Types of epinephrine autoinjectors, compared

Once upon a time, people living with life-threatening allergies in the United States had basically one choice for an epinephrine autojector: the EpiPen.

First approved for sale to patients by the FDA in the 1980s, and redesigned to be slightly more user-friendly in 2009, the EpiPen opened the market for epinephrine autoinjectors, and dominated it for the next thirty years.

Before the EpiPen, to self-administer epinephrine during a severe allergic reaction, people with life-threatening allergies to food, insects, or medications relied on cumbersome syringes and vials– which were fragile, challenging to carry in a purse or pocket, and even more challenging to use correctly and quickly when anaphylaxis symptoms struck. For people who were accustomed to fumbling with fragile pre-filled syringes, or, worse, trying to draw up a correct dose with a sharp needle and a glass vial during a reaction, the rugged, simple-to-use EpiPen autoinjector was an amazing improvement.

Since its debut, the EpiPen has become one of those brand names– like Band-Aid, Tylenol, or Kleenex– that is almost synonymous with the type of product it represents. To many people, just as a small self-adhesive bandage is simply called Band-Aid, an epinephrine autoinjector is called an EpiPen.

But in recent years, a number of new types of epinephrine autoinjectors have become available to patients. And, even as brand-name EpiPen prices have skyrocketed over the past decade, manufacturing problems with the EpiPen have caused recalls and shortages of the device.

Is the old standby, brand-name EpiPen really still the best option among EAIs? Or would one of these EpiPen alternatives– which contain exactly the same type of injectable epinephrine as an EpiPen, but in some cases, use a different injector design– work better for you? Here is a breakdown of different epinephrine delivery options to help you decide:

The EpiPen

EpiPen brand epinephrine autoinjectors
EpiPen brand epinephrine autoinjectors – Mylan

The Pros:

High prices and ongoing EpiPen shortages have many patients who have used the EpiPen for years considering a switch to a different epinephrine delivery option. But the classic autoinjector has a few important things going for it:

Lots of people with allergies already know how to use the EpiPen.

For those who are already well-trained on how to use the EpiPen, the idea of switching to a different device, with different directions, might be frustrating. This might be especially true for small children. If you’ve already spent a year diligently training your easily-distracted, needle-phobic five-year-old to self-carry and self-inject an EpiPen, convincing the kid to switch to an entirely different device might feel like a challenge.

Lots of people who don’t have allergies already know how to use EpiPens, too.

School nurses, teachers, childcare providers, EMTs, and other people who train to administer epinephrine autoinjectors on others as part of basic first aid or job training are often first taught with brand-name EpiPen training devices and materials. If you choose to use a different style of EAI, you might find that you need to retrain caregivers, colleagues, family, or friends.

The EpiPen has safety features some other EAIs don’t have.

The 2009 redesign of the EpiPen equipped it with a few safety features that many users appreciate. First, the EpiPen’s color coded top and bottom ends (blue to the sky, orange to the thigh) help to prevent users from using the device upside-down and accidentally injecting themselves in a finger or thumb instead of properly injecting themselves or another person in the thigh.

Second, a pop-out needle cover automatically engages after the EpiPen is fired, protecting the user and bystanders from any unplanned encounters with a used needle by completely enclosing it. This feature can be especially reassuring in daycare or school settings.

The Cons:

EpiPens are expensive.

Anyone who has had to pay the list price can tell you: EpiPens cost several hundred dollars. The price for the brand name device is so high that many insurance companies have started limiting the number of brand name EpiPen sets they will cover within a certain timeframe, or have entirely stopped covering them. And if you have a high deductible plan, even if your insurance technically covers the EpiPen, you may face some serious sticker shock when it comes time to pick up that prescription.

EpiPen shortages keep happening.

Mylan, the EpiPen maker, has suffered repeat production and supply problems over the past few years, and rolling shortages nationwide have meant many pharmacies simply can’t keep brand name EpiPens in stock.

This ongoing access issue has been much more than an annoyance for people who rely on epinephrine as a life-saving medication. The shortages haven’t just caused people with life-threatening allergies temporary difficulties in accessing their medication– they have also caused many people who have been loyal EpiPen users for years to lose trust in Mylan as a company.

The old standby is, well, old.

The EpiPen’s design hasn’t changed in ten years, and while the 2009 redesign did introduce a few nice new features like the automatic needle cover, the basic shape and underlying mechanism are very similar to the original EpiPen designed in the 1980s.

While this means you are getting a familiar, time-tested device in an EpiPen, it also means you won’t be getting newer EAI features, like the recorded audio instructions offered by the Auvi-Q.

Learn how to use an EpiPen brand epinephrine autoinjector at the EpiPen website.

The Mylan Generic

Mylan generic epinephrine autoinjectors

The Pros:

Do you wish you could buy an autoinjector that was just like an EpiPen, but less expensive? If so, the Mylan generic EAI is the probably right device for you.

It’s the EpiPen you recognize, in a plain wrapper.

The Mylan generic epinephrine autoinjector is made by the same company that makes the EpiPen. It has the same design as the post-2009 brand name EpiPen, comes with the same directions, and contains the same medication in the same formulation.

The Mylan generic is less expensive than the brand name EpiPen.

Did we mention already that the brand name EpiPen is really expensive? Like, as in, Congress investigated EpiPen maker Mylan for price gouging expensive?

The Mylan generic EAI retails for about half the price of Mylan’s brand name device.

The Cons:

It’s the EpiPen you recognize, in a plain wrapper– and maybe that’s actually not what you want.

The Mylan generic autoinjector has the same design as the brand name EpiPen– which means it has the same design-based limitations mentioned for the EpiPen above. If you are looking for innovative EAI features like a retracting needle or audio cues, you will not find them here.

It is less expensive than the EpiPen, but it may NOT be your least expensive option.

Patient costs for different EAIs can vary depending on your region, your pharmacy, and your insurance plan. But the Adrenaclick generic epinephrine autoinjector often costs less than the Mylan generic EAI.

Learn more about the Mylan generic epinephrine autoinjector at the Mylan generic website. (Note: the user directions are the same as for the EpiPen above.)

The Adrenaclick

Adrenaclick brand name epinephrine autoinjectors
Adrenaclick brand epinephrine autoinjectors – Amedra

The Pros:

It’s time-tested: the Adrenaclick EAI has been around longer than you might think.

