Practical Strategies for Avoidance: Minimizing the Risk at School
Avoidance is the cornerstone of preventing an allergic reaction. Much can be done to reduce the risk when avoidance strategies are developed. General recommendations for food allergens and insect stings as well as additional strategies for avoiding specific food allergens are provided below.
For food-allergic individuals, the key to remaining safe is avoidance of the food allergen. It must be stressed that very small or minute amounts of certain foods can cause severe reactions when ingested. This may happen if people at risk touch an allergenic substance and then subsequently put their hand to their mouth or eye. Even a very small amount "hidden" in a food or a trace amount of an allergen transferred to a serving utensil has the potential to cause a severe allergic reaction. For foods such as fish and shellfish, egg and milk, vapour or steam containing proteins emitted from cooking these foods have been shown to trigger asthmatic reactions and even anaphylaxis.
While it is difficult to completely eliminate all allergenic ingredients due to hidden or accidentally introduced sources, it is possible and extremely important to reduce the risk of exposure to them. Effective ingredient label reading, special precautions for food preparation, proper hand washing, and cleaning go a long way toward reducing the risk of an accidental exposure.
Parents of food-allergic children are often concerned that the odour or smell of a particular food such as peanut butter will cause a life-threatening or anaphylactic reaction. Inhalation of airborne peanut protein can cause allergic reactions. The odour alone (without airborne proteins) has not been known to cause an anaphylactic reaction. Direct ingestion of an allergy-causing food poses the greatest risk for the sensitized individual. The following guidelines are recommended to reduce the risk of exposure for people with food allergy:
• Adult supervision of young children while eating is strongly recommended.
• Individuals with food allergy should not trade or share food, food utensils, or food containers.They should also place meals on a napkin or personal placemat. Young children should eat in the same location while at school. Air space above meals should be kept free and clear.
• Parents should work closely with foodservice staff to ensure that food being served during lunch and snack programs is appropriate. Food-allergic children should only eat food which parents have approved if there is any uncertainty.
• The use of food in crafts and cooking classes may need to be modified or restricted depending on the allergies of the children. Non-food items such as stickers and pencils should be considered for some class and school celebrations where young children are involved. If teachers have a system in place to reward students, they should consider non-food items for extra time for a special activity.
• Ingredients of food brought in for special events by the school community, served in school cafeterias, or provided by catering companies should be clearly identified. Parents of food-allergic children should be consulted when food is involved in class activities. Food should not be left out where young children with food allergies can help themselves.
• All children should be encouraged to comply with a "no eating" rule during daily travel on school buses.
• All children should wash their hands before and after eating.
• Surfaces such as tables, toys, etc. should be carefully cleaned of contaminating foods.
The risk of insect stings is higher in the warmer months. General guidelines to reduce the risk of exposure to insect stings include:
i. Keep garbage cans covered with tightly fitted lids in outdoor play areas. Consider restricting eating areas to designated locations inside the school building during daily routines. This allows for closer supervision, avoids school yard cleanup, and helps reduce the revalence of stinging insects.
ii. Have insect nests professionally relocated or detroyed, as appropriate.
iii. People who are allergic to stinging insects should:
- Carry an epinephrine auto-injector with them during insect season (varies by region).
- Stay away from areas where stinging insects gather such as gardens, hedges, fruit trees, and garbage cans.
- Wear light colours and avoid loose flowing garments or hair that could entrap an insect (tie hair back).
- Wear shoes instead of sandals during the warm weather; do not go barefoot.
- Avoid highly fragrant varieties of products such as perfumes, colognes, suntan lotions, cosmetics, hair sprays or deodorants which attract insects.
- Drink from cups or use a straw rather than beverage cans or bottles where insects can hide. Use a straw if drinking beverages outdoors.
- Consult with an allergist to determine if they are a candidate for venom immunotherapy (de-sensitizations program).
Reactions to medication, exercise and latex are rare in school settings. Care of children with these allergies should be individualized based on discussions amongst the parents, physicians, and school personnel. The emergency protocol, as described earlier in this document, would apply.
