An in-depth conversation with a leading food allergy specialist on what every center director needs to know about protecting young children

When it comes to anaphylaxis preparedness in early childhood settings, few experts bring the unique combination of medical expertise and practical childcare insight that Dr. Alice Hoyt offers. As Chief Allergist at the Hoyt Institute of Food Allergy, Chair of Code Ana, and Founding Partner of the Early Childhood Anaphylaxis Collaborative, Dr. Hoyt has dedicated her career to improving food allergy outcomes for children and supporting the educators who care for them.

Dr. Hoyt’s credentials are extensive: board-certified in internal medicine, pediatrics, and allergy & immunology, with over a decade of academic, evidence-based practice. But what sets her apart is her deep understanding of the real-world challenges facing early childhood programs. Through her work with the Early Childhood Anaphylaxis Collaborative and her top-ranked podcast “Food Allergy and Your Kiddo,” she bridges the gap between medical best practices and practical implementation in childcare settings.

We sat down with Dr. Hoyt to discuss the most pressing questions center directors and compliance officers have about anaphylaxis preparedness, from understanding the real risks to implementing sustainable response protocols.

Understanding the Scope and Risk

Dr. Hoyt, many center directors wonder how significant the anaphylaxis risk really is in early childhood settings. What should they know?

The statistics might surprise many childcare leaders. We know that children under six are the most likely age group to experience their first allergic reaction, and these initial reactions often happen in childcare settings rather than at home. What makes this particularly challenging for early childhood programs is that symptoms in young children can look very different from what most people expect.

I often tell directors that persistent crying, eye rubbing, or regurgitation after eating might actually be early signs of anaphylaxis, not typical childhood behaviors. Young children can’t articulate what they’re feeling, so these seemingly normal behaviors can actually be critical warning signs.
Perhaps most concerning is that up to one-third of anaphylaxis events in childcare occur in children with no previously known allergies or whose allergies aren’t documented with staff. This means that even centers with excellent individual allergy action plans may not be fully prepared for every scenario.

From a compliance perspective, what are centers’ actual legal obligations when it comes to anaphylaxis preparedness?

Legal requirements vary significantly by state and locality, but I’m seeing a clear trend toward more comprehensive requirements. Many states now have laws that allow or encourage early childcare centers to stock undesignated epinephrine, and some require specific training protocols for staff.

What I emphasize to directors is that compliance isn’t just about meeting minimum legal standards—it’s about creating a comprehensive safety framework. Centers need to consider how anaphylaxis preparedness fits into broader duty of care obligations, health and safety regulations, and licensing requirements. The goal should be creating protocols that can withstand scrutiny from regulators, parents, and potentially legal proceedings.

Developing Response Plans and Protocols

You often talk about the difference between individual allergy action plans and center-wide anaphylaxis response plans. Can you explain this distinction?

Absolutely, and this is a critical distinction that many centers miss. Individual allergy action plans are specific protocols for children with diagnosed allergies, typically provided by the child’s physician and parents. These are essential, but our research shows that 1 in 7 children with diagnosed food allergies don’t have these plans on file with their childcare provider.

A center-wide anaphylaxis response plan is different—it establishes protocols for recognizing and responding to severe allergic reactions in any child, whether they have known allergies or not. This plan should outline recognition symptoms specific to young children, step-by-step response procedures, clear staff roles and responsibilities, emergency contact protocols, and comprehensive post-incident documentation requirements.

I tell centers that they need both, but the center-wide plan is actually more critical because it covers those unexpected first reactions that we see so often in early childhood settings.

How can centers ensure their anaphylaxis response plan actually works when it matters most?

This is where I see many well-intentioned plans fail. The most comprehensive plan will fail if staff can’t execute it under pressure. Effective implementation requires several key elements that I’ve learned from working with centers across the country.

First, regular training that goes beyond just reviewing procedures—staff need hands-on practice with epinephrine auto-injectors and scenario-based drills. I recommend practicing with the actual devices they’ll use, not just watching videos.

Second, meticulous documentation of who’s been trained, when, and what specific competencies they’ve demonstrated. This isn’t just for compliance—it’s about ensuring that when an emergency happens, you know exactly who can respond effectively.

Third, regular plan reviews and updates based on new research, regulatory changes, or lessons learned from incidents. The field of food allergy management evolves rapidly, and plans need to keep pace.

