Marcus Shaker, MD, a professor of pediatrics and medicine at the Dartmouth Geisel School of Medicine

Marcus Shaker, MD

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Early Introduction, Rescue Refeeding, and Home OIT: Reframing Pediatric Food Allergy Management

No Testing Required: Reframing Early Allergy Introduction

 in infancy, one of the most persistent misconceptions is that allergy testing must come first. Marcus Shaker, MD, of Dartmouth Geisel School of Medicine at Dartmouth Health Children’s, pushed back on that assumption in his Eastern Allergy Conference (EAC) 2026 presentation, emphasizing that no testing is required before early introduction of allergenic foods in most cases.

No allergy testing is required before early introduction of allergenic foods

Early introduction should be pursued with small amounts, advancing as tolerated; any reaction warrants a pause and physician consultation

Children who develop food allergies may be strong candidates for rescue refeeding via early food immunotherapy, which carries a low rate of severe reactions

Home-based OIT models, including Dartmouth's published approach, can improve access and cost-effectiveness

The best general approach: feed early and feed often—but with open communication between families and clinicians throughout

Using a case-based approach, Shaker walked through the case of a child with a suspected egg allergy as a clinical illustration. While further evaluation with a board-certified allergist-immunologist would be appropriate before additional egg exposure, he noted that peanut introduction could proceed without testing. Families could try a small amount, approximately a sixteenth of a teaspoon of peanut flour mixed into a soft food, advancing as tolerated. If any reaction occurs, the guidance is clear: pause and seek evaluation.

“There's very good data that this is a safe and effective approach with a low rate of severe reactions, even safer in infants,” Shaker told HCPLive. “We have health economic data that [shows immunotherapy] can save potentially millions or even billions of dollars over time.”

Rescue Refeeding: A Viable Path When Allergy Develops

For children who develop food allergies, Shaker emphasized that a diagnosis is no longer a one-way door to indefinite avoidance. In 2026, he noted, early food immunotherapy represents a viable "rescue refeeding" approach, with strong supporting evidence for both safety and efficacy.

Oral immunotherapy in early childhood is effective and safe in preschoolers, with particular safety advantages in young infants.

 Shaker described the rate of severe reactions as low and characterized the evidence base as solid.

For families of a child with a confirmed egg allergy, Shaker outlined a collaborative path: working with a board-certified allergist-immunologist to review and implement a rescue refeeding protocol as a long-term partnership, rather than a discrete intervention.

The Dartmouth Spoon Sheet Approach: Home Multi-Food OIT

Shaker referenced Dartmouth's own published experience as an example of how immunotherapy can be made more accessible. The Dartmouth Spoon Sheet Home OIT Program evaluated children with food allergies receiving oral immunotherapy, with a meaningful proportion receiving multi-food OIT that included peanut, tree nut, or milk.

The program is designed to address equity and access barriers, particularly relevant in rural settings where repeated clinic visits for dose escalation can be prohibitive. Repeated clinic visits for food oral immunotherapy can limit equity and access in rural locations, and home protocols are cost-effective.

Shaker said that the role of the clinician is not simply to convey data but to meet families where they are emotionally. He cited Sir William Osler—"The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head"—as a framing device for the conversation about food allergy management.

Read part 1 of our interview with Shaker here: 

Early Allergen Introduction in Infants: Reducing Food Allergy Risk Without Routine Testing

Shaker M. Food Allergy Prevention and Rescue Refeeding in 2026. Session presented at the Eastern Allergy Conference (EAC) 2026 in Palm Beach, Florida, on May 28.

Chua GT, Mack DP, Shaker MS, Chan ES. Oral food immunotherapy in patients with atopic dermatitis. 

2024;133(3):278-283. doi:10.1016/j.anai.2024.05.022

Shaker M, Hughes S. Real-World Multi-Food Home Oral Immunotherapy Using Daily Micro-Dose Schedules Has Low Rates of Adverse Reactions. 

Journal of Allergy and Clinical Immunology

doi:https://doi.org/10.1016/j.jaci.2023.11.394

Videos

At EAC 2026, Dartmouth Children's Health allergist Marcus Shaker, MD, outlined a framework built on shared decision-making for families navigating food allergy in infancy.

in Palm Beach, Florida, Marcus Shaker, MD, from Dartmouth Geisel School of Medicine, Dartmouth Health Children’s, highlighted one of the most important shifts in modern 

 prevention, which is the move toward early introduction of allergenic foods in infancy.