Avoidance Strategies for Specific Food Allergens
Avoidance of Food Allergens
While research efforts are underway worldwide to better understand food allergy, a cure has not been found. Currently, physicians cannot safely determine which patients may be at risk for a mild or moderate allergic reaction and which patients might go on to develop a severe or potentially fatal allergic reaction to a food. A very small or minute amount of a food allergen can trigger an allergic reaction if ingested. Therefore, avoidance of an allergenic substance is the only way to prevent an allergic reaction. For many people at risk of food anaphylaxis, a lifelong avoidance diet will be necessary.
It is difficult to imagine how daily life in impacted when basic safety depends on avoiding a food which has the potential to cause a life-threatening allergic reaction. Consider how many times a day the average person eats something. For the majority of people, this is done without thought. For those at risk for a life-threatening or anaphylactic reaction, however, nothing can be taken for granted. Every bite counts.
Individuals at risk of food anaphylaxis must take ownership for their own safety. This involves sticking to basic rules such as:
- Washing hands before and after eating
- Eating only foods which are safe. Food-allergic individuals should always read food labels and avoid high risk foods such as bulk foods and foods which are known to often contain an allergenic substance (e.g. peanuts/nuts in ice cream, baked goods, or ethnic foods.)
- Inquiring about the preparation of foods outside of the home.
- Learning how to use an auto-injector and teaching others to assist them in an emergency
- Carrying life-saving medication (an epinephrine auto-injector) with them at all times and wearing medical identification, such as a MedicAlert bracelet.
- Refraining from eating if they do not have their auto-injector
Note: It is prudent for parents of young children (especially in high-risk families with a history of allergy) to try new goods at home before they are introduced in a day care or other setting.
Awareness and support from others in the community can help to create safer environments for individuals at risk of anaphylaxis. Ways to reduce the risk of accidental exposure include:
- Washing hands and mouth after eating
- Taking precautions to minimize the risk of cross-contamination in food preparation.
- Reading food labels and asking food-allergic individuals about their specific needs.
- Not sharing food with friends who have good allergy or pressuring them into accepting a food they do not want.
- Properly cleaning surfaces and disposing of food items after meals and snacks
- Ensuring that young children have adult supervision while they are eating.
Where younger children are involved, some food restrictions or special measures may be developed. Special accommodations should be handled on an individual basis. Parents of food allergic children and school staff are encouraged to work collaboratively to develop strategies which are both realistic and reasonable for their environments.
Many school principals ask the entire school community to read food labels and to not send in products with an allergenic substance such as peanuts. It is important to note that food restrictions alone do not take the place of effective risk reduction strategies. The emphasis should be on preventing an allergic emergency through education, awareness, and training and being prepared to respond during an emergency.
Parents of young food-allergic children should condition them to not accept foods which parents have not approved. They should also ask school staff not to offer food to their children without their prior approval. People who do not have a food allergy may not understand ingredient labeling practices. Assumptions about goods can put allergic individuals at risk. Therefore, parents should reach food-allergic children to stick to strict safety rules (not sharing or accepting food, carrying epinephrine, etc.) even in schools which have implemented a restriction on products with peanuts and nuts. Schools can be expected to create an ‘allergy aware’ environment. It is unrealistic, however, to expect an ‘allergen-free’ environment.
The following sections provide information about the most common food allergens in the school setting as well as examples of ways in which they are being managed in the school environment.
Avoidance of Peanut
Recent studies suggest that peanut allergy among North American children has doubled in the past decade. 1,2 A study conducted in Montreal schools estimated the prevalence of peanut allergy to be 1.34 to 1.5%.2
Peanut allergy requires stringent avoidance and management plans as it is one of the most common food allergies in children, adolescents, and adults. 3 Reactions to peanuts are often more severe than to other foods. Peanut has been a leading cause of severe, life-threatening, and even fatal allergic reactions. 4,5 Despite appropriate counseling on peanut avoidance, the majority of subjects followed up for 5 years experienced adverse reactions from accidental peanut exposure. 6 Very minute quantities of peanut, when ingested, can result in a life-threatening reaction.