If one of your worries about trying a new-to-you style of epinephrine injector is that the product might not have been around long yet enough for design flaws to be revealed, you can set that concern aside with the Adrenaclick by Amedra.

The Adrenaclick brand epinephrine autoinjector first hit the market, with its current design, in 2009. Due to distribution issues, production delays, company buyouts and mergers (six different companies have owned the rights to produce the brand name Adrenaclick since it was invented!) and a brief discontinuation of the product back in 2012, the Adrenaclick has never been as well-marketed, as well-known, or as widely-used as its competitors.

But the Adrenaclick’s basic design– which is actually not that different from the design the original EpiPen had before its redesign– has remained the same for nearly a decade. That means lots of patients have used the Adrenaclick successfully– and continue to trust it.

The Cons:

The Adrenaclick lacks key features that other epinephrine autoinjectors offer.

The EpiPen and the Auvi-Q each require the user to remove one safety cap in order to inject epinephrine. The Adrenaclick design requires that the user remove two caps– one from each end of the device. That makes the user instructions slightly more complicated than those for the EpiPen or Auvi-Q– which can matter when a person who is trying to self-administer epinephrine is disoriented due to anaphylaxis symptoms, or when an untrained bystander is trying to figure out how to use the EAI.

The Adrenaclick also lacks an important safety feature that other EAIs offer. The EpiPen and Auvi-Q both have a mechanism in place to automatically cover the needle after an injection. The EpiPen uses an automatic pop-out needle cover; the Auvi-Q, a retracting needle. But the Adrenaclick needle is left exposed after use, and must be manually covered by carefully placing the device back in its carrying case after use.

The Adrenaclick doesn’t come packaged with a trainer.

Unlike the EpiPen or Auvi-Q, a free trainer is not included in every Adrenaclick package. Instead, you have to order a trainer separately through the mail.

This is a serious disadvantage for people who need to learn how to use an epinephrine autoinjector right away because they are newly diagnosed, or because they are new to the Adrenaclick and do not have a backup supply of a more familiar EAI available to use until the trainer comes.

Its unpopularity means bystanders, caregivers, and medical professionals may not have seen an Adrenaclick before and may not know how to use it.

This is an issue with ANY autoinjector. But Teva’s EAI design is less different from an EpiPen than the Adrenaclick design is, and the Auvi-Q offers recorded instructions that play automatically when you use the device, that can walk an untrained person through the injection process. Someone who has not been previously trained on how to use the Adrenaclick autoinjector would have to consult the product packaging to figure out how to use one in an emergency.

If you do decide to switch from an EpiPen to an Adrenaclick, make sure that any friends, family, caregivers, coworkers, teachers, etc. who might need to help treat an allergic reaction with the Adrenaclick have get trained on how to use one, if they have not already learned.

The brand name Adrenaclick may not cost you any less than the Mylan generic.

Depending on what coverage your insurance offers and which pharmacy you use, the brand name version of the Adrenaclick may actually cost you more than the Mylan generic. But the makers of the Adrenaclick offer a second EAI option which, depending on where and how you buy it, may be much cheaper than either: the Adrenaclick generic, explored below.

Learn how to use the Adrenaclick epinephrine autoinjector at the Adrenaclick website.

The Adrenaclick Generic

Adrenaclick generic epinephrine autoinjectors
Adrenaclick generic epinephrine autoinjectors – Impax

Note: some refer to this generic EAI as “the Impax generic” after the company that makes it, or “the CVS generic” because CVS pharmacies offer it preferentially over other generic EAIs.

The Pros:

It has all the same features as the brand name Adrenaclick, except for the branding. But it costs less.

The Adrenaclick generic offers all of the features of the regular Adrenaclick: the same time-tested design, with the same medication inside. But its retail price is much lower than the brand name Adrenaclick.

The Adrenaclick generic might be the least expensive EAI option for you.

Depending on your pharmacy and insurance options, the Adrenaclick generic epinephrine autoinjector may be the cheapest EAI you can buy in the United States.

Some pharmacies offer this generic autoinjector for as low as $100 for a two-pack.

Other pros are the same as those listed for the brand name Adrenaclick.

The Cons:

See the cons list for the brand name Adrenaclick above. They are the same, except for the price for the Adrenaclick generic, which as noted above is quite low compared to other EAIs.

Learn how to use the Adrenaclick generic epinephrine autoinjector by Impax at the Adrenaclick generic website.

The Auvi-Q

Auvi-Q epinephrine autoinjectors and trainer by kaléo
Auvi-Q epinephrine autoinjectors and trainer – kaléo

The Pros:

The Auvi-Q offers a unique set of user-friendly features different from any other epinephrine autoinjector on the market.

The Auvi-Q was actually designed by people with food allergies to be a more user-friendly EAI option. The Auvi-Q inventors, who grew up carrying (and sometimes forgetting) their own EpiPens, set out to create a device that would be both more convenient to carry and easier to use than an EpiPen. If you are looking for the autoinjector with the most innovative, user-friendly features, the Auvi-Q is definitely the EAI you want in your pocket.

Speaking of which . . .

The Auvi-Q will fit in your pocket. Really.

Unlike the tube-shaped EpiPen, Teva, or Adrenaclick, or their generic dopplegangers, the Auvi-Q will actually fit in most normal-sized pants pockets comfortably. It is roughly the size and shape of a small cell phone or wallet– making it the ideal option to slip discreetly into a jeans pocket or a small purse.

An Auvi-Q will tell you, or a bystander, how to inject epinephrine, out loud.

In addition to printed directions that appear on the device (similar to the directions printed on other autoinjectors), the Auvi-Q offers automatic, recorded step-by-step voice instructions that walk a user through using the device properly during an allergic reaction. (That’s actually where the Auvi-Q name comes from: the autoinjector has both “audio” and “visual” cues: au + vi + qs. Get it?)

Auvi-Qs feature a retracting needle.

A retracting needle that automatically snaps back into the device after use, to protect the user and bystanders from accidental needle injuries. This is a similar feature to the EpiPen’s pop-out needle cover, and is an advantage over the Adrenaclick or Adrenaclick generic.

Auvi-Q is the only epinephrine autoinjector that offers a dose sized for babies.

Maker kaléo recently designed a new version of the Auvi-Q that contains the correct dose of epinephrine for infants and toddlers weighing 16.5 – 33 pounds. No other EAI on the market in the U.S. offers this option. Up to this point, parents, caregivers and health care providers, when faced with an infant or toddler who was suffering a life-threatening allergic reaction, but was under the 33 pound weight minimum for “junior” epinephrine autoinjectors, could only choose between treating a reaction with a cumbersome needle and syringe, or with devices designed and dosed for older children.

You may be able to get Auvi-Qs for free through Auvi-Q maker kaléo’s zero co-pay program.

If you have private commercial health insurance, but your insurance does not cover the Auvi-Q, you may be qualify to receive a set of Auvi-Q autoinjectors for free from the manufacturer. Various restrictions apply to this offer; contact kaléo for details.

The Cons:

Auvi-Q is only available by mail-order, or at certain Walgreens locations.

Auvi-Qs are probably not available at your corner pharmacy. Currently, the only way to get an Auvi-Q set is to ask your doctor to contact the Auvi-Q manufacturer, kaléo, and ask to set up mail delivery through one of the mail order pharmacies kaléo partners with, or arrange to pick your set up at a participating Walgreens– which is the only brick-and-mortar pharmacy that carries the Auvi-Q, and which, according the to Auvi-Q website’s FAQ, only allows in-store pickup of Auvi-Qs for those whose insurance covers it; participants in Auvi-Qs zero copay or affordability programs must still use a mail-order pharmacy.

This means, firstly, that your prescribing doctor has to be familiar with the Auvi-Q ordering process in order for you to get one. Secondly, if you do take delivery by mail (which is the most common way to get an Auvi-Q) you will have to deal with the typical issues associated with the delivery of mail order medications: delivery can take several days, and there is some chance that your package of live-saving medicine might wind up rain-soaked, overheated, smashed, taken by porch pirates, delivered to the wrong house, etc.

For patients who need access to epinephrine autoinjectors immediately– because they are newly diagnosed, because they used their entire supply to treat a reaction, because a school or daycare is demanding a new set for the office, etc., the delay and potential logistical issues associated with mail-order might be a dealbreaker. But you may be able to get around this problem if you are able to pick your prescription up at a Walgreens that has Auvi-Qs in stock.

Your insurance may not cover Auvi-Q. And the list price is very expensive.

Auvi-Q maker kaléo has come under some criticism for its complicated pricing system– which lists an insurance company price of several thousand dollars per set that many insurance companies simply refuse to pay.

Patients are basically never asked to pay the insurance company price for the Auvi-Q, though. Many patients whose insurance companies will not cover the Auvi-Q qualify for the zero copay plan mentioned above; others may qualify for kaléo’s patient assistance program for low-income households. And the cash price that kaléo charges patients who want to purchase the device directly is significantly lower than the insurance company price– more in line with the cost of other EAIs like the Adrenaclick or the Mylan generic.

If, as a patient, you do ever get quoted an exorbitant price in the several thousand dollar range for an Auvi-Q by an insurance company, doctor, or pharmacy, make sure to check directly with kaléo to make sure you are not missing out on one of their discount programs.

Auvi-Q is not as familiar to the public as the EpiPen.

Like the Adrenaclick, the Auvi-Q is both newer to the market and less popular than the EpiPen, which means that healthcare providers, caregivers, school staff, etc., who may have already been trained to use EpiPens, might not be familiar with the Auvi-Q and might not know how to use it.

While this is technically a disadvantage, the Auvi-Q’s voice instructions theoretically make it the easiest epinephrine autoinjector for an untrained bystander to use correctly (assuming they can hear and understand instructions in English). And as the Auvi-Q has become more popular and more widely advertised, lack of public familiarity with the device has become less of an issue.

Learn how to use the Auvi-Q epinephrine autoinjector at the Auvi-Q website.

The Teva Generic

Teva generic epinephrine autoinjectors
Teva generic epinephrine autoinjectors – Teva

The Pros:

Teva’s EAI is a lot like the brand name EpiPen you may already be used to.

The Teva generic epinephrine autoinjector contains the same active ingredient as the classic EpiPen: epinephrine. And it’s available in the same adult and junior dose sizes as an EpiPen. The shape and style of the autoinjector are also similar in many ways to an EpiPen, but, the two-cap design, involving a sealed twist cap at the bottom of the device, means the usage directions are slightly different.

The Teva generic costs less than a brand name EpiPen

The Teva generic is priced a couple of hundred dollars lower than Mylan’s brand name device.

The Cons:

The Teva generic is just different enough from the EpiPen to be potentially confusing.

The Teva generic looks very similar to an EpiPen– moreso than any other device on this list besides Mylan’s own generic. But the directions for use are just different enough that they could cause a delay in someone using the medication properly if they mistook the Teva device for a more familiar EpiPen or Mylan generic.

The Teva generic is not less expensive than the Mylan generic, and may cost more than the Adrenaclick generic.

Teva’s generic version of the EpiPen costs about the same as Mylan’s generic. At that price, it might not make sense for someone who has already been trained to use an EpiPen to switch to a new autoinjector with different instructions– unless the EpiPen and Mylan generic are both unavailable locally due to Mylan’s ongoing shortage issues.

Teva seems to have its own EAI shortage problems.

Teva received approval from the FDA to start selling its generic epinephrine autoinjector back in 2018, but, by mid-2019, the company had still not made the device widely available at pharmacies. Teva has been slow to ramp up production of their autoinjector to meet demand, even with ongoing EpiPen and Mylan generic shortages providing Teva with what should be a prime opportunity to find some new customers.

Learn how to use the Teva generic epinephrine autoinjector at the Teva website.

The Symjepi Syringe

Symjepi epinephrine syringes with carrying case
Symjepi epinephrine syringes with carrying case –

Note: it’s important to state that the latest epinephrine delivery device on the U.S. market, which just became available directly to patients in mid-2019, is not an epinephrine autoinjector.

The Symjepi is a pre-filled syringe, not really that unlike the single-dose, pre-filled syringes many people with life-threatening allergies used to carry before the EpiPen became available. The key difference between the Symjepi syringe and the old school pre-filled epinephrine syringe kit your grandmother might have used is that the Symjepi is made of a rugged plastic material and comes with a needle cap and a hard plastic carrying case. This design makes the Symjepi less likely to break than a standard pre-filled syringe, and the opaque syringe and case also protect the epinephrine inside from light exposure, which is important, since epinephrine quality can be degraded by repeat exposure to light.

Because the Symjepi syringe is not actually an epinephrine autoinjector, it’s not exactly in the same category as the devices above, and should not be considered a one-to-one replacement for someone who currently carries EAIs. But the Symjepi may meet the specific needs of some people with life-threatening allergies, perhaps especially as a backup option, which is why I will include some pros and cons for it here.

The Pros:

The Symjepi syringe is smaller than an epinephrine autoinjector.

Because it does not contain an autoinjection mechanism, the Symjepi syringe is smaller than an autoinjector. This means it should easily fit into a pocket or purse. It also means it would take up less space in a medicine cabinet or portable first aid kit.

The Symjepi features a post-injection needle cover.

Nothing about the Symjepi is automatic; it is a fully manual device. So the needle cover on the Symjepi does not pop out automatically after use like it does on the EpiPen and Mylan generic autoinjectors. But the Symjepi does feature an integrated needle cover that the user can physically pull out to cover the needle after use.

The Symjepi is less expensive than some autoinjector options.

Priced under $300, the Symjepi is definitely cheaper than a brand-name EpiPen, and also is less expensive than the typical patient cash price for an Auvi-Q. However, it is comparable price-wise to some of the generic epinephrine autoinjector options, so depending on insurance coverage and local pricing, it may not be the cheapest option for you.

The Cons:

The Symjepi is more complicated to use than an autoinjector.

The Symjepi device is a syringe. To use it, you must remove the needle cap to expose the needle, inject the needle into the thigh at the correct location and angle, and then depress the plunger to dispense the medicine inside. This might not seem like a very complicated set of directions, but consider how it differs from an autoinjector:

  • When you use an autoinjector, the plastic base of the device helps stabilize it against the thigh before the needle is released, making it easier to insert the needle at the correct angle. With the Symjepi, you uncover the entire needle when you remove the cap, and must judge the correct insertion angle for yourself.
  • You must remember to insert the needle first and then push the plunger second. If you accidentally push down on the plunger at all before inserting the needle, some or all of the epinephrine will leak out of the needle end of the syringe before you can inject it into the thigh.

These differences could make it difficult for a person who is disoriented from anaphylaxis symptoms (which commonly include dizziness, confusion, and shortness of breath) to use the Symjepi properly. The Symjepi would also likely be more difficult for a small child to use than an autoinjector.

Adults with some basic experience using other types of syringes to inject medication may feel quite comfortable using the Symjepi, though, especially if they are not planning to use it to inject themselves during anaphylaxis, but instead, planning to use it to treat another person with an allergy. It could be a good option for school nurses to keep stocked in their offices, or for EMTs to carry on ambulances, in place of bulkier or more expensive options.

The Symjepi is not significantly less expensive than autoinjectors with more user-friendly directions and better safety features.

A patient who can get an Auvi-Q — with a convenient wallet-shaped profile, a retracting needle and voice instructions — for free through kaléo’s zero copay program, or who can get an Adrenaclick generic autoinjector for, say, $250 at their local pharmacy, is probably not going to want to pay $280 or so for what is essentially a beefed up version of the pre-EpiPen era pre-filled syringe.

If Symjepi manufacturer Adamis does not lower the price of their epinephrine syringe to offer a significant savings in comparison with generic epinephrine autoinjectors, they may struggle to compete with the other devices already on the market that offer more features.

Learn how to use the Symjepi epinephrine syringe at the Symjepi website.

Featured epinephrine autoinjector photo by Tony Webster, used under Creative Commons license.

Food allergies, school, and the real world

School desks | When Peanuts Attack

“Eventually you’re going to have to teach that kid to live in the real world, you know.”

In the context of conversations about the management of food allergies in school, I have heard this phrase more times than I can count, offered as an argument against making accommodations to keep children with food allergies safe and included in school environments. And over the many times I’ve heard it, I have come to realize that it is a very illogical argument. There are at least two major logical problems with it:

First, let’s address that word, “eventually.”

Eventually, three-year-olds will be twelve-year-olds, and will need to cross streets on their own, without holding anyone’s hand. Does that mean we should let three-year-olds cross busy intersections alone now, without help, unsupervised?

Eventually five-year-olds will be sixteen, and will need to know how to drive. Does that mean we should hand five-year-olds the keys to our cars, and let them start practicing today?

Eventually ten-year-olds will be twenty, and will (we hope), move out of their parents’ houses, and live on their own. Does that mean we should make ten-year-olds, now, regularly spend entire weekends home alone, cooking, cleaning and managing the whole household for themselves?

Eventually children will be adults. And while it’s absolutely true that it is vitally important to prepare all children for adulthood by teaching children how to make responsible decisions and take good care of themselves, children are not adults now, and should not be expected to take on adult responsibilities before they are ready.

Children are still learning how to navigate the “real world” adults live in, and need education, guidance, and assistance from adults to do so safely. Whether we are talking about crossing the street, or reading a food label, driving a car, or self-administering an EpiPen during a severe allergic reaction, children should not be expected to take on responsibilities they are not mentally or physically ready to handle.

Here is a simple fact that seems to come as a genuine surprise to some adults who lack experience dealing with food allergic kids, but is incontrovertibly true: children with food allergies are not naturally wiser or more mature than other children. Developing a dairy allergy does not magically grant a two-year-old the ability to read food labels for the word “milk;” getting diagnosed with a peanut allergy does not instantly make a three-year-old more capable of self-control when faced with a tempting candy bar. Having to carry an EpiPen does not necessarily cure a four-year-old of a fear of needles. A five-year-old with a tree nut allergy who is forced to sit in the hallway during a kindergarten cupcake party feels just as left out as any child that age excluded from a party would.

The issue of schoolchildren with food allergies being children, with a maturity level similar to that of any other children, does not disappear at the middle or high school level, either. Studies show that tweens and teens are impulsive, and take risks, because their still-developing brains lack adult-level impulse control. Teens with food allergies have the same teenage brains as teens without food allergies. Teens with food allergies are, also, subject to the same forces of school stress and peer pressure that teens without food allergies deal with. And like, other teens, as teens with food allergies gain independence and spend more time away from their parents, they sometimes face tough decisions that their still-growing brains may not be fully equipped to handle well.