Most importantly, your plan needs to be easily accessible and actionable. If staff have to hunt through binders or navigate complex systems during an emergency, precious time is lost.

Training and Staffing Considerations

What level of anaphylaxis training should centers require for different staff roles?

I recommend a tiered approach based on risk and responsibility. All staff who interact directly with children should be trained to recognize anaphylaxis symptoms in young children and know the basic response protocol, including when and how to call for help.

However, designated staff members—particularly those in supervisory roles or who are present during meal times—should have more comprehensive training, including hands-on experience with epinephrine administration. I always recommend having multiple trained staff members present during high-risk times like meals and snacks.

From my work with centers, I’ve learned that documentation is absolutely critical here. You need to track not just who’s been trained, but what specific training they received, when it expires, and how you’ll ensure refresher training happens on schedule. This becomes a significant operational challenge as staff turnover occurs and training requirements evolve.

Speaking of staff turnover, how can centers maintain training compliance with high turnover rates?

Staff turnover is honestly one of the biggest operational challenges I see centers face with anaphylaxis preparedness. The solution lies in systematic approaches that don’t rely on individual memory or manual tracking.

I always recommend building anaphylaxis training into the standard onboarding process, with clear timelines and competency requirements. Establish automated reminders for refresher training and maintain centralized records that track each staff member’s training status in real-time.
Consider implementing just-in-time training resources that staff can access immediately when needed. The goal is creating systems where training compliance happens automatically as part of normal operations, rather than being a separate administrative burden that’s easy to overlook during busy periods.

Medication Management and Procurement

Should centers stock undesignated epinephrine, and how do they determine what to keep on hand?

Given that one-third of anaphylaxis events occur in children with no known allergies, I consider stocking undesignated epinephrine a best practice rather than just an option. Many states now specifically allow or encourage this practice, and I expect this trend to continue.

The key considerations are ensuring you have appropriate weight-based doses for your population and understanding the procurement and storage requirements. Epinephrine auto-injectors typically come in specific dosing ranges, so centers need to analyze their enrollment demographics to determine what products to stock.

Storage requirements include temperature control, security considerations, and expiration date management. Centers also need protocols for staff authorization to administer undesignated epinephrine and comprehensive documentation requirements for when it’s used.

How should centers manage epinephrine expiration dates and replacement costs?

This is a practical challenge that every center faces. Epinephrine management requires systematic tracking of expiration dates, proper storage conditions, and budget planning for replacements. Auto-injectors typically have 12-18 month shelf lives, so you’re looking at regular replacement costs that need to be built into operational budgets.

I always tell centers to consider the total cost of ownership, which includes not just the medication cost but also staff time for inventory management, training on different devices, and the administrative overhead of maintaining compliance documentation. Some centers find that standardizing on specific devices reduces training complexity and operational burden.

Automated tracking systems can provide alerts for approaching expiration dates and help ensure you never find yourself in an emergency situation with expired medication—a scenario that unfortunately I’ve seen happen.

Documentation and Incident Management

What documentation do centers need to maintain for anaphylaxis preparedness?

Comprehensive documentation serves multiple critical purposes: regulatory compliance, liability protection, quality improvement, and operational continuity. From my experience working with centers and regulatory bodies, key documentation includes staff training records with dates and competencies demonstrated, detailed incident reports that capture what happened and how the response protocol was followed, medication inventory logs including expiration dates and storage conditions, and regular plan reviews and updates.

The challenge I see repeatedly is maintaining this documentation consistently over time and across multiple staff members. Manual systems often fail during busy periods or staff transitions, leading to gaps that could become compliance issues or liability concerns.

How should centers handle documentation if an anaphylaxis incident actually occurs?

This is where advance planning really pays off. Incident documentation needs to happen quickly but thoroughly. I recommend that immediate documentation capture the timeline of events, specific symptoms observed, interventions taken, staff involved, and emergency services contacted. This initial report should be completed while details are fresh, ideally within hours of the incident.

Follow-up documentation should include family notifications, regulatory reporting if required, post-incident plan review, and any recommended changes to protocols or training. Centers need to consider how they’ll maintain confidentiality while ensuring that lessons learned can improve overall preparedness.

The documentation process itself should be streamlined and integrated into existing incident management workflows. Complex or time-consuming documentation processes often result in incomplete records, which serves no one’s interests when you’re trying to improve care or demonstrate compliance.

