Q:

An incoming kindergartner is severely peanut/tree nut allergic. Several questions: Is a peanut free zone in the cafeteria the best way to accommodate lunch times? Will soap and water denature the offending proteins, or is something else or stronger needed? Is a hand sanitizer such as Purell adequate for hand cleaning? Thank you!

A:

Thank you for your recent inquiry.

There are a number of very excellent guidelines regarding the management of food allergy in schools. For your convenience, I have copied below abstracts of three of these which I have found particularly helpful. These should serve as future references for you in regards to the management of food allergy in schools.

You will note that Dr. Todd Mahr is the co-author of the most recent of these which was published in “Pediatrics.” Dr. Mahr is a nationally known expert in this area, and I am asking him to share his opinion and knowledge with us regarding your inquiry. As soon as we receive his response, we will forward it to you.

Thank you again for your inquiry.

J Sch Health. 2004 May;74(5):155-60.
Guidelines for managing life-threatening food allergies in Massachusetts schools.
Sheetz AH, Goldman PG, Millett K, Franks JC, McIntyre CL, Carroll CR, Gorak D, Harrison CS, Carrick MA.
Source
School Health Services, Massachusetts Department of Public Health, 250 Washington St., Boston, MA 02108, USA.
Abstract
During the past decade, prevalence of food allergies among children increased. Caring for children with life-threatening food allergies has become a major challenge for school personnel. Prior to 2002, Massachusetts did not provide clear guidelines to assist schools in providing a safe environment for these children and preparing for an emergency response to unintended allergic reactions. In 2001, the Asthma and Allergy Foundation of America/New England Chapter, Massachusetts Department of Education, Massachusetts Department of Public Health, Massachusetts School Nurse Organization, parents, and other professional organizations forged a successful collaboration to develop guidelines for managing life- threatening food allergies in schools. The guidelines assist schools by providing information on food allergies and anaphylaxis, emphasizing the need for team planning and development of an individualized health care plan, giving guidance on strategies to prevent accidental exposure to specific allergens in school settings, and offering information on emergency responses should unintended exposures occur. The collaborative process for developing the guidelines, which continued during the distribution and implementation phases, set a tone for successful multidisciplinary teamwork in local schools

J Allergy Clin Immunol. 2009 Aug;124(2):175-82, 182.e1-4; quiz 183-4. Epub 2009 Jun 3.
Management of food allergies in schools: a perspective for allergists.
Young MC, Muñoz-Furlong A, Sicherer SH.
Source
Division of Allergy and Immunology, Children's Hospital Boston, Harvard Medical School, Boston, Mass 02115, USA.
Abstract
Epidemiologic studies indicate that food allergy has increased among school-aged children and now affects approximately 1 in 25. Food allergy and other triggers of anaphylaxis pose considerable challenges in the school setting. The cornerstones of management include methods to prevent relevant exposure to allergens and plans to recognize and treat allergic reactions and anaphylaxis. Numerous studies have identified gaps in the implementation of procedures to address these simple tenets. Guidelines and policies have been proposed from various stakeholders to improve the safety and management of schoolchildren with food allergy and anaphylaxis. However, there remain knowledge gaps that preclude suggesting definitive evidence-based guidelines to approach all aspects of management. The allergist plays a key role in guiding families, schools, administrators, and policymakers in developing meaningful plans to improve the safety of the school setting for children with food allergies and anaphylaxis. We review literature that is relevant to key elements that can assist the allergist in addressing patient- and school-specific issues. We additionally focus on areas of current controversy, provide information about available resources, and highlight areas in need of further study

Pediatrics. 2010 Dec;126(6):1232-9. Epub 2010 Nov 29.
Management of food allergy in the school setting.
Sicherer SH, Mahr T; American Academy of Pediatrics Section on Allergy and Immunology.
Collaborators (11)
Sicherer SH, Bahna SL, Chipps BE, Fasano MB, Lester MR, Mahr TA, Matsui EC, Virant FS, Williams PV, Muñoz-Furlong A, Burrowes DL.
Abstract
Food allergy is estimated to affect approximately 1 in 25 school-aged children and is the most common trigger of anaphylaxis in this age group. School food-allergy management requires strategies to reduce the risk of ingestion of the allergen as well as procedures to recognize and treat allergic reactions and anaphylaxis. The role of the pediatrician or pediatric health care provider may include diagnosing and documenting a potentially life-threatening food allergy, prescribing self-injectable epinephrine, helping the child learn how to store and use the medication in a responsible manner, educating the parents of their responsibility to implement prevention strategies within and outside the home environment, and working with families, schools, and students in developing written plans to reduce the risk of anaphylaxis and to implement emergency treatment in the event of a reaction. This clinical report highlights the role of the pediatrician and pediatric health care provider in managing students with food allergies.