In fact, teens with food allergies face a higher risk of suffering a fatal allergic reaction than young children with food allergies do.

Kids with food allergies are just that– kids. Like other kids, they are still learning; like other kids, they can be impulsive, or forgetful; they don’t always listen to adults, and don’t always follow directions. Like other kids, they want to be included in a group, and feel hurt when they are left out.

So, even though it’s true that children with food allergies will eventually be adults, it is not appropriate or safe to treat children now as if they were already adults.

Here is a second major logical problem with this argument:

Schools for children are not at all like “the real world” adults live in.

The rules for adults in the real world and the rules for children in school are very different, and for good reason. In order to function, schools need to have conduct rules in place that keep children focused on their schoolwork, and safety rules that protect children from their own immaturity and lack of life experience. It is very common for schools to have rules such as: you must follow the same schedule as the rest of the classroom. You must ask a teacher for permission to speak. You may not leave the classroom without permission. You may not leave the building during the school day. Etc.

But, some of the very same restrictions and rules that help schools function as safe, orderly places for educating children can actually cause pretty serious day-to-day challenges for children with food allergies, of a sort that most adults with food allergies do not actually face on a daily basis in “the real world.”

Imagine you are an adult with a peanut allergy. Imagine that you work at an office with a cafeteria area, where employees can eat lunches that they have brought from home. Suppose you have a co-worker who is relentlessly fond of eating peanuts and peanut butter, who nearly always brings these foods at lunch time, and sometimes even heats peanutty foods in the office microwave, causing allergenic proteins to aerosolize and fill the cafeteria with fumes that could, at best, make you sneeze and cough, or, at worst, send you to the hospital.

As an adult, working in an office environment, you have many choices.

Perhaps the simplest choice you have is to avoid the workplace cafeteria altogether. You can eat lunch at your desk, or go out every day to an allergy-friendly restaurant that is safe for you.

Or, you can have a friendly conversation with your coworkers, explain how this problem affects you, and ask if they would be willing to keep the peanuts at home. As an adult, your explanation of your health issues is likely to be taken seriously. Because the coworkers you are talking to about your problem are also adults, they can control what they choose to bring in for lunch daily; they can most likely easily choose to accommodate you.

If your coworkers are not accommodating, you can choose to take the issue up with your manager, or with your workplace’s human resources department. You can choose to file an ADA complaint. You can choose to ask to be transferred to a different office, or to work remotely. You can even choose if necessary, to quit, and find another job.

Now imagine that you are an elementary-aged child with a peanut allergy who eats lunch in a school cafeteria where, every day, other children bring lunches containing peanuts and peanut butter to school. And imagine that your school has made no accommodations for your allergy.

Can you choose to eat at your desk? Probably not. Most schools require children to eat lunch in the lunchroom. If your school makes no accommodations for your allergy, you will have to eat in the cafeteria, right next to the kids eating your allergen at school.

Can you choose to leave school and have lunch elsewhere? Almost certainly not! Elementary school students aren’t allowed to leave school without permission. They cannot drive themselves home, or to safe restaurants, to eat in safety and peace. Most kids in school have busy, working parents who would not necessarily be able to pick them up for lunch every day even if it were allowed.

Can you try to have a friendly conversation with your fellow students? Sure. But remember: they are kids. Do they understand what food allergies are? Will they believe you when you say, “This food you love to eat could kill me”? If your school is making no accommodations, it’s unlikely that the school has held any special awareness assemblies about food allergies to educate your fellow students. And anyway, if you’re in elementary school, your fellow students are probably not packing their own lunches: their parents are.

So do you, a child, try to contact your friends’ parents and explain?

What about contacting HR? Nope, no such department for students. The management? Well, that would be your teachers and school administrators, who, as we mentioned have already decided against accommodating you. Can you switch schools? Sure, if your parents can afford and are willing to move to a new school district, or pay for you to go to a private school, or arrange to have you homeschooled.

But what if none of those possibilities will work for your family?

The “real world” children encounter in school is a far different one than the “real world” adults encounter in the workplace. Children with food allergies who are in school have far less control over their own environment, and less freedom to make choices to keep themselves safe. For that reason alone, it’s essential for the safety of children with food allergies that adults in charge in the school environment cooperate with the families of children with food allergies to make sure those children can attend school safely.

Eventually, kids with food allergies will be adults living in an adult world. To help them get there safely, though, they need understanding and assistance now from the adults who have been charged with helping to guide them through life.

Road Tripping with Food Allergies, Part Three: Find Safe Food on the Road

Food allergy road sign | When Peanuts AttackSo you, savvy food allergy traveler, did the right thing, and planned ahead for a safe, food-allergy friendly road trip. You made a list of allergy-friendly restaurants on your route. You packed safe snacks– more than you thought you would need.

But you’ve had an unexpected travel delay, you’re nowhere near a safe restaurant, your food supplies are running low, and frankly, you’re flat-out sick of snack bars. Now what?

We all know travel plans are subject to change. Even careful travelers who plan ahead for safe food allergy management can run into circumstances that leave them at a loss for safe food options. Maybe you got a flat tire in Nowhere, Kansas (reader, it has happened to me!). Maybe the mini fridge in your hotel room died overnight, and several meals’ worth of carefully chosen allergy-safe food spoiled without warning. Maybe you accidentally left a suitcase full of safe snacks in a motel closet three entire states ago.

What do you do now?

Here are some ideas:

Try to find a grocery store.

You may be able to replace some safe, non-perishable food supply as you go if you stop at a town with a grocery store. That Kroger in Vandalia, MO may not stock the safe granola bars you packed, but at the very least, you know they will have pantry staples and fresh produce. And the selection at a new-to-you, out-of-town grocery store may surprise you. You might even find allergy-friendly brands that aren’t available in your state.

Check out the nearest gas station’s snack selection.

It may not be as unsafe as you think. You probably won’t want to risk eating hot food cooked at a gas station restaurant. But gas station convenience stores tend to stock a wide variety of travel-friendly pre-packaged foods– a few of which might be on your safe food list.

