“Is there a doctor or medical professional on board?” Answer that call and you may be treating anaphylaxis in a cramped cabin, mid-turbulence, with no medical history, no weight, no records, and no emergency department nearby. You should be able to assume one thing: that the aircraft’s medical kit holds the right medication, in a usable form, at the right dose. Under a new Federal Aviation Administration (FAA) proposal, that assumption may not hold.
Current regulations prescribe the specific medications airlines must carry, including epinephrine. The FAA wants to scrap that list for a flexible, “performance-based” standard: Kits would only need to provide initial treatment for nine life-threatening conditions, anaphylaxis among them, and each airline would decide which medications to carry and how much. The proposal’s own language is telling. Treatment for anaphylaxis “could include medication such as epinephrine.”
That word “could” should alarm every medical professional. Epinephrine isn’t one option among several; it’s the first-line treatment for anaphylaxis. Antihistamines ease itching and hives, but they don’t reverse a reaction and can’t substitute for epinephrine. Prompt treatment means better outcomes, and that matters even more in the air, where advanced care is hours away. Yet the proposal doesn’t clearly require epinephrine in every kit. It doesn’t require an auto-injector or nasal spray. It doesn’t specify doses for infants, children, and adults. It doesn’t say how many doses must be aboard.
No medical professional should be handed an antihistamine, an unsuitable dose, or a vial to draw epinephrine from mid-turbulence while a passenger struggles to breathe. FDA-approved, easy-to-administer epinephrine devices exist. They should be required.
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A firsthand account shared with No Nut Traveler, the food-allergy nonprofit I run, shows why mentioning epinephrine isn’t enough without specifying quantity and patient size. On a July 20, 2026, Alaska Airlines flight from Iceland to the United States, a twelve-year-old passenger and an unrelated adult, both with tree nut allergies, reacted after eating the same pasta salad. The child’s parents had disclosed his allergy and reconfirmed the meal was nut-free; the crew checked the allergen information on file, which also showed it was safe. Only after both passengers became ill did the family learn a last-minute catering substitution had introduced cashew oil into the dressing, and that the allergen information was never updated.
The proposal doesn’t answer the questions that incident raises. If two passengers need epinephrine and the aircraft carries only one device, who gets it? If that device is intended for an adult, is it appropriate for a child? What if either needs a second dose? These aren’t theoretical; they’re decisions a responding medical professional may have to make in minutes, with limited information and no backup.
That gap is compounded by a second problem: incomplete allergen labeling. Restaurant-style airline meals in the U.S. aren’t required to carry the same labeling as packaged grocery food. The FDA told me it encourages transparency, but it does not require it. Dr. Anna Nowak-Wegrzyn learned about labeling in the air through her own patient, who developed anaphylaxis after eating airline pasta with red sauce. The label listed milk, egg, and wheat, but not tree nuts. Both the patient and the flight attendant believed the meal was safe. It wasn’t.
Flight attendants who assure passengers a meal is safe are relying on catering information they have no way of knowing is incomplete. The consequences can be fatal. According to a lawsuit filed by his family, seventeen-year-old Jason Hu of Pennsylvania died from anaphylaxis aboard a Qatar Airways flight. He and his father had disclosed his severe allergies, and a crew member allegedly assured them a sandwich was safe. That crew member likely believed the information they’d been given.
Patients are taught to read labels, disclose allergies, ask questions, and avoid unverified food. A passenger can do all of that and still meet an undeclared allergen in the air. When incomplete allergen information can legally move through airline catering, a reaction isn’t unforeseeable; it’s a predictable emergency that airlines must be ready for. That is why the medical kit’s contents matter.
The FAA frames this proposal as flexibility, and flexibility has a real upside: Airlines could adopt new FDA-approved devices without waiting for regulations to catch up. But flexibility needs a safety floor beneath it, and this proposal doesn’t clearly have one. Its advisory circular includes a recommended medication list, drawn from a 2025 FAA/Aerospace Medical Association working group report, naming epinephrine and referencing a “premeasured auto-delivery device vs. vial-drawn kit.” That may sound reassuring, until you read the fine print. Advisory circulars describe an acceptable means of complying with a rule, not the only means. They do not have the force and effect of law, and they do not bind airlines.
I asked the FAA directly: What legal weight does that list carry if it isn’t binding, and will the rule require epinephrine dosed for infants, children, and adults rather than one adult-dose product with a dosing chart? Its written response: “FAA is unable to respond to your questions beyond providing you with the same information which you cited from the NPRM and advisory circulars.” The agency invited me to raise these concerns as a public comment instead and said my questions and its response would be added to the docket.
That’s the problem in a sentence. If the FAA cannot confirm the final rule requires epinephrine, age-appropriate dosing, adequate quantities, and an easy-to-administer device, no one can assume those protections will exist. A recommendation in nonbinding guidance is not a guarantee.
The current list has always been a floor, not a ceiling. Airlines add to it freely, and the FAA notes that Southwest, United, Alaska, Delta, American, and Frontier all voluntarily added opioid-overdose medication. But that same freedom hasn’t produced consistent anaphylaxis preparedness: Only JetBlue and Southwest have confirmed they voluntarily carry epinephrine auto-injectors beyond what’s required. If flexibility alone worked, modern epinephrine devices would already be standard industry-wide. They aren’t.
A passenger shouldn’t have different access to lifesaving medication depending on which airline they happen to fly, and a federal safety rule should set one dependable baseline. This proposal would erode that baseline further by eliminating the exemption process: Today, an airline that can’t carry a required medication must formally request an exemption, leaving a record of what’s missing and why. Once specific medications are no longer required, an airline can simply choose different contents: no exemption, no record, no accounting.