Sincerely,
Phil Lieberman, M.D.

We have received a response from Dr. Todd Mahr, which is copied below. Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. Todd Mahr:

As to peanut free zones, part of this is referenced below, but generally, these are hard to follow, they ostracize the peanut allergic child, and it is a slippery slope as to other food allergies, i.e. what do you do with the egg allergic, wheat allergic, etc. We generally teach the child to take a tray, use this as a barrier to the table, and emphasize no sharing of food. I know of schools that will try peanut free zones, but I try and not endorse these. Obviously this takes staff involvement.

By the way, a nice new tool to share with school staff is www.allergyready.com, a free site with a great video for school staff.

From an upcoming Food Allergy and Anaphylaxis Network  updated statistics report:

A study showed that peanut can be cleaned from the hands of adults by using running water and soap or commercial wipes, but not antibacterial gels alone. In addition, peanut was cleaned easily from surfaces by using common household spray cleaners and sanitizing wipes but not dishwashing liquid alone. [i]

Some studies have shown that most individuals with peanut and soy allergies can safely eat highly refined oils made from these ingredients. However, cold-pressed, expeller-pressed, or extruded oils should be avoided. Talk to your doctor about avoiding oils made from ingredients to which you are allergic. [ii], [iii], [iv], [v], [vi], [vii]

Casual exposure, such as skin contact and inhalation, to peanut butter is unlikely to elicit significant allergic reactions. [viii], [ix]

Note: Casual exposure presents a greater risk to young children who frequently put their hands in their mouths. Depending on the amount of contact and the location of the contact, these reactions are occasionally more serious.

Food proteins released into the air from vapor or steam from foods being cooked (e.g., fish, milk) can potentially cause allergic reactions, but this is uncommon and has been noted mainly with fish. Reactions from vapor or steam are similar to what you would expect from pollen or animal dander exposures for example, hay fever or asthma symptoms [x], [xi]

[i] Perry TT, Conover-Walker MK, Pomes A, Chapman MD, Wood RA. Distribution of peanut allergen in the environment. J Allergy Clin Immunol.2004; 113(5): 973-976.

[ii]Bush RK, Taylor SL, Nordlee JA, Busse WW. Soybean oil is not allergenic to soybean-sensitive individuals. J Allergy Clin Immunol.1985; 76: 242-245.

[iii]Taylor SL, Busse WW, Sachs M1, Parker JL, Yunginger JW. Peanut oil is not allergenic to peanut-sensitive individuals. J Allergy Clin Immunol.1981; 68: 372-5.

[iv] Hoffman DR, Collins-Williams C. Cold-pressed peanut oils may contain peanut allergen. J Allergy ClinImmunol.1994; 93: 801-2.

[v]Keating MU, Jones RT, Worley NJ, Shively A,Yunginger JW. Immunoassay of peanut allergens in food-processing materials and finished foods. J Allergy Clin Immunol.1990; 86: 41-4.

[vi]Crevel RW, Kerkhoff MA, Koning MG. Allergenicity of refined vegetable oils. Food and Chemical Toxicology.2000; 38(4): 385-393.

[vii]Hefle SL, Taylor SL. Allergenicity of edible oils. Food Technol. 1999; 53: 62-70

[viii]Simonte SJ, Sonhui M, Shideh M, Sicherer S. Relevance of casual contact with peanut butter in children with peanut allergy. J Allergy Clin Immunol, 2003(112):180-182.

[ix]Wainstein BK, Kashef S, Ziegler M, Jelley D, Ziegler JB. Frequency and significance of immediate contact reactions to peanut inpeanut-sensitive children. Clin Exp Allergy. 2007; 37(6): 839-845.

[x]Crespo JF, Pascual C, Dominguez C, Ojeda I, Munoz FM, Estaban MM. Allergic reactions associated with airborne fish particles in IgE-mediated fish hypersensitive patients. Allergy.1995; 50: 257-61.

[xi]Roberts G, Golder N, Lack G. Bronchial challenges with aerosolized food in asthmatic, food-allergic children.Allergy.2002; 57: 713-7.

Todd A. Mahr, M.D.
Pediatric Allergy & Immunology
Gundersen Lutheran Medical Center
1900 South Avenue, C02-007
La Crosse, WI  54601

AAAAI - American Academy of Allergy Asthma & Immunology