Q:

8/27/2013
As a pediatrician and mother of a child with peanut allergy, I have a million questions/concerns as I battle to keep my daughter safe from accidental peanut exposure. Why do allergists not recommend banning peanuts from schools? Being that the mainstay of treatment is avoidance and having epinephrine, it seems to me it is impossible to avoid peanut in our public elementary school environments. I have read that the likelihood of outgrowing peanut allergy is greatest before age 8, so the early elementary years are CRITICAL for peanut allergic children if we are to maximize their chances of outgrowing this allergy.

In my opinion, Allergists are contradicting themselves by recommending strict avoidance but not peanut bans in schools. Allergists claim that banning peanuts would give a false sense of security. I strongly disagree with this reasoning. Young kindergarteners should not be made exclusively responsible for their well-being. They are not mature enough to know where hidden peanut may lay or to keep their hands away from their mouths/faces. I believe it is UNSAFE to throw our tiny kids into peanut butter jars, which is what our schools are, and expect them not to be exposed. No wonder so few kids (15-20%) outgrow their peanut allergy. Where is the evidence-based medicine that proves that banning peanuts from school is not helpful for avoidance? I haven't found it. I know there will be parents who will not comply with the peanut ban, but most will. Reducing the peanut content in our kids' environment will still be better than having a huge amount of peanut all over the schools. Peanut bans would not mean letting our guards down, we would still have epis, etc.

I strongly urge the AAAI to reconsider their peanut management recommendations, because the current ones do us a disservice. I am entering discussions with my schools administrators to seek a peanut ban and am having a very tough battle with them. The reason I seek a ban is because their current policies do not work. They do not ENFORCE a peanut-free zone in the classrooms. Posting a sign on the door does no good if parents are still allowed to pack peanut-containing products. No one checks snacks/lunches to ensure compliance. I refuse to accept the current lax policies and will not throw my child into the lions to fend for herself at age 5. If age 5 is considered mature for peanut self-management, then why don't we teach sex education in kindergarten? Thus, we could start preparing them for the real world as early as possible. That's ridiculous, right? That's how I see the attempts to prepare a child for age 5 to manage her peanut allergy. There will be plenty of time to do that later when she is more capable to make decisions. My main concern at age 5 is to keep avoiding peanuts/treenuts strictly so she may have a chance to outgrow it! If she keeps being exposed to peanuts in school, her antibody levels may rise with each reaction and she would never outgrow it. I strongly urge the AAAI and all allergists to consider your stance on this recommendation. Having your strong support in favor of peanut bans would help families seeking strict avoidance if peanut in all environments, home and school. Thank you.

A:

Thank you for your letter.

I clearly understand your position, and from reading your e-mail, I also feel that you have become familiar with the position of experts in this field who have not advised the banning of peanuts. Some of the opinions you expressed make me realize that you are already aware of the rationales that have been employed to justify the opinion that banning peanuts in schools would be inadvisable. This is an issue which has been debated almost endlessly, and there are proponents of both sides of the argument. Both sides are sometimes strongly invested in their own views of this issue, as I can tell you are. Both sides can be argued vigorously.

We have many issues in anaphylaxis that fit into the same category. The reason for the debate is that such issues cannot be answered on the basis of controlled trials, and therefore we have no true definitive supporting evidence for either side of the issue.

One such issue, for example, revolves around when to administer epinephrine in a potential case of anaphylaxis. This occurs when a child, thought to be allergic to a food, ingests the food, but has no symptoms after the ingestion. There are proponents of administering epinephrine immediately and there are other proponents who state that the child should be watched and administered epinephrine only if symptoms occur. There are no clear-cut data to support either side. We will never be able to attain these data because we cannot do controlled trials.

We have no controlled trials to compare outcomes in schools where peanuts are banned versus schools where they are not. I do not think this study will ever be done, in part because of the emotional investment in the issue.

So, I do not think it would do a great deal of good to become, on this website, involved in these polemics. However, we are placing your letter online so it can be reviewed by our readers, many of whom are experts and publish in this area.

Thank you again for your interest in our website, and for the expression of your opinion.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology