Schools, childcare facilities lack adequate policies for food allergies

Increased awareness is necessary to assure that reactions are properly treated.

Issue: September 2008

Many children attend schools or day care facilities that do not have clear policies for food allergies, and the staff is often ill prepared to handle emergency reactions, according to the results of a recent survey.

The survey was conducted by researchers at the University of Michigan Health System.

“Every food-allergic patient who is attending a school or childcare facility should unequivocally have a self-injectable epinephrine device at school with them, and they should be sent to school with a very clearly written allergy action plan,” Matthew Greenhawt, MD, previously a fellow in the division of allergy and clinical immunology at the University of Michigan Health System and currently an associate at the Allergy & Asthma Center LLC in Atlanta, told Infectious Diseases in Children. “As physicians, we can certainly write letters that explain the rationale behind the treatment and … make sure that parents know how to use the device so they can also teach others.”

Self-reported responses from 409 food-allergic children or their guardians indicated that 42% of participants had multiple allergic reactions in school or childcare settings and that 43% had symptoms consistent with the criteria for anaphylaxis established by the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network. Even though that about half of these children had action plans and epinephrine available, the plan was only followed in 25.2% of cases, and only 32% of children were administered epinephrine. “That’s a huge discrepancy based on the levels of severity,” Greenhawt said.

Education and communication

Simply providing school personnel with treatment plans and medication may not be enough. Training those who care for these children to recognize symptoms of allergic reactions and to understand the ways in which unintended or accidental exposure to allergens occur may improve the care they receive in these settings.

Encouraging hand washing after food contact, warning young children not to share food, clearly labeling food ingredients and posting signs that warn children not to eat certain foods if they are allergic to a given ingredient are all techniques that can reduce the likelihood of exposure, according to the researchers.

Implementing nut-free policies, such as providing children with a designated table in the lunchroom, is another option, although there are no results of studies that have indicated that this is effective. Also, emphasizing one allergen vs. another is somewhat controversial, according to Greenhawt. “Some of these children, certainly the older kids, may feel a stigma. They have to sit at a certain table, they can’t eat this, they can’t eat that. Those are the things we hope to avoid through more awareness,” Greenhawt said.

The researchers also compared treatment quality among children who attended facilities with nursing available vs. those where no nurse was on staff. The results were as follows:

Received treatment at school, 47.2% vs. 34%.
Had allergy action plan on file, 66.9% vs. 47.6%.
Had allergy action plan followed, 62.2% vs. 39.2%.

“This is something that should not be overlooked in terms of providing as safe an environment as possible,” Greenhawt said. However, 30.9% of those who had reactions in kindergarten or later reported that the school did not employ a nurse. “It has been rather eye-opening to learn how few facilities have an on-site nurse,” he said.

Involving parents to improve school preparedness in treating these children is essential. Although physicians can create treatment plans and write letters, the burden of responsibility rests mainly with the parents. It is important for parents to ascertain if the school has faculty prepared to recognize and treat their child’s food allergies, and being prepared themselves to educate the faculty about their child’s food allergies is also important, according to Greenhawt. The ability to bring about changes by voicing their concerns should not be underestimated. Schools are more likely to implement policy changes in response to specific parent requests, according to information from a poster presentation at the 2008 American Academy of Allergy, Asthma and Immunology Annual Meeting, held in Philadelphia earlier this year.

“The school study has a lot of importance,” Greenhawt said. “It highlights that there is a lot of work to be done and provides the basis for physicians to look at this again in another five years to see if we’ve corrected our mistakes.” – by Nicole Blazek

For more information:

Greenhawt MJ, McMorris MS, Furlong TJ. Self-reported allergic reactions to peanuts and tree nuts occurring at school and child care centers. #369. Presented at: 2008 American Academy of Allergy, Asthma and Immunology Annual Meeting; March 14-18, 2008; Philadelphia.