Helping Families Manage Food Allergy in Schools

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The Growing Problem of Food Allergy

Food allergy is a growing epidemic in the United States. The Centers for

Disease Control and Prevention estimate that nearly 3 million children

younger than 18 years are affected by food allergy; over the past 10 years,

the number of new cases of food allergy has increased 10-fold.[1] Food

allergy can have a wide-ranging, negative effect on children and their

families, affecting not only life at home but also work, education,

vacation, and entertainment. Virtually no life activity remains unaffected

by the presence of a potentially fatal allergy.[2] Recognizing that there is

no known cure or proven treatment, the number of cases of food allergy is

expected to increase. Studies have also suggested that many food allergies

persist longer than was once previously assumed.[3] The chances are high

that an individual parent or child will interact with a food-allergic person

every day. Although much work has been accomplished in spreading the message

that food allergens can potentially be life-threatening, a clear lack of

understanding about this issue in many persons *without* food allergy

remains.[4] The main management strategy for food allergy -- avoidance -- is

difficult to implement, a fact often underappreciated by unaffected

individuals. Food allergy has become a global social issue, and protecting

the health and self-esteem of affected children as well as the quality of

life of the family, is a responsibility that must be shared by the entire

community.

Sending a food-allergic child to school, camp, or child care can be a

daunting task for a parent and may be associated with much anxiety.

Increasingly, allergists and nonallergists are being asked to help prepare

students and their families to make a safe transition. This involvement

consists of ensuring the following:

- Each student has a self-injectable epinephrine device;

- The family and child (if age-appropriate) know how and when to use the

device;

- The family can train others to use the device; and

- The student has an emergency action plan for the facility to follow in

case of a reaction.

Often, more detailed involvement is requested in guiding classroom and/or

facility-wide policies, such as the establishment of section 504 plans or

other individualized health plans that afford protection and services for

food-allergic children at school. Understanding real vs perceived risks of a

potential food-induced reaction at school or child care can be helpful in

planning.

Let's review the published evidence to gain a better understanding of this

situation.

How Common Are Reactions at School? What Are the Chances That a Reaction

Will Occur at School or a Child Care Center?

Reactions do occur at school and can be severe under certain circumstances;

however, their overall occurrence is still rare. There are no exact data

detailing how often reactions occur in school.[5] One study found that they

occurred more frequently in younger children, particularly those in

preschool and kindergarten.[6] The reasons for this are not entirely clear,

although a contributing factor may be that food allergy commonly first

presents at that age, and therefore some initial reactions may occur in the

school or child care setting. Another potential contributor is that common

allergenic foods (eg, peanut butter) may be used in class projects, which

increases the potential for exposure. In addition, older children may be

more experienced and better trained in knowing what they can and cannot eat,

explaining the lower rate of reactions in the older age range.

Sadly, there is a growing trend among some parents to “home-school” their

food-allergic children out of fear that their child is at high risk for a

reaction that will not receive adequate protection at school. This

misperception diminishes quality of life for these families. There are no

data to support the need for home-schooling to provide protection and

decrease risk.[5] It is important to understand that the vast majority of

even severely food-allergic children can and *do* attend school safely every

day, and there seems to be little risk in attending school for food-

allergic children.[5-7]

What Route (eg, Oral, Contact, Inhalation) Is Most Likely to Cause a

Reaction at School or Child Care?

The highest risk for any food-induced reaction stems from direct ingestion

of the food. Moreover, the risk for a severe allergic reaction from an

unintended environmental exposure, such as contact with a contaminated

surface or inhalation of air-borne particles, seems to be extremely low.

Unfortunately, a common misperception held by many persons in the

food-allergic community is that these are realistic risks. This belief

causes unnecessary alarm and anxiety and may lead to requests for

unwarranted precautions to be taken at school or child care, or may

influence the decision to home-school.[8,9] However, the evidence to the

contrary is quite clear.

Peanut and tree nut particles are commonly believed to have the potential to

provoke a reaction from air-borne inhalation.[5,6,10] In a study from s

Hopkins, researchers failed to detect measurable quantities of peanut in air

filters around the necks of volunteers who danced on peanut shells scattered

on the floor of a poorly ventilated room.[8] Similarly, in a study from

Mount Sinai, blinded participants inhaling from a jar of peanut butter at

very close range did not experience significant allergic reactions from the

exposure.[9] This same study also did not find detectable levels of peanut

on surfaces first smeared with peanut butter then cleaned with commercial

products. Detectable levels were also not found on hands coated with peanut

butter and then washed with soap and water, nor after cleaning with liquid

hand sanitizer.

Skin contact as a route of exposure may be of particular concern in younger

children who are more prone to touch contaminated items and not wash their

hands before placing them in their -- or someone else's -- mouth. This is

why a policy supporting strict handwashing after food contact in young

children is important (to prevent both allergic reactions and infections).

Nonetheless, these children still need to ingest the food to cause severe

symptoms, although cases of contact urticaria can occur from certain foods

in allergic children. Contact urticaria is generally self-limited to a

cutaneous reaction that causes some mild discomfort without further

generalization to other organ systems.[11] Wiping down the skin area of

allergen contact often resolves the reaction. However, contact urticaria

could be misinterpreted by a frightened observer unfamiliar with the child's

reaction history as a sign of a more severe reaction.

Inhalation reactions are frequently reported anecdotally, although again,

evidence to support this as a reaction-inducing mechanism is

limited.[6-9]What most likely occurs in these cases is that dust or

particles are briefly

released into the air but settle quickly, and unnoticed contact between the

skin -- and subsequently the oral mucosa -- and the now-contaminated surface

occurs, introducing unrecognized ingestion. (For example, a hand might touch

a contaminated counter, and then is brought to the mouth.) Alternatively,

anxiety in this situation may induce subjective symptoms like wheezing or

shortness of breath attributable to paradoxic motion of the vocal cords,

pharyngeal tightening, a globus sensation, itching, and even urticaria.

To summarize a point that is often misperceived: The greatest risk for a

reaction at school or child care in a food-allergic child is from direct

ingestion of the allergen and not from other routes of exposure. This is

essential to keep in mind when making any classroom or facility

recommendations.

rest can be found at www.medscape.com (free registration) Under Medscape

Pediatrics

let me know if you have problem finding it...

--

Ortiz, MS, RD

*The FRUGAL Dietitian* <http://www.thefrugaldietitian.com>

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