David, not his real name, of Princeton, N.J., is allergic to milk products and is severely allergic to peanuts and tree nuts. The 7-year-old sits at a special table in the cafeteria. But when his elementary school science class was using milk in a lab experiment recently, David didn't think it would hurt to peer through a microscope. Yet his eye started itching, and he was sent to the nurse.
Fortunately, David's reaction was mild. Had he been exposed to peanuts, the incident could have been much more serious, and even fatal. David is one of about 2 million schoolchildren who have food allergies. District administrators need to be equipped with procedures to meet the challenges that this situation creates.
Problems on the Rise
Since 1960, the incidence of food allergies in children has grown fivefold, from 1 in 100 children to 1 in 20 children, according to the Food Allergy Initiative. For example, the number of children with allergies to peanuts doubled from 1997 to 2002. An October 2004 article in the Journal of School Nursing revealed that 79 percent of all reactions at school occurred in classrooms.
Food allergies cause anaphylactic shock, the most severe type of allergic reaction, which can lead to death within minutes if left untreated. According to the federal Centers for Disease Control and Prevention, this affects 30,000 people and causes 150 deaths annually. It's unknown why severe food allergies are on the rise, says Steven Taylor, professor of science and technology at the University of Nebraska. Some scientists believe that there is a genetic link, but there are other theories.
Eight allergens account for 90 percent of allergic reactions in most people: milk, eggs, peanuts, wheat, soy, tree nuts - like walnuts and almonds, fish and shellfish. Some children outgrow their allergies to milk, wheat, soy and eggs, but rarely outgrow allergies to peanuts and fish, and fewer children outgrow milk and egg allergies, says Dr. Helen Skolnick, an allergist in Princeton, N.J.
Allergies occur when the body's immune system reacts to normally harmless proteins by producing antibodies to attack them, which can cause a rash or upset stomach. Children may also develop hives or skin reactions from touching peanut butter or milk, but they will not go into anaphylactic shock unless they ingest it, says Dr. Nicholas Pawlowski, an allergist at Children's Hospital of Philadelphia in King of Prussia, Pa. Every child reacts differently, however, so allergy plans must be individually tailored with the help of consulting physicians.
Federal and State Legislation
While there are no standard guidelines from the federal government, many states are developing food allergy plans, and the Food Allergy and Anaphylaxis Network (FAAN) and related organizations offer guidelines that district leaders can use. Some districts have comprehensive guidelines in place, while others have informal action plans or no plans at all. But recent and proposed legislation may offer districts more guidance in the near future. Several states, including Connecticut, Massachusetts, New York, New Jersey, Tennessee and Vermont, have mandated school guidelines, and legislation is pending in Illinois and Washington. In Massachusetts, for example, the allergy guidelines document is 82 pages long and outlines the roles of parents, students and school staff. It also includes procedures to prevent severe allergic reactions in classrooms, on school trips and buses, during gym and recess, in cafeterias, and during after- and before-school programs.
In 2005, U.S. Rep. Nita Lowey (D-N.Y.) proposed federal legislation, entitled the Food Allergy and Anaphylaxis Management Act, to set voluntary federal guidelines for preventing food allergies and procedures for responding to anaphylactic shock. In 2006, Sen. Christopher Dodd (D-Conn.) introduced a similar bill in the Senate. The current versions of these bills in the House and Senate, which may be acted upon in the next congressional session, would help create more uniform policies, advocates say. This legislation would also assure parents nationwide that they can move to other districts without having to educate new school staff s about food allergies.
New Roles and Potential Lawsuits
However, many school officials indicate that they are not comfortable dealing with allergy guidelines because medical needs go beyond their usual roles, says Raymond E. Lechner, superintendent of schools at the Wilmette (Ill.) Public Schools District 39, which developed one of the nation's first food allergies plans in 2005. "Schools are set up to teach children, and as the responsibilities of schools grow we are charged with more and more responsibilities, social, legal and medical," he explains. This is territory that most educators know little about.
The question of what guidelines schools should have for children with food allergies also might concern some officials about potential lawsuits from parents, officials say. One example concerns the use of EpiPens. Many children, like David, have in their school nurse's office this most commonly used self-administered injector of epinephrine, or adrenaline, to treat anaphylactic shock. New Jersey adopted a law last year which states explicitly that nurses and other trained school staff that use EpiPens for students cannot be sued by parents who believe they were administered incorrectly. But since specific guidelines are not expected until this summer, nurses and staff are still worried about potential lawsuits, says Agnes Golding,director of student services in the Princeton (N.J.) Regional School District.
Despite some state mandates, many districts use a patchwork approach to food allergies that may vary from school to school within a district and include different ways of handling allergies. "All of us are becoming increasingly aware that there's a gap in the state and in our own procedures," says Golding. And district leaders in New Jersey are scrambling to interpret the new law, she says. For example, some administrators interpret the law to mean that schools must find a nurse or delegate who can administer an EpiPen to accompany children with severe allergies on school trips, or else cancel the trip, she says. But school nurses say that their state association disputes that notion. "I'm in a position where I'm trying to decide whether we develop our own guidelines, or wait and see what the state says, and then be behind the curve," Golding says.
The Wilmette Model
The Illinois Food Allergy Education Association has called Wilmette's policy "the most extensive school food allergy policy" in the state. It has also been used as a model in Arizona and in various districts across the United States.