Look for safe options in less-than-safe restaurants.

Consider that even restaurants that you don’t ordinarily think of as allergy-safe places may have a few pre-packaged items you can eat, even if they can’t offer you a full safe meal. For example, a fast food restaurant may have oranges, or pre-packaged apple slices, as sides on the kids’ menu, that you can order separately. A coffee shop may have pre-bottled, sealed drinks and pre-packaged, sealed, ingredient-labeled snacks you can safely buy, even if their espresso bar is a cross contact nightmare. A hotel breakfast bar with a definitely-not-safe-for-you granola buffet might have a safe brand of pre-packaged yogurt or juice boxes stored separately in the fridge. A roadside cafe may have packaged crackers or fresh, uncut produce available if you ask.

But do try to make sure, if you are prone to contact or airborne reactions to your allergen, that you do not accidentally linger in an unsafe-for-you space while hunting for safe food. If you have a seafood allergy, and that seaside cafe is steaming shrimp, don’t stick around. If the very thought of peanut dust makes your eyes itch, and that roadhouse by the truck stop has peanut shells on the floor, back straight out.

And if any restaurant’s staff make you feel unwelcome or unsafe, walk away.

Remember: it’s better to skip a meal on the road than to eat an unsafe meal that causes a reaction.

Read more in this series:

Road Tripping with Food Allergies, Part One: Plan Your Route
Road Tripping with Food Allergies, Part Two: How to Pack

Road Tripping with Food Allergies, Part Two: How to Pack

Pack your suitcase | When Peanuts AttackPicture this: After a long day of driving that included a wrong turn at Albuquerque, a crazy detour around unexpected road construction, a sudden thunderstorm, and at least five separate arguments between two cranky kids in the back seat of your car, it’s well past dinner time, and you find yourself, not sitting down to eat at the amazing, allergy-friendly restaurant you made a reservation at two weeks ago, but instead, standing in front of a rest stop vending machine, staring in despair at a selection of 12 suspicious looking snack-foods you cannot see the ingredient labels for.

Fear not, food allergic friends! This sad scene won’t happen to you on your road trip, because you are going to follow these tips on packing for food-allergy-friendly travel by car. Here’s how to avoid running out of safe meals and snacks.

Pack more allergy-safe, non-perishable food than you think you will need.

During travel, delays and detours happen. Plan ahead for the possibility of missed turns and missed safe meal destinations– by packing extra emergency snacks. If your trunk space is limited, and you have to make a choice between packing safe food, or an extra pair of flip-flops, pack the food. You can buy a pair of souvenir flip-flops when you get to Florida.

While it’s a good idea to bring a cooler or an insulated bag with ice packs and a few tasty safe perishables, keep in mind that, unless you are traveling in an RV with a fridge, you will probably only reasonably be able to keep your food temperature-safe for a few hours on the road. When packing for a journey, focus primarily on nonperishable snacks that won’t quickly melt or spoil. Depending on your allergies, allergy-safe snack bars, dried fruit, applesauce, jerky, pretzels, crackers, or popcorn can be good shelf-stable options. Fresh fruits, like oranges and bananas, hold up well for a day or two in the car, and come in their own biodegradable packaging. (Make sure, if you do bring fresh fruit, that you wash it well before you pack it, so that you don’t find yourself trying to decide whether rinse your apple in a gas station bathroom sink.)

And if you do want to bring along some fresh potato salad, or your famous bacon-swiss-and-avocado sandwiches, consider freezing perishable foods overnight before packing them in your cooler, to help them stay in a safe temperature range longer.

If you find yourself strapped for cooler space for both perishables and cold drinks, consider freezing few bottles of water or and using them in place of ice packs.

Pack wet wipes and cleaning supplies to clean allergens from your hands and surfaces.

Washing your hands before you eat is a healthy practice in general, but for people with food allergies, hand washing before eating can be life-or-death essential. Keep a pack of hand wipes or baby wipes in a place in your car that is easy for both the driver and the passengers to reach. That way if you wind up having lunch on the go, you’ll be prepared.

Pack some extra cleaning wipes, or a spray cleaner and some paper towels, in your trunk to wipe down restaurant tables, picnic tables, and hotel room surfaces.

Consider packing your own small cooking appliances. When you’re traveling with food allergies, a mini microwave, a hot plate, an Instant Pot, or a rice cooker can really come in handy, allowing you to prepare safe meals on your own clean equipment in a hotel, at a campground, or in a relative’s home.

If you do decide to BYO small kitchen appliance, do a little research on the places you’ll be staying to make sure that your appliance will be allowed, and that you will have a safe, clean place to plug it in and set it up.

Pack your epinephrine autoinjectors, your antihistamines, and any other allergy medication you think you might need, and make a plan to keep your medicine in a safe temperature range and close at hand.

A person with a food allergy should never leave home without epinephrine! It’s especially important to make sure not to forget your epi when traveling. Triple-check before you leave to make sure that any medications you may need on your trip are packed safely in a place where you can easily access them in an emergency.

To maintain full effectiveness, epinephrine autoinjectors must be kept within a certain safe temperature range. This can be especially difficult to manage when traveling in the summer. Autoinjectors should never be left sitting for hours in a hot car! Exposure to high heat degrades epinephrine and can damage the autoinjector device.

Make sure before you leave that you have a way to keep your epinephrine from overheating– or freezing– on the road. Insulated epinephrine carriers can help, but they may not be enough when you are traveling far. And while ice packs can keep epinephrine autoinjectors cool, if you place an autoinjector directly in ice or next to an ice pack in a cooler or insulated bag, you risk freezing your medicine instead of overheating it!

Many people with food allergies recommend using the Frio brand evaporative cooling pack for trips in the summer heat. Originally designed to keep insulin at room temperature, it also works well to cool (but not freeze) epinephrine autoinjectors. And you don’t need a freezer to recharge the Frio– all you need is clean water. Just make sure to follow the manufacturer’s instructions to keep your medicine dry and keep your Frio working properly.

You can also try this road-tested food allergy travel trick: put your epinephrine in a small insulated bag, put a small ice pack in a second small insulated bag, and put them both in a larger insulated bag. This system protects the epinephrine autoinjector from direct contact with an ice pack, which helps to prevent freezing. If you do try this route, make sure you monitor the temperature of your epinephrine regularly to make sure it does not get too hot or too cold.

