Q:

9/26/2013
I was recently asked to help with food allergy guidelines for our preschool and synagogue. There is no RN on staff at the school. I've read through the prior questions and the AAP Pediatrics recommendations for food guidelines in schools but very little has been written about guidelines in a "preschool setting" and how this should vary based on whether a child has allergy to a high risk food allergen such as peanut/tree nut or history of anaphylaxis to milk etc. vs. a milder allergy to soy and wheat. Given this is an age when kids do not yet know they can't share a snack and touch the table and put their hands to their mouths, and there is no RN on site, I think we have to be very careful. I know the recent death of a teenager brought a lot of media attention and there could have been early signs of anaphylaxis that were unrecognized. However, the case does raise the awareness that we don't treat textbooks, we treat patients who have to be aware of the symptoms of anaphylaxis and often these symptoms can be subtle.

1) Would you make the class room peanut/tree nut free if there was a child with a high risk food allergen?

2) Do you think you need to go as far as applying this recommendation to the whole school? I think it should be class room specific. Would you make the kitchen used for cooking in the synagogue peanut/tree nut free if also used in the school? I think this would be the safest approach unless everything was properly cleaned after a bar mitzvah or holiday meal. However, there is still the risk for cross contamination. Maybe the preschool can have its own set of pans and utensils that are "peanut/tree nut free"

3) How do you feel about allowing parents to bring in snacks that say "may contain peanuts/tree nuts" or "processed on a plant that may contain peanuts/ tree nuts"? Since the peanut allergic child should not share snacks and the risk of reaction is probably less than 3%, do you agree these snacks are not as risky if from a larger company vs. small health food store where there may be less consistency in processing?

4) How would you approach guidelines in a kosher school where meat is not allowed for lunch and a child has a history of anaphylaxis to milk? Has this ever been brought up with you? You really can't make the lunches dairy free. Would you have the allergic child sit at a separate table?

5) Has the recent death of the teenager changed your approach to handling peanut/tree nut allergy?

6) Do you usually tell parents of tree nut allergic children to avoid all things that say "may contain tree nuts" or, if they have eaten bars produced by Quaker (larger name companies) do you mention the risk is low? Do you leave it up to the parent to decide?

7) If there is no RN on staff and a patient has a peanut allergy, what is your recommendation regarding administering Benadryl and epinephrine and going to the ER? Does your recommendation change based on history of reaction and presence of asthma?

8) Have you ever recommended the use of epinephrine before symptoms arise after accidental exposure and if so, what triggers you to do so? Have you ever recommended Benadryl before symptoms arise or do you think this can mask a more serious reaction?

Just trying to think out guidelines for the preschool setting. Do you have references that you think are worth reading in this area for this age group and for scenarios where a school does not have an RN? Thank you in advance fro your time in answering these questions.

A:

Thank you for your inquiry. You evidently have done a great deal of research in this area, and done due diligence in exploring the issues which you have outlined quite well.

Before proceeding to answer you, it should be clear that the guidelines you have read have also looked at these issues in detail. They have been derived as carefully as possible by experts in the care of children with allergy, including not only physicians, but school nurses and parents and have often been included.

Having lived through the development of many of these, the one thing that we have learned is no matter what one puts in the guidelines, there are going to be dissenting opinions. In a situation such as yours, at least in my experience, no guideline you put together will be without controversy amongst the parents of students who have to live with these guidelines. All previous guidelines have taken this into consideration, and I think have done a superb job in dealing with these issues as best it can be done.

Also, I would state to you that your situation is in essence no different from that that is faced by schools with children in early grades as well as preschool. You should note that the vast majority of these venues do not have school nurses available, and many that do have school nurses do not have them on the campus every day. So, your situation with no R.N. on the staff is really the “rule” rather than the “exception.”

Also, all of the guidelines that have been written in this regard, to my knowledge, have been quite aware that peanut and tree nut differ in terms of their potential to cause severe reactions and this consideration has been included in the production of these guidelines. The age of the child has also been discussed almost endlessly in the production of these guidelines as well. Their efforts, like yours, have all been directed with safety as the first priority and with the sense that we “have to be very careful.”

I do not think that the death of the teenager recently reported would have any impact on the production of these guidelines had they been created after this death. Unfortunately, as you know, we have had, almost every year, deaths of teenagers from food allergy, not only in school settings, but in the home and in other venues as well. All of these guidelines have been put together to deal with patients, and although they appear in textbooks, I can assure you they are not meant to deal with issues on a theoretical basis; they are meant as practical guides, and all sides of the issues involved have been taken into consideration.

With that preamble, I will try and answer your questions specifically.
1 Of course, one could always do “the safest thing.” Whether that “safest thing” is actually needed from a practical standpoint is, in many instances, unknown. However, based on a review of all present consensus guidelines, to my knowledge, one would not make classrooms, schools, or kitchens peanut/tree nut-free.

2. One of the most contentious issues regarding food allergy is whether to restrict children from bringing snacks that may contain peanuts or tree nuts, or processed in a plant that may contain peanuts and/or tree nuts. Opinions differ in this regard. In many instances, some schools do this up to the third or fourth grade and then desist in this policy. I see nothing wrong with this approach, and if it does not create a great deal of consternation among the other parents, it could be well argued that it is an advisable approach until children reach an age where they can be relied upon to avoid accepting snacks from their peers.

3. There is no information regarding whether snacks are safer if obtained from a larger company versus a small health food store. However, if you decided to institute this policy, I would make it universal. It is difficult enough to institute and maintain this policy without adding an extra decision burden upon the parents. So I would not make any distinction between "large" and "small" producers.

4. I would never ask an allergic child to sit at a separate table. I think this stigmatizes the child, and has the potential of producing more harm than good. It should be no more difficult making a lunch milk and meat-free than meat-free alone, and if you do have a significant number of young children allergic to milk, I believe that this dietary measure should be instituted.

5. As noted, the recent death of a teenager is one of many that we have observed through the years, and would not change my approach to these issues.

6. I usually tell parents of tree nut-allergic patients to avoid anything that may contain tree nuts. Although I do agree with you that the risk is low, it is an important safety measure, and as mentioned, I would not make the distinction between large and small companies.

7. At your institution, you should require a note from the child’s physician as to how to proceed if symptoms occur or if the ingestion of a substance to which the child has a known allergy occurs. There should be written instructions on file so that the person in the classroom can institute the policy. These should be readily available. Different allergists require different procedures, and it is best to have the child’s personal physician responsible for the procedure that is to be instituted. Your staff members should be trained, of course, to recognize anaphylaxis. The physician responsible for the patient should be the one to make the decision as to what effect asthma may have in that individual child, and how it may alter the approach to managing a reaction or a potential reaction.

8. I have personally recommended the use of epinephrine before symptoms arise in many instances, but this may vary from case to case, and other allergists may have different criteria. This is why you need individual instructions from the child’s personal physician.

In terms of food allergy, we do not recommend diphenhydramine being taken as prophylaxis.

In terms of further reading, I would suggest the following:

a. On our Ask the Expert website, we have an entry posted on 8/20/2013 entitled “When should an epinephrine injection be given to a patient with a known food allergy who has ingested the food in question but has no symptoms.” You can access this by entering the word “epinephrine” in our search box at the site.

b. Guidelines for the treatment of anaphylaxis published by the Washington State School District may be accessed online.

c. AAAAI Board of Directors, “Position Statement: Anaphylaxis in Schools and Other Childcare Settings,” 2008.

d. Management of food allergies in school: a perspective for allergists. J Allergy Clin Immunol 2009, Volume 124, Number 2, pages 175-182.

Once again, thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology