities, such as the nose, mouth, 

and GI tract), or both. You also have trouble breathing or a drop in blood 

pressure (pale, weak pulse, confusion, loss of consciousness). 

• You have two or more of the following symptoms that occur within 

minutes to several hours after exposure to a suspected allergenic food: 

– Hives, itchiness, or redness all over your body and swelling of the 

lips, tongue, or the back of the throat 

– Trouble breathing 
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DIAGNOSIS AND MANAGEMENT OF ANAPhYLAxIS CAUSED bY FOOD 

– Drop in blood pressure 

– GI symptoms such as abdominal cramps or vomiting 

• Your blood pressure drops, leading to weakness or fainting, within minutes 

to several hours after exposure to a food to which you know you have an 

allergy. 

Timing	of	anaphylaxis 

An anaphylactic reaction can occur as: 

• A single reaction that occurs immediately after exposure to the allergenic 

food and gets better with or without treatment within the first minutes to 

hours. Symptoms do not recur later in relation to that episode. 

• Two reactions. The first reaction includes an initial set of symptoms that 

seem to improve and go away but then reappear. The second reaction can 

occur between 8 and 72 hours after the first reaction. 

• A single, long-lasting reaction that continues for hours or days following 

the initial reaction. 

What else you should know: The delayed use of the drug epinephrine has been 

associated with deaths due to anaphylaxis. Most of these cases are allergic 

reactions to peanut or tree nuts. 

Diseases such as asthma, chronic lung disease, and cardiovascular disease may 

increase the risk of death from anaphylaxis. Medications such as those that 

treat high blood pressure also may affect symptom severity and response to 

treatment. 

There are no useful laboratory tests to perform when a patient is experiencing 

an anaphylactic reaction. After the patient has been successfully treated, 

laboratory testing may suggest what foods caused the reaction. An oral food 

challenge test can then be done to confirm the diagnosis of food allergy. 

How	should	anaphylaxis	be	treated? 

Guideline 42 recommends treating anaphylaxis immediately after symptoms 

begin with an intramuscular (IM) injection of epinephrine. 
NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

27 

DIAGNOSIS AND MANAGEMENT OF ANAPhYLAxIS CAUSED bY FOOD 

After epinephrine has been given, the patient may be placed in a reclining 

position to help restore normal blood flow. A healthcare professional also 

may give the patient any of the following secondary treatments: 

• Medications to help the patient breathe 

• Antihistamines to relieve itching and hives 

• Corticosteroids to prevent pain, swelling, and redness 

• Medications to help restore normal blood pressure and maintain a normal 

heart rate 

• Supplemental oxygen therapy 

• Intravenous (IV) fluids 

What else you should know: Epinephrine should be given immediately to treat 

anaphylaxis. Delays in giving epinephrine to patients can result in rapid decline 

and death within 30 to 60 minutes. Epinephrine acts immediately, but it may be 

necessary to give repeat doses. 

If you or someone you know is having an anaphylactic episode, health 

experts advise that you do the following as quickly as you can: 

• Remove the allergenic food from the mouth or skin. 

• If an auto-injector is available, inject epinephrine into the thigh muscle. 

• Call 9-1-1 if you are not in a hospital, or summon a resuscitation team 

in the hospital. 

When medical help arrives, the patient should be placed lying down, if 

possible, with the legs raised and given oxygen and IV fluid. 

What else you should know: Antihistamines should only be used as a 

secondary treatment. Giving antihistamines instead of epinephrine may place 

you at significantly increased risk for a life-threatening allergic reaction. 

How	should	anaphylaxis	caused	by	food	be	managed? 

Guideline 43 recommends that a healthcare professional should assist patients 

experiencing anaphylaxis by immediately giving IM epinephrine and then 

transferring the patient to an emergency facility. The healthcare professional 
NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES 

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DIAGNOSIS AND MANAGEMENT OF ANAPhYLAxIS CAUSED BY FOOD 

should observe the patient for 4 to 6 hours or longer and oversee any further 

necessary treatment. 

Before leaving emergency medical care, your healthcare professional should 

provide the following: 

• An epinephrine auto-injector or a prescription for two doses and training 

on how to use the auto-injector 

• A follow-up appointment or an appointment with a clinical specialist such 

as an allergist/immunologist 

• Information on where to get medical identification jewelry or an 

anaphylaxis wallet card that alerts others of the food allergy 

• Education about allergen avoidance, recognizing the symptoms of 

anaphylaxis, and giving IM epinephrine 

• An anaphylaxis emergency action plan (see sample plan on the next page) 

What else you should know: 

• Always carry your epinephrine auto-injector and know how to use it 

• Know how to properly store your auto-injector, make sure the color of the 

liquid within the injector remains clear (discard if not clear), and know 

when it expires (usually after 1 year) 

• Instruct family and friends on how to use the auto-injector for times when 

you are unable to inject yourself 
NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

29 

SAMPLE ANAPhYLAxIS EMERGENCY ACTION PLAN 

❏ Yes	(high	risk	for	severe	reaction) 							 ❏

_______________________________________________________________________________ 

____________________________________ _________________________________________ 

__________________

Sample Anaphylaxis Emergency Action Plan 

(Adapted From JACI Publications†) 

NAME: ______________________________________________________ AGE: ______________ 

ALLERGY	TO: ____________________________________________________________________ 

Asthma:	 No 

Other	health	problems	besides	anaphylaxis: ___________________________________________ 

Current	medications,	if	any: ________________________________________________________ 

Wear medical identification jewelry that identifies the anaphylaxis potential and the food allergen triggers. 

SYMPTOMS	OF	ANAPHYLAXIS	INCLUDE: 

• 

• 

• 

• 

• 

• 

MOUTh—itching, swelling of lips and/or tongue

ThROAT*—itching, tightness/closure, hoarseness

SKIN—itching, hives, redness, swelling

GUT—vomiting, diarrhea, cramps

LUNG*—shortness of breath, cough, wheeze

hEART*—weak pulse, dizziness, passing out

Only a few symptoms may be present. Severity of symptoms can change quickly.

* Some symptoms can be life-threatening! ACT	FAST! 

WHAT	TO	DO: 

1. INJECT EPINEPHRINE IN THIGH USING (check one): 

❏	 EpiPen Jr (0.15 mg) ❏	 Adrenaclick 0.15 mg 

❏	 EpiPen (0.3 mg) ❏	 Adrenaclick 0.30 mg 

Note: Patients should be allowed to self-carry and self-administer epinephrine. 

Other medication/dose/route: _________________________________________________________ 

IMPORTANT:	Asthma	inhalers	and/or	antihistamines	can’t	be	depended	on	in	anaphylaxis! 

2. CALL 9-1-1 or RESCUE SQUAD (before calling contacts)! 

3. EMERGENCY CONTACTS 

#1: home _________________ work__________________ cell__________________

#2: home _________________ work__________________ cell__________________

#3: home _________________ work__________________ cell

DO	NOT	HESITATE	TO	GIVE	EPINEPHRINE! 

COMMENTS: 

Doctor’s	Signature/Date	 Parent’s	Signature	(for	individuals	under	age	18	years)/Date 

†Adapted from J Allergy Clin Immunol 1998;102:173–176 and J Allergy Clin Immunol 2006;117:367–377. 
NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES 

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GLOSSARY 

Glossary

Allergen-specific immunotherapy is a type of treatment in which a patient 

is given increasing doses of an allergen—for example, milk, egg, or peanut 

allergen—with the goal of inducing immune tolerance (the ability of the 

immune system to ignore the presence of one or more food protein allergens 

while remaining responsive to unrelated proteins). 

Allergic contact dermatitis (ACD) is a form of eczema caused by an allergic 

reaction to food additives or molecules that occur naturally in foods such as 

mango. The allergic reaction involves immune cells but not IgE antibodies. 

Symptoms include itching, redness, swelling, and small raised areas on the 

skin that may or may not contain fluid. 

Allergic proctocolitis (AP) is a disorder that occurs in infants who seem healthy 

but have visible specks or streaks of blood mixed with mucus in their stool. 

Because there are no laboratory tests to diagnose food-induced AP, a healthcare 

professional must rely on a medical history showing that certain foods cause 

symptoms to occur. Many infants have AP while being breast-fed, probably 

because the mother’s milk contains food proteins from her diet that cause an 

allergic reaction in the infant. 