In the high school environment, teens at risk of anaphylaxis must adhere to key safety rules. When food is concerned (any food ), this involves reading food labels carefully and taking special precautions such as asking food service staff about the preparation and handling of food in the cafeteria, if they purchase their lunch at school. Students with food allergy should eat with a friend and advice others quickly if they feel they are having an allergic reaction. They should not eat if they do not have their epinephrine auto-injector with them.
Food Service companies have a responsibility to train their staff to understand the risk of crosscontamination in the purchasing, preparation, and handling of food items. Food Service staff should participate in regular school staff training on anaphylaxis management; they must be aware of students at risk for food allergy.
Avoidance of Milk and Egg
While many young children outgrow an allergy to milk and egg within the first decade of life, some will continue to remain at risk of anaphylaxis, and should therefore follow key safety rules such as carrying epinephrine at all times. Anaphylactic reactions to milk and egg can occur when relatively small quantities are ingested. Therefore, the allergic child must avoid all traces of milk and egg.
Under proposed new labeling regulations in Canada, all traces of milk, egg and other major allergens will be listed on processed food. Currently, however, there can be legally undeclared ingredients. In addition, common names for milk and egg may not be noted, e.g. casein (milk). This can make avoidance of these allergens particularly challenging.
Elementary schools have adopted different strategies to reduce the risk of exposure for milk and egg-allergic children.
- Some schools ask families not to send milk products in classes where there are milk-allergicchildren.
- Some schools have milk programs but classes with milk-allergic children do not participate
- Some schools allow milk products in classrooms where there are milk-allergic children and have implemented practices to reduce risk:
- Children are given straws to put in bevel-topped milk containers (distributed through milk programs) and are taught to close the top once the straw is inserted.
- Children who bring milk from home are asked to bring it in a plastic bottle with a straw
- Children at risk for milk allergy sit at a table where spillable milk products are not being consumed. Alternatively, they sit at the same table but not directly beside classmates who have spillable milk products, e.g. milk, yogurt
- On pizza days some parents of milk-allergic children take their kids home for lunch (where they have this option); others send their child with an alternative lunch so that they can still participate; others ask that their child eat in a pizza-free classroom. Special care should be taken to ensure that children properly wash their hands and mouths after pizza lunches and that all surfaces are properly cleaned.
- In classrooms where there are young egg-allergic children, parents and staff have worked to reduce the risk of accidental exposure by:
- Avoiding egg in cooking classes or egg shells in craft activities. (This includes both egg whites and yolks, either cooked or raw.) Some food products which may contain egg protein are: bread brushed with egg white, deli meats with egg, drinks such as orange julep, and egg substitutes. Non-food items which may contain egg protein include: egg tempera paints, cosmetics, and shampoo.
- Selecting activities which do not involve the use of real egg for special activities, e.g. Easter egg decorating or hunts with wooden or plastic eggs.
- Seating children with egg allergy away from those who bring eggs for lunch or snack (e.g. hard-boiled, egg salad sandwiches) or whose food may contain egg (e.g. mayonnaise)
- Asking children to enjoy eggs and egg salad at home.
Individuals with egg allergy are advised to consult with their allergist about drugs (such as anaesthetics) and vaccines or flu shots which may have egg protein.
Avoidance of Fish and Shellfish
Fish and shellfish allergies can be severe and life-threatening; therefore, strict avoidance must be practised. Individuals with a specific shellfish allergy are advised to consult with their allergist about possible sensitivity to other species of shellfish. The same would be true for fish allergy. The risk of accidental exposure through cross-contamination in the stage and handling of fish or shellfish could be high. Fish- and shellfish-allergic consumers should look for ‘may contain’ warnings on food ingredients labels and be especially careful when purchasing fresh fish or shellfish, which is often stored in a common area in grocery stores. It is important to note that exposure to airborne fish particles have been known to cause an allergic reaction.
Casual Contact with Food Allergens
A recent U.S. study7 explored the commonly held beliefs that peanut odour and skin contact with peanut products pose a significant risk to peanut-allergic individuals. Many people believe that the mere presence of peanut products can contaminate the surrounding airborne environment, making an area unsafe for a peanut-allergic child.
