Q:

9/13/2012
Our school district of approximately 11,000 students in grades K-12 just completed a district policy and handbook for the management of severe allergies in our schools. I have read your recommendations for model school policies and these have been very helpful to us in developing our policy. I have read all the information I have found on your website re: skin exposure. I realize the risk is small, but more likely in younger children and/or if skin is broken.

One question yet to be answered is whether the food products that do not contain an allergen themselves, but are made in a factory that also manufactures an allergen, need to be avoided in classrooms where the allergic food is restricted. We have K-3 rooms restricted from allergic foods if a student with severe allergies attends the classroom, but not in grades 4 and older. We require education in the older classrooms so students can learn how to be safe while allowing the allergic product into the room. Thank you in advance for answering this question.

A:

Thank you for your inquiry.

I am referring your question to Dr. Scott Sicherer who is a coauthor of “Management of Food Allergies in Schools: A Perspective for Allergists”, and the “Development and Validation of Education Materials for Food Allergy.

When I hear from Dr. Sicherer, I will forward his response to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

We have received a response from Dr. Scott Sicherer. Thank you again for your inquiry and we hope this response is helpful to you.
 
Sincerely,
Phil Lieberman, M.D.
 
Response from Dr. Scott Sicherer:
Your question about whether products with advisory labeling need to be restricted from a classroom that is restricting an allergen cannot be answered with a single definitive decision. The decision to restrict an allergen from a classroom is partly safety, partly conceptual. As you mention, the risk of having a severe reaction from being near or touching an allergen is low.(1) The main issue is to avoid ingestion.(2) The conceptual concern for very young children is about hand to mouth contact (child licks fingers after they were touching peanut left on a table) or more massive skin exposure from contacting an allergen that would at least irritate eyes or cause some skin rashes to direct contact or perhaps also result in hand to mouth transfer (e.g., using peanut in craft projects, smoothing finger paint with egg white, having children eating powdery cheese "doodle" snacks, baking with wheat flour, etc).

However, the concept might (in my opinion erroneously) be that a classroom is "safe" such that a child may eat another child's food or snacks brought in because it is "nut free" or "allergen free". This is NOT a good idea, since people not living with food allergy do not understand nuances like cross contact and advisory labeling. In fact, that is a good reason to use terms like "allergen safe" or "allergen aware" rather than "allergen free" for classrooms or tables. The allergic child should have her own food or only eat food that is confirmed safe. "No food sharing" policies should trump the other "rules" that have much less risk reduction potency (hand washing, exclusion of a food, etc).

Now on to advisory labeling. This is voluntary labeling- there is no specific law about it. . Many terms are used: "May contain", "in a facility with" "on equipment with", etc. For peanut we found about 7% of products labeled that way had detectable protein and about 3% had enough to potentially trigger a reaction in a sensitive person.(3) Importantly, the actual words used on the label did not reflect risk, counter to what consumers we surveyed thought. We found similar results for other allergens (egg, milk), although chocolate products were found to have higher rates of milk contamination.(4;5) A big problem is that large numbers of snack foods, nearly 40% based on our nationwide store study of over 50,000 products, have advisory labels.(6) So there is a lot to avoid! The general advice is to avoid these products, although clearly many children might be able to ingest the small amounts of the allergen without symptoms.

That is the background to your question. The answer to your question requires a consideration of the conceptual issues, practical ones, and preferences. If a child with allergy is not eating the product, it would be extremely remote to expect that the trace contamination that is usually not in the product to begin with, and if it is in the product might not universally trigger a reaction when the product is ingested, would pose an ingestion risk to a child who is not eating it (who might touch something that another child touched with the food and then has hand to mouth transfer). I think you would agree that the risk of a significant or any reaction is remote. However, there may be a conceptual discomfort to allow a food in the classroom that the child is clearly not allowed to eat (whether or not they share foods to begin with, which I would advise strongly against). Similarly, there may be a discomfort having a food in the classroom that the child might "grab and eat" which would pose a risk. As you mention, the decisions may be related to age, but they may also be related to: extent of supervision, developmental level of the child involved, parental preferences, specific issues of the children involved, the view of "community" sharing in the safety, the view of "real world", etc. The final decisions, I think, need to be made locally and may vary by the specific circumstances in the school or classroom.

References
(1) Simonte SJ, Ma S, Mofidi S, Sicherer SH. Relevance of casual contact with peanut butter in children with peanut allergy. J Allergy Clin Immunol 2003; 112(1):180-2.

(2) Sicherer SH, Mahr T. Management of Food Allergy in the School Setting. Pediatrics 2010; 126(6):1232-9.

(3) Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol 2007; 120(1):171-6.

(4) Ford LS, Taylor SL, Pacenza R, Niemann LM, Lambrecht DM, Sicherer SH. Food allergen advisory labeling and product contamination with egg, milk, and peanut. J Allergy Clin Immunol 2010; 126(2):384-5.

(5) Crotty MP, Taylor SL. Risks associated with foods having advisory milk labeling. J Allergy Clin Immunol 2010; 125(4):935-7.

(6) Pieretti MM, Chung D, Pacenza R, Slotkin T, Sicherer SH. Audit of manufactured products: use of allergen advisory labels and identification of labeling ambiguities. J Allergy Clin Immunol 2009; 124(2):337-41.

Scott H. Sicherer, MD
Professor of Pediatrics
Jaffe Food Allergy Institute
Mount Sinai School of Medicine
New York, NY

AAAAI - American Academy of Allergy Asthma & Immunology