Anaphylaxis is a serious allergic reaction that involves more than one body 

system (for example, skin and respiratory tract and/or gastrointestinal tract), 

begins very rapidly, and may cause death. 

Angioedema is swelling due to fluid collecting under the skin, in the abdominal 

organs, or in the upper airway (nose, back of the throat, voicebox). It often 

occurs with hives and, if caused by food, is typically IgE-mediated. When the 

upper airway is involved, swelling in the voicebox is an emergency requiring 

immediate medical attention. Acute angioedema is a common feature of 

anaphylaxis. 

Contact urticaria (hives) occurs when the skin comes in contact with an 

allergen. The hives can be local or widespread. They are caused by antibodies 

interacting with allergen proteins or from the direct release of histamine, a 

molecule involved in allergy. 
NIAID I SUMMARY FOR PATIENTS, FAMILIES, AND CAREGIVERS 

31 

GLOSSARY 

Corticosteroids are a class of drugs similar to the natural hormone 

cortisone. These drugs are used to treat inflammatory diseases, such as 

allergies and asthma. 

Cross-reactive foods are foods that are seen as similar to allergenic foods by 

the immune system. An antibody that reacts with the allergenic food also reacts 

with the cross-reactive food. For example, a person who is allergic to shrimp 

also may be allergic to lobster, because shrimp and lobster are closely related 

foods. In this case, lobster would be a cross-reactive food. 

Eczema (atopic dermatitis, atopic eczema) is a disease of the skin. Symptoms 

include scaly, itchy rashes and blistering, weeping, or peeling of the skin. The 

causes of the disease are unclear. There may be a problem in the skin’s ability 

to maintain an effective barrier against environmental factors, such as irritants, 

microbes, and allergens. A person who has a biological parent or sibling with 

a history of allergy and eczema is at risk for developing food allergy. 

Enterocolitis is an inflammation of the colon and small intestine. 

Enteropathy is a disease of the intestine. 

Eosinophilic esophagitis (EoE) is a disorder associated with food allergy, 

but how it is related is unclear. It occurs when types of immune cells called 

eosinophils collect in the esophagus. Both IgE- and non-IgE-mediated 

mechanisms appear to be involved in EoE. 

Epinephrine (adrenaline) is a hormone that increases heart rate, tightens the 

blood vessels, and opens the airways. Epinephrine is the best treatment for 

anaphylaxis. 

Exercise-induced anaphylaxis is a type of severe, whole-body allergic reaction 

that occurs during physical activity. Food is the trigger in about one-third of 

patients who have experienced exercise-induced anaphylaxis. This reaction is 

likely to recur in patients. 

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated 

disorder that usually occurs in young infants. Symptoms include chronic 

vomiting, diarrhea, and failure to gain weight or height. When the allergenic 

food is removed from the infant’s diet, symptoms disappear. Milk and soy 

protein are the most common causes, but some studies report reactions to 

rice, oat, or other cereal grains. A similar condition also has been reported 

in adults, most often related to eating crustacean shellfish. 
 

GLOSSARY 

Immunotherapy with cross-reactive allergens is a type of treatment in 

which a patient is given increasing doses of an allergen to induce tolerance 

to a similar allergen that is causing a reaction. 

Noncontact food allergy develops as a result of the food allergen being 

ingested. Specific IgE antibodies to the food are only made after eating the 

food, not after simply touching the food. 

Systemic contact dermatitis is a rare disorder with symptoms that include 

eczema, fever, headache, and stuffy nose. To develop systemic contact 

dermatitis, a person first develops specific IgE antibodies to the allergen 

through contact with the skin. If the person subsequently swallows the 

allergen or is exposed to it though a skin cut or puncture, symptoms develop. 

NIAID I GUIDELINES FOR ThE DIAGNOSIS AND MANAGEMENT OF FOOD ALLERGY IN ThE UNITED STATES 

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Credits:

Front cover ©iStockphoto
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

National Institutes of Health 

National Institute of Allergy 

and Infectious Diseases 

NIH Publication No. 11-7699 

May 2011 

www.niaid.nih.gov