, Shaker emphasized that translating research findings into everyday clinical practice remains a challenge for both healthcare providers and families.

Using a case-based approach, he explored a common scenario: a child with a family history of food allergy whose parents are unsure when and how to introduce allergenic foods.

 The discussion centered on helping clinicians offer evidence-based guidance while acknowledging the realities and anxieties that many families face.

Early introduction of allergenic foods can reduce the risk of developing food allergies.

Routine allergy testing before first exposure is not recommended for most infants.

Avoiding foods based solely on test results may lead to unnecessary dietary restrictions.

Why Routine Allergy Testing Before Food Introduction Is Not Recommended for Most Infants

A key theme of Shaker’s presentation was that routine pre-introduction allergy testing is generally not required before introducing common allergenic foods. He noted that several landmark studies demonstrated a reduction in allergy risk when foods such as peanuts are introduced during infancy.

However, he cautioned against overinterpreting these findings. Although some infants may benefit from targeted evaluation, broad testing strategies can create confusion and unintended consequences. Positive test results do not always predict true clinical allergy, particularly in children who have never eaten the food in question.

Shaker explained that avoiding foods solely because of test results may prevent families from introducing foods that could be tolerated and potentially beneficial. Instead, decisions should be individualized, taking into account the child’s history, risk factors, and family circumstances.

Why Shared Decision-Making Is Key to Food Allergy Prevention Counseling

Shaker stressed the importance of shared decision-making. Parents bring their own values, preferences, and concerns to the discussion, and clinicians must balance scientific evidence with practical considerations.

He also noted that current practice parameters support a conditional recommendation for early allergen introduction, reflecting both the strength of the evidence and the need for flexibility in implementation.

For attendees, the message was clear: early introduction remains a valuable tool for food allergy prevention, but success depends on thoughtful communication, individualized care, and helping families navigate decisions with confidence.

Shaker M. Food Allergy Prevention and Rescue Refeeding in 2026. Poster presented at EAC 2026 on May 28.

Derman C. Early Peanut Introduction Guidelines Linked to Drop in Food Allergy Rates. HCPLive. Published on October 20, 2025. Accessed June 1, 2026. 

https://www.hcplive.com/view/early-peanut-introduction-guidelines-linked-drop-food-allergy-rates

Marcus Shaker, MD, discusses early allergen introduction, food allergy prevention, and the role of routine testing at EAC 2026.

Frequently asked questions (FAQ) about treating anaphylaxis:

When should I give my patients epinephrine for suspected anaphylaxis?

What’s the best observation period when treating anaphylaxis?

What test should I order for patients who experienced anaphylaxis?

Why should I instruct patients to call 911 after using an epinephrine auto-injector?

asked Marcus Shaker, MD, MSc, professor of pediatrics and medicine at the Geisel School of Medicine at Dartmouth, rapid-fire FAQ questions about the treatment of 

When should epinephrine be administered for suspected anaphylaxis?

 Right away. Epinephrine is the first-line treatment for suspected anaphylaxis.

What's the best observation period when treating anaphylaxis?

 The best observation period varies and depends on context and severity of anaphylaxis. For patients who have resolved non-severe anaphylaxis for at least an hour, the likelihood of recurrence of anaphylaxis is in the range of 5%.

What test should you order for patients who experienced anaphylaxis?

 The blood test is called the serum tryptase, and it can be very helpful in establishing a diagnosis.

Why do some patients need to call 911 even after using an epinephrine auto-injector?

 If symptoms are severe or don't immediately resolve or nearly resolve, patients may need additional epinephrine.

They may need additional support, including oxygen and IV fluid. Anaphylaxis can be severe and life-threatening, so if symptoms have not completely resolved or if they recur, patients should call 911 and seek care immediately.

2025 American College of Allergy, Asthma, & Immunology Annual Scientific Meeting

 in Orlando, Florida, from November 6 – 10, Shaker presented on misconceptions many people have surrounding epinephrine use in anaphylaxis management.

 According to Shaker, one of the most enduring myths both clinicians and patients have about epinephrine is that it is dangerous

“It's not,” Shaker told HCPLive during the meeting. “Epinephrine is the first-line treatment of anaphylaxis, and if you're having a severe allergic reaction, it is the recommended approach.”

Another misconception he listed was the necessity of calling 911 after administering epinephrine. Although patients may need to call 911 in certain situations, such as experiencing persistent or worsening symptoms, cardiovascular involvement, or a history of severe reactions, involving emergency services is not always necessary. Shaker said this misconception may result in patients not using their epinephrine to avoid a hospital visit. This myth can also feed the misbelief that epinephrine is dangerous.

At the conference, Shaker also discussed the nuanced approach clinicians must take when managing patients with a known trigger for anaphylaxis.

For instance, it may not be helpful to test a patient for peanut allergies if they are already 100% certain they have a peanut allergy. In this case, it would be more logical to shift the focus from diagnosis to treatment and preparedness.

Clinicians have many food allergy treatment options to select from, including oral and sublingual immunotherapy, biologics such as omalizumab, and a growing range of epinephrine delivery options. He said all of these options allow for richer discussions with patients and families about goals of care and management preferences.

Shaker M. Epinephrine Misconceptions Persist in Anaphylaxis Care, With Marcus Shaker, MD. HCPLive. November 7, 2025. 

https://www.hcplive.com/view/epinephrine-misconceptions-persist-anaphylaxis-care-marcus-shaker-md

Shaker M. When to Prescribe Epinephrine for Known Anaphylaxis Triggers, With Marcus Shaker, MD. HCPLive. November 7, 2025. 

https://www.hcplive.com/view/when-prescribe-epinephrine-known-anaphylaxis-triggers-marcus-shaker-md

Articles

Epinephrine is the primary treatment for suspected anaphylaxis and should be administered immediately. Observation periods vary based on the severity of the reaction, with a 5% recurrence rate for non-severe cases. Serum tryptase tests can aid in diagnosis. Patients should call 911 if symptoms persist or worsen after using an epinephrine auto-injector. Misconceptions about epinephrine's safety and the necessity of emergency services can hinder proper use. Clinicians should focus on treatment and preparedness, especially when triggers are known, and consider various allergy treatment options.

A quick guide for clinicians on epinephrine dosing, optimal observation periods, and the role of tryptase and other labs in anaphylaxis care.


Anaphylaxis Treatment FAQ: When to Give Epinephrine, Order Tests, Call 911

Epinephrine Misconceptions Persist in Anaphylaxis Care, With Marcus Shaker, MD

American College of Allergy, Asthma & Immunology (ACAAI) Annual Scientific Meeting

, Marcus Shaker, MD, MSc, professor of pediatrics and medicine at the Dartmouth Geisel School of Medicine, addressed persistent misconceptions surrounding epinephrine use in 

 management and how shifting these perceptions could save lives.

According to Shaker, one of the most enduring myths among both clinicians and patients is that epinephrine is dangerous.

“It's not,” Shaker said. “Epinephrine is the first-line treatment of anaphylaxis, and if you're having a severe allergic reaction, it is the recommended approach.”

Another widespread misunderstanding, Shaker noted, is the belief that administering epinephrine automatically requires calling 911. Although activating emergency services may be appropriate in some situations, such as persistent or worsening symptoms, cardiovascular involvement, or a history of severe reactions, it is not always necessary.

“This idea that ‘if I use epinephrine, I have to call 911’ can actually lead to people not using epinephrine. One, because of cost, and two, because of inconvenience, and three, because of fear that epinephrine is dangerous,” Shaker said. “I believe that patients should be empowered to use epinephrine when they are having a severe allergic reaction, and they shouldn't feel that if they use it, they have to call 911.”

He also highlighted the importance of clinician-patient connection, noting that anaphylaxis management in 2025 is increasingly centered on individualized care.

“I think engaging with patients and conversations around what matters to them and how they want to manage their allergy, giving them empowerment and how they manage their allergy, is very important, addressing needle phobia and fear, using novel approaches to deliver lifesaving therapies, improving access,” Shaker said. “Probably the most important thing is that patients and families have a connection with the clinician that they're working with, and they feel heard, and they feel that their values and their preferences matter, because they do. So much of how we manage anaphylaxis and risk for anaphylaxis in 2025 is about connecting with people, understanding what's important to them, because there's so many options [that] we have available now, much more than we used to, and the future is bright.”

A reported disclosure for Shaker includes 

Shaker, M. A Case of Anaphylaxis of Known Cause: When to Test, When to Prescribe Epinephrine, When to Prescribe 911. Presented at ACAAI 2025 in Orlando, Florida, on November 7, 2025.

At ACAAI 2025, Shaker dispels epinephrine myths, emphasizing that it is safe, effective, and underused in anaphylaxis care.