Regulatory and Quality Assurance

How do licensing inspectors typically evaluate anaphylaxis preparedness?

From my conversations with regulatory officials and center directors, I’ve learned that inspectors increasingly focus on whether centers have comprehensive, documented systems rather than just checking boxes on individual requirements. They’re looking for evidence that anaphylaxis preparedness is systematic, current, and actually implemented rather than just existing on paper.

Common inspection focus areas include staff training documentation and currency, medication storage and inventory management, incident response procedures and documentation, and integration with overall health and safety protocols.

Inspectors appreciate centers that can demonstrate continuous improvement in their anaphylaxis preparedness—showing that they regularly review and update their approaches based on new guidance, lessons learned, or changes in their program.

How can centers demonstrate continuous improvement in their anaphylaxis preparedness?

Continuous improvement requires systematic data collection and analysis. I recommend that centers track training completion rates and identify patterns in any gaps. Monitor incident response times and outcomes to identify improvement opportunities. Regularly review and update protocols based on new research or regulatory guidance.

The most effective approach I’ve seen is integrating anaphylaxis preparedness into broader quality management systems, with regular reviews, measurable outcomes, and documented improvements over time. This demonstrates to regulators, parents, and staff that you’re committed to excellence rather than just minimum compliance.

I always encourage centers to participate in professional development opportunities and stay current with organizations like the Early Childhood Anaphylaxis Collaborative to ensure their approaches reflect current best practices.

Implementation and Operational Integration

From your work with centers, what’s the biggest operational challenge in implementing comprehensive anaphylaxis preparedness?

Without question, the biggest challenge is integration—making anaphylaxis preparedness feel like a natural part of daily operations rather than an additional burden. Many centers struggle with the administrative overhead of maintaining training records, tracking medication inventories, and ensuring consistent documentation across all staff and shifts.

The most successful implementations I’ve observed are those that integrate anaphylaxis preparedness into existing operational workflows and systems. When compliance happens automatically as part of normal operations, it’s sustainable. When it requires separate, manual processes, it often fails during busy periods or staff transitions.

How can center directors get buy-in from staff who might feel overwhelmed by additional requirements?

Staff buy-in comes from demonstrating value rather than just imposing requirements. I always encourage directors to help staff understand how anaphylaxis preparedness protects the children they care about, supports their professional development, and actually makes their jobs easier by providing clear protocols for emergency situations.

Focus on making compliance as straightforward as possible. Provide clear, accessible training and resources. Use systems that automate administrative tasks rather than creating manual work. Recognize and celebrate staff who demonstrate excellence in anaphylaxis preparedness.

Most importantly, position anaphylaxis preparedness as part of your center’s commitment to excellence rather than just a regulatory requirement. When staff see it as supporting their mission of caring for children, they’re much more likely to embrace it fully.

What final advice would you give to center directors who are just starting to develop their anaphylaxis preparedness programs?

Start with the fundamentals, but think systematically from the beginning. Develop your center-wide response plan first, then build training and operational procedures around it. Don’t try to do everything at once—focus on creating sustainable systems that will work consistently over time.

Connect with other professionals who are facing the same challenges. The Early Childhood Anaphylaxis Collaborative exists specifically to support centers with resources, training, and peer learning opportunities. You don’t have to figure this out alone.

Remember that anaphylaxis preparedness isn’t just about compliance—it’s about creating an environment where children with food allergies can thrive safely, where parents have confidence in your program, and where staff feel prepared and supported when they need to respond to emergencies.

About Dr. Alice Hoyt

Dr. Alice Hoyt is Chief Allergist at the Hoyt Institute of Food Allergy, Chair of Code Ana, and Founding Partner of the Early Childhood Anaphylaxis Collaborative. Board-certified in internal medicine, pediatrics, and allergy & immunology, she has over a decade of experience in academic, evidence-based medicine with a focus on food allergy management in young children.

Dr. Hoyt hosts the top-ranked food allergy podcast “Food Allergy and Your Kiddo” and has helped establish food allergy centers of excellence at major medical institutions. Her work bridges medical expertise with practical implementation guidance for early childhood educators.

For more resources on anaphylaxis preparedness, visit the Early Childhood Anaphylaxis Collaborative or learn more about Dr. Hoyt’s work at Food Allergy and Your Kiddo.