For some conditions, that flexibility might not compromise safety. But there is no substitute for epinephrine in anaphylaxis. Once the required list and the exemption process are both gone, who would know if epinephrine were missing? How would passengers, medical professionals, or regulators find out? If every operator sets its own quantities, how would anyone know whether a given aircraft carries enough epinephrine for a child and an adult, for repeat dosing, or for two emergencies at once? Removing the required list removes part of the disclosure and enforcement trail that came with it. We may end up knowing less about what’s onboard, not more.
The FAA says it will collect data to guide future adjustments, but in-flight anaphylaxis isn’t systematically recorded today. FAA officials have repeatedly told me the agency doesn’t require airlines to report these reactions and doesn’t track them; reporting varies by airline, and thus many reactions may never enter any database. That makes the real burden hard to calculate and feeds the assumption that these events are rare. Absence of data is not evidence of absence.
The 2025 FAA/Aerospace Medical Association working group report anchors the FAA’s recommended medication list. It drew its data from medical kit providers, who can track when a kit is opened and restocked, but not anaphylactic reactions passengers treat without ever touching the kit. Reactions managed with a passenger’s own medication, or never reported to the crew, may therefore be absent from the data used to estimate how often these emergencies occur.
A large global study of food-allergic air travelers, led by researchers at Northwestern University’s Center for Food Allergy & Asthma Research (CFAAR) and published in JACI: In Practice in 2024, may help answer questions about how often allergic reactions occur during flights. The study approached the question differently: It asked passengers directly and found a much higher rate than previous studies.
Of 4,704 people surveyed, roughly 1 in 12 (8.5 percent) reported an in-flight allergic reaction. Only about half of those reactions were ever reported to a crew member or airline. Among passengers who used epinephrine, more than 90 percent relied on their own supply rather than the aircraft’s kit, precisely the population that kit-provider and airline data may miss. These findings do not prove that other published estimates or conclusions about trends over time are wrong. But they strongly suggest that studies relying primarily on medical kit use and airline reports (when airlines are not required to report these events) may undercount the true number of in-flight allergic reactions.
The recent lawsuit that disclosed the in-flight anaphylaxis death of Jason Hu from 2024 didn’t even become public until 2026. How many more reactions, diversions, or deaths go uncounted for lack of standardized reporting? A performance-based standard built on kit-provider data can’t adapt to passenger needs the FAA hasn’t actually measured. We cannot evaluate what we don’t count.
The proposal isn’t without merit. It names anaphylaxis as one of nine life-threatening conditions kits must address, and it repeatedly invokes “modern” medications and equipment as the goal. But “modern” is never defined, and naming a problem is not the same as requiring a solution. The final rule should require easy-to-administer epinephrine, dosed for infants, children, and adults, in quantities sufficient for repeat dosing and simultaneous emergencies. It should state plainly that antihistamines cannot substitute for epinephrine, and it should require real crew training and standardized reporting of in-flight allergic reactions. Most of all, the word “could” has to go.
The public comment period closes October 5, 2026. More than 700 people have weighed in, but physicians, medical professionals, and health care organizations haven’t yet matched the urgency of the issue. If you treat patients with food allergies, make sure they know airline meal assurances may not offer the protection they expect. And if you might one day answer the call (“Is there a medical professional on board?”), this rule concerns you directly.
The FAA has invited recommendations. Take the agency at its word, and insist these ambiguities get fixed before the rule is final. Tell the FAA:
- Epinephrine must be required, not suggested.
- Binding requirements cannot be replaced by recommendations in a nonbinding advisory circular.
- Easy-to-administer doses appropriate for infants, children, and adults must be available.
- Kits must contain enough medication for repeat dosing and simultaneous emergencies.
- Antihistamines cannot substitute for epinephrine.
- Crew preparedness cannot be left entirely to airline discretion.
- Airlines must report in-flight allergic reactions so the FAA can track and evaluate the standard.
No one should be asked to save a life at 35,000 feet without the medication to do it. Once the rule is final, concern will be too late.
Submit a public comment to the FAA by October 5, 2026.
This article is discussed on The Podcast by KevinMD: Food allergies are treated differently, airline by airline.
Lianne Mandelbaum is a leading advocate for airline safety measures to protect food-allergic passengers. As president of No Nut Traveler and airline correspondent for Allergic Living, she drives policy change by collecting testimonials from food-allergic families to share with lawmakers, media, and advocacy groups. She can be reached on X @nonuttraveler, Facebook, and LinkedIn.
A sought-after speaker and media source, Lianne participated in a Medscape panel on emergency medical kits on planes and contributed global data on airline travel and food allergies at the GA²LEN Anacare Anaphylaxis & Food Allergy Forum. Her travel tips were also featured by Stanford’s Sean N. Parker Center for Allergy Research. She also appeared on Bloomberg to discuss the challenges faced by food-allergic travelers and advocate for policy changes.
Her advocacy led to a Department of Transportation ruling recognizing food allergy as a disability. She co-designed a global air travel and food allergy survey with Northwestern University’s CFAAR, which was presented at AAAAI and published in The Journal of Allergy & Clinical Immunology. She is the co-author of “Understanding Experiences, Barriers, and Facilitators of Safe Airline Travel—A Global Survey of Food Allergy Patients and Caregivers” (The Journal of Allergy & Clinical Immunology). She also contributed to “10 Practical Priorities to Prevent and Manage Serious Allergic Reactions: GA²LEN ANACare and EFA Anaphylaxis Manifesto” (Clinical and Translational Allergy) and “Ever Treat a Patient on a Plane? Why Med Kits Need an Update” (Medscape). Additionally, she collaborated with stakeholders to include anaphylaxis and necessary medications in the FAA Reauthorization Act of 2024.