Lechner says that the first step in devising a policy is gathering a "large committee of stakeholders," including teachers, administrators, school nurses, and especially parents. Wilmette's committee initially reviewed other guidelines, including those from Massachusetts and FAAN, met repeatedly with stakeholders, and reworked the guidelines several times over seven months. "We kept changing and adjusting and modifying until we clearly had something that everybody could work with," Lechner says.
For example, an initial plan was to store EpiPens in classrooms and on buses, until school nurses recommended that students themselves carry them.
But a stumbling block for Wilmette and most school districts is privacy, which prevents schools from divulging student health information. David's science teacher, for example, was doing an experiment with milk because he had never been informed of David's allergy.
In Wilmette, parents can opt to keep their child's allergy information private, but they are clearly encouraged to share the information with district teachers and staff. Administrators can then post a picture of each allergic child in teachers' lounges and cafeteria kitchens and give the information to bus drivers, since children can have severe allergic reactions anywhere and at any time.
All homeroom teachers in Wilmette have folders on their desks with photographs of children who have food allergies, with details of how they react to those foods and the emergency procedures to take if they are ingested. The folders ensure that the information is also available to substitute teachers.
All staff development on food allergies is done in the district during regular school hours, and the costs have therefore been minimal. The biggest expense for the district has been approximately $2,000 for wet cloths used to wipe away food residue on desks and cafeteria tables. But the district would likely buy the cleaning cloths anyway, to avoid spreading germs, Lechner says. "We are focused on washing our hands for everything," he says.
School guidelines for dealing with food allergies in general should address three main areas: medical management, risk reduction, and implementation and communication, says Robert Pacenza, executive director of the Food Allergy Initiative, based in New York.
The medical management plan should outline allergies and their severity, and spell out how each student's allergies should be addressed. One student who inadvertently eats something with milk, for example, might only require an antihistamine like Benadryl, whereas another student might have a severe reaction that would require an injection. The risk reduction plan should detail how the school will reduce each student's risk of being exposed to allergens throughout the school day, in before- and after-school programs and on class trips. Finally, the implementation and communication plan should spell out the role of the parent, school and student. The FAAN guidelines, for example, state that it is the family's responsibility to notify the school about a child's allergies, provide documentation and properly labeled medication, educate the child about the allergies, and meet with school officials and the student to review procedures before a reaction occurs.
The district would then be responsible for reviewing the health information and working with school teams to devise prevention plans. Each student has the responsibility to not share food with others or eat anything with unknown ingredients, to manage the allergy depending on his or her developmental level, and to notify an adult immediately if anything is ingested that may contain an allergyprovoking good.
It's important for districts to avoid potential landmines in developing policies. While the Wilmette district has peanutand nut-free classrooms for children with severe allergies, the policy does not ban peanuts or peanut butter throughout the schools because those regulations seemed likely to upset parents with children who are not allergic.
"The key for school districts is to not set up an 'us against them' policy," Lechner explains. "We didn't want to pit parents of kids with allergies against parents of kids who like peanut butter. We're making kids safe and letting kids have peanut butter at school."
In the Appoquinimink (Del.) School District, a pre-K12 district with over 8,000 students, birthdays in the five elementary schools are celebrated once a month in the cafeteria. Teachers use pencils and stickers as special prizes in the classrooms instead of candy and food as they did years ago, explains Loretta Newsom, a school nurse at Cedar Lane Elementary School. The policy not only avoids potential allergic reaction to certain foods, but it also helps prevent obesity, she says. "Making changes in your school to accommodate food allergies is not as hard as you think," says Appoquinimink superintendent Tony Marchio. The district also educates staff members on how to use EpiPens, and children who are old enough and responsible can carry their own, or they are stored in the nurse's office.
In the Penn-Traff ord (Pa.) School District, children in the five elementary schools are not allowed to bring cupcakes or home-baked cookies for birthday parties and other celebrations. Instead, they must order snacks from the school's cafeteria service from a preapproved list of snacks that do not contain peanuts or tree nuts. Parents of children with serious egg or milk allergies, for example, would receive a list of snacks that do not contain those allergens, explains Peggy DeNinno, assistant to the superintendent. Parents bring orders to the nurse, who double-checks that thesnack includes only safe ingredients for the particular class. One student, for example, has a serious allergy to cinnamon, so the snack list for that class has foods that do not contain that spice.
In the past, school nurses in Appoquinimink would monitor treats brought in for parties and holidays, which meant going to classrooms and making on-thespot assessments. "They were spending their days sifting through snacks," De-Ninno says. Parents can also buy snacks as long as the principal or school nurse approves the ingredients, she adds.
The Appoquinimink policy has angered some in the local Parent-Teacher Organization, who say it is more expensive and that they want the freedom to bake goodies to bring to school. DeNinno says the food service works to provide snacks at cost to parents, and the policies ensure that the 180 allergic students out of 4,500 in the district will be safe. "We certainly don't frown on fun," says DeNinno. "But food does not always have to be at the center of that festive atmosphere."
Lechner urges district leaders not to be afraid of establishing food allergy guidelines but instead to "embrace it." Such guidelines make students, teachers, parents and staff members feel safer and be safer. "It's part of our routine now," he says, "and it's wonderful."
Jeanne Jackson DeVoe is a freelance writer based in New Jersey.