Allergic reactions to foods such as peanut butter are triggered by specific food proteins. Food odour is caused by chemicals called pyrazines. Smelling peanut butter odour (pyrazines) is different from inhaling airborne peanut particles (proteins) which might occur from the mass shelling of peanuts in a poorly ventilated area. Peanut-allergic people may feel unwell if they smell peanut butter, but this is likely due to a strong (and understandable) psychological aversion. Inhaling airborne peanut particles can cause allergic reactions with symptoms such as rashes, runny nose, itchy eyes, and occasionally wheezing or difficulty breathing, but anaphylaxis is thought to be unlikely. Some people worry that just touching small amounts of peanut butter will result in a significant or life-threatening allergic reacion. The researchers noted
that a very small amount of peanut butter induced only a local reaction when touched; however, the same amount could cause anaphylaxis should it be unintentionally transferred to the mouth.
While the researchers hope that their study will allay concerns about casual exposure to peanut, they advise continued caution: “ Indeed, trace quantities of peanut can induce reactions when ingested, and intimate kissing, although perhaps considered casual contact, is also akin to ingestion.” They add: “Specifically, on the basis of this study alone, we would not recommend changing any school policies that protect children with peanut allergy.” The researchers also stressed that they did not study effects of having a large amount of peanut or peanut butter in the room and that further investigation would be required.
Foods with “May Contain” Warnings
While it is the responsibility of allergic consumers to always read food labels, confusion can be created by strong brand awareness and unfamiliarity with food labeling regulations. Here are some examples which consumers need to be aware of:
- Some popular brands which are widely recognized as being safe for allergic consumers may be used in other products which may contain peanuts/nuts (e.g. peanut-free chocolate in ice cream which has a ‘may contain’ warning).
- An allergen-free claim on certain products may be specific to only one size or format of the brand, not to all products using the same brand name. In some cases, the brand name has been used in new products which contain the allergen.
- Product formulations (recipes) may change and ingredients of a particular brand may not be the same in all formats or all sizes. For example, a regular size candy bar may be considered to be free of an allergen such as peanut; however, the snack size version could have a ‘may contain peanuts’ warning. This could be due to the risk of cross-contamination if the product is run on the same equipment as products which contain peanut. Products may also be produced in a different format or in a different production factory.
- Food labeling standards in other countries may not be the same as Canada’s. Imported products may pose a risk to allergic consumers. Researchers found that 31% of imported chocolate bars from Eastern Europe without a precautionary label actually contained detectable levels of peanut protein.8
Food-allergic individuals and those who buy on their behalf must read food ingredient labels every time they purchase a product.
Food-allergic consumers are encouraged to read food ingredient labels three times: once when purchasing an item, a second time when putting the product away, and a third time just before serving.
A recent U.S. study suggests that liquid or bar soap and antibacterial wipes can effectively remove peanut butter residue from hands. However, anti-bacterial hand sanitizers and water alone are not as effective.9 In the same study, researchers found that common household cleaning products such as Formula 409 (Clorox), Lysol sanitizing wipes, and Target brand cleaner with bleach were effective in removing residual peanut allergens from surfaces. Not all products may be available in Canada, but the research suggests that comparable products would work equally well. Dish soap did not effectively remove
residue of peanut butter from surfaces.9 It is important to start cleaning with a clean cloth or paper towel at the anaphylactic student's desk.
Many schools provide a list of ‘safe foods’ to all families to help them comply with a ‘no peanut or nut’ request. While this is well-intended, schools and food-allergic consumers are encouraged to use them as a guideline only. Many of these lists could be inaccurate or outdated.
Parents of children with food allergy should teach them to always read food ingredients labels and not to accept or share foods which the parents have not approved, even in so-called ‘peanut free’ schools. It is unrealistic to expect others who are not affected by food allergies to understand the details required to properly read a food label. Others may not recognize alternate names for foods (e.g. casein = milk), and assume that a product is okay is there is no ‘may contain’ warning (which is voluntarily put on by manufacturers).