Read more food allergy travel tips:

Road Tripping with Food Allergies, Part One: Plan your Route
Road Tripping with Food Allergies, Part Three: Find Safe Food on the Road

Road Tripping with Food Allergies, Part One: Plan Your Route

Road trip | When Peanuts AttackAh, the open road. How it calls in the summer. Pack a suitcase, grab a friend, or your family, and get away from it all! Set out in your car with the windows down, the radio on, and a map to someplace you’ve never been before in your pocket. See the sights: rolling hills, cows, impressive sculptures of cows, and giant balls of twine!

Eat at random roadside cafes and truck stop diners!

Wait. Actually, if you have a food allergy, you should probably not do that last thing.

Use these actually road-tested tips for taking a safe road trip with a food allergy instead.

Before you go, plan your route.

When I say plan your route, I do not mean, put your destination into the map app on your phone on your way out the door.

I mean, a few days or weeks before your trip, sit down and do some real research. Try to figure out which roads you are likely to take, and which towns you are likely to make stops in, and map out essential allergy resources along your path. You can use Google Maps to find allergy-friendly restaurants you trust, and grocery stores where you can buy extra food in a pinch. Try to find at least two or three safe sources of food in each town you plan to stop for a meal in, in case it turns out that a restaurant or store on your route has changed policies or is closed.

You can also use Google Maps to locate hospitals along your route or at your destination, just in case.

You may want to print this information out and put it in a folder, in case you run into areas with poor cell phone service coverage and no WiFi.

While drawing up your road trip game plan, make sure to leave a little wiggle room in your stop and meal schedule for spontaneous side-trips or unscheduled detours along the way. (If the kids decide they really DO want to see that giant ball of twine, you won’t want to disappoint them, right?)

It’s extra work, but a bit of allergy-related planning before you leave can save you from big headaches later on the road.

Call ahead to hotels or motels you plan to stay at, to ask allergy-related questions and request accommodations in advance.

When you make your reservation, ask to have a note put into your reservation file that a person with a life-threatening food allergy will be staying in the room. Why is this important? Well, some hotels offer complementary snacks or meals to guests– and if you have a peanut allergy, you probably do not want someone handing you an unwrapped fresh-baked peanut butter cookie at the front desk, or leaving the “gift” of a bag of chocolate covered peanuts on your pillow. Also, some hotels offer special deep cleaning services for guests with allergies– to make extra sure that the previous guests’ cookie crumbs don’t wind up in your bed. Some hotels even offer special allergy-friendly rooms, with features like carpet-free floors, allergy-blocking mattress covers, and built-in air filters. But you won’t know if these services are available unless you ask!

And don’t forget to ask hotel staff whether a fridge or a microwave will be available for you to use. Even when hotels advertise that fridges and microwaves are available, it is sometimes the case that they are located not in the guest rooms but in shared common areas, or only available in certain rooms. So if keeping and cooking safe food in your room is part of your plan (and if you are traveling with a food allergy, it probably should be), make sure you discuss the details on exactly which kitchen appliances will be available, and where.

If you will be staying with friends or family along the way, make sure you speak with them well ahead of time about what your needs will be while traveling.

Remember that even very well-meaning and sympathetic people who do not manage food allergies in their own households on a daily basis may forget things that seem obvious to you. Talk to your hosts early enough in your planning phase that, if it turns out you do not feel comfortable staying with them after all, you will be able to make alternate arrangements.

Read more in this series:

Road Tripping with Food Allergies, Part Two: How to Pack.
Road Tripping with Food Allergies, Part Three: Find Safe Food on the Road.

Peanut-free Easter treats for kids

Chocolate Easter Bunny | When Peanuts AttackIt can be a bit of a challenge to find peanut-free treats for Easter baskets. Most of those cute chocolate bunnies and eggs on grocery and drug store shelves have a not-so-cute MAY CONTAIN PEANUTS OR TREE NUTS warning on the back. And even candies that don’t have allergen advisory labeling may pose some risk, since companies are not required by the FDA to label for the risk of accidental allergen cross contact.

Luckily, this year, the Easter Bunny has helpfully provided When Peanuts Attack with a list of allergy-friendly companies that make safe Easter treats for children with peanut allergies.

Peanut-free Easter chocolate:

Vermont Nut Free and Divvies make chocolate treats– including Easter bunnies and other holiday favorites– in facilities that are 100% free from peanuts and tree nuts. Treats from Divvies are also vegan.

Peanut-free Easter jelly beans:

Gimbal’s jelly beans are not just peanut-free– they are free from all of the top 8 major food allergens. Unlike the chocolate bunnies at Vermont Nut Free and Divvies, which are a seasonal treat only, you can get your jelly bean fix from Gimbal’s year round. Surf Sweets also makes jelly beans (and gummy bears and worms) that are top 8 allergen free.

Peanut-free Easter cookies:

Many varieties of Lofthouse Cookies are made in a peanut-free facility, and they tend to offer seasonal decorated cookies for each major holiday. (Just make sure to check the package carefully as Lofthouse does make some cookies that contain nuts in a second, separate facility. The peanut-free flavors are clearly labeled as such with a peanut-free logo.) Cookies from Fancypants Bakery are also made in a dedicated peanut-free facility (that is also free of tree nuts).

Treats without tricks for a food allergy friendly Halloween

Participating in the Teal Pumpkin Project this year, but stumped on finding food allergy friendly, food-free treats for Halloween? Here are some ideas for treats without tricks:

Teal Pumpkin treats: spinning tops
Spinning tops.

Teal Pumpkin treats: plastic spiders
Plastic spiders.


Teal Pumpkin treats: bouncy balls

Bouncy balls.

Teal Pumpkin treats: glow sticks

Glow sticks.

Teal Pumpkin treats: water bottles

Water bottles. (Seriously — these were my most popular item last year — do you know how far kids walk trick-or-treating?)

Want to put out a separate bowl of allergy-friendly candy, too, in addition to your food-free Teal Pumpkin treats? Try these nut-free and top 8 free Halloween candies.

Questions on how to participate? Find more information about the Teal Pumpkin Project on When Peanuts Attack, or go directly to FARE’s Teal Pumpkin information page.

There is no A for effort in food allergies

FAILIt does not matter how much love you put into it.

It does not matter how long you spent preparing it.

It does not matter how pretty it looks, or how much money you spent on it.

It does not matter whether it’s delicious.

It doesn’t matter how hard you feel you tried to make the food safe, or how much you wanted the food to be safe.

If a food is not safe for a person with a food allergy to eat, it’s just not. And you should not expect a person with a food allergy to eat it.

So you tracked down that peanut-free cupcake mix– the expensive one, that says “nut-free facility” in  bold print, right on the box. You scrubbed out your pans, and you made sure that you used clean bowls and spoons. You made the frosting from scratch– just butter and sugar and vanilla, you swear! And you checked the ingredients on that vanilla, too? Great job.


Then you forgot, and put those sprinkles on top. The ones that say, on the back of the package, MAY CONTAIN PEANUTS.


Now you’re not sure it’s safe.

You went to all this trouble. You really, really wanted to make a safe cake. The sprinkles were an accident. And now you’re so disappointed, to think that all of your earnest effort might go to waste. I get that. Really, I do.

But . . .

If you focus on your feelings now, instead of the health and safety of the person you meant to make a cake for, and try to hide your mistake, or pressure that person into eating food you’re not sure is safe,  you will be risking making a small mistake into a very, very, very big mistake.

A call-the-ambulance mistake.

That’s not really what you want to do, is it?

I certainly hope not.

So, take a deep breath. Own up. Tell the truth.

When it comes to cooking for a person with a food allergy, there is no A for effort. Food, no matter how lovingly prepared, if not safe, IS NOT SAFE, and should not be eaten. The most delicious food in the world is not worth risking a life over. And you need to learn not to take that personally.

How to report an allergic reaction to the FDA or USDA

U.S. government chemist Margaret FosterDid you know that undeclared food allergens are a leading cause of food recalls in the United States? According to the U.S. Food and Drug Administration (FDA), from September 2009 to September 2012, about one-third of reports to the agency for serious food safety violations involved top 8 food allergens that were not properly listed on food labels.

The foods most often reported to the FDA for containing undeclared allergens include bakery products (like bread, cakes, and cupcakes), snack foods, candy, and dairy products. The allergens most often involved in FDA food safety recalls have been milk, wheat and soy.

The FDA has found that common causes of recalls for undeclared allergens in foods include accidental cross contact due to the processing of multiple types of food on shared equipment, and labeling errors that cause allergenic ingredients that were intentionally included in a food not to be properly listed on the ingredient label. On rare occasions foods are contaminated with allergens, either deliberately or accidentally, through no fault of the food manufacturer, before they ever reach the factory, as was the case in 2015 when a spate of recalls for undeclared peanut involving a wide variety of items containing the spice cumin happened after a large supply of ground cumin was adulterated (possibly deliberately) with ground peanut shells and/or peanut flour.

The FDA and the United States Department of Agriculture (USDA) urge Americans who have experienced allergic reactions after eating products that were not properly labeled for allergen content to report those reactions to the appropriate food safety agency. Reactions to most common pre-packaged, processed foods such as bread, cereal, crackers, snack bars, fruit snacks, prepared frozen meals, bottled drinks, etc. should be reported to the FDA. Reactions to fresh meat products, like fresh cuts of beef, chicken or turkey, should be reported to the USDA. (If you are not sure which agency to contact for a particular food product, I suggest trying the FDA first, as the FDA is responsible for about 80% of U.S. food.)

You can make a report to the FDA or the USDA by following the directions at the links below:

Report an allergic reaction to the FDA

Report an allergic reaction to the USDA

Help kids with food allergies have a safe and happy Halloween

Have a safe and happy HalloweenNOTICE for anyone who would like to help keep the 1 out of 13 American kids who have food allergies safe and out of the hospital tonight:

Consider the following options for safer Halloween treats:

Nut-free candies: Tootsie Rolls, Tootsie Pops, Charms lollipops, Charms Blow Pops, Dubble Bubble bubble gum, Charleston Chew, Dots gumdrops, Sweetarts, Nerds, Laffy Taffy, Smarties.

Top-8-allergen-free candies: Dum Dums lollipops, YumEarth lollipops, YumEarth gummy candies, Surf Sweets jellybeans, Surf Sweets gummy candies.

Candy alternatives: Bouncy balls, glow bracelets, glow sticks stickers, plastic spiders, plastic skulls, pencils, bubble bottles.

Note that even allergy-friendly candies might be packaged with candies that contain common food allergens, especially in holiday mix bags. Some children can react to trace amounts of allergen. So always check with a food allergic child’s parents before allowing a child with a food allergy to eat a piece of candy, even if you think it is safe.

If you are planning to participate in the Teal Pumpkin Project, and welcome children with food allergies and other dietary restrictions to trick-or-treat safely at your home by offering non-food treats, like the candy alternatives listed above, make sure to go and get detailed Teal Pumpkin Project directions and a free printable Teal Pumpkin sign at FARE.

If a child with a food allergy will be attending a party at your home tonight, ASK THE CHILD’S PARENTS what foods are and are not safe for that child to eat. Do not assume that a child can safely eat a food just because “It’s not peanut-flavored” or “it doesn’t look like it has dairy.” Many foods contain hidden allergens and even trace amounts of an allergen can cause a severe allergic reaction for some people. If a child with a food allergy says “No thank you” to a cookie or cupcake or piece of candy you offer tonight, please listen and don’t push, even if you think the food you are offering is allergy-safe. Kids with food allergies aren’t being picky or rude when they refuse an offered treat. They are just trying to stay healthy. It’s actually very hard for kids with food allergies to say “No thank you” all night long while other people all around them are enjoying fun food without a care!

If a child with a life-threatening food allergy will be in left your care tonight, make sure that child will be carrying epinephrine. Ask what you can do to help recognize the signs of an allergic reaction, and ask whether the child or the child’s parents would be willing to train you on how to administer the child’s medicine, just in case. YOU CAN LEARN TO USE AN EPINEPHRINE AUTOINJECTOR. These devices are very safe and easy to use. It takes just minutes of training to learn how to save a life.

Happy Halloween, and thanks for helping to keep kids with food allergies safe!