Managing Peanut Allergy in School
A MOTHER ASKS:
My 4-year-old son will be attending preschool for the first time, and he is seriously allergic to peanuts. What instructions do I give his teachers so that he remains safe when he is out of my care?
THE PARENT COACH ADVISES:
Often parents are concerned about food allergies because of a positive family history and will ask for their pediatrician’s help in eliminating a food from the child’s diet at school. In other instances, a positive blood or skin test result without any clinical history may confuse both the parents and the pediatrician. For the child who is “seriously allergic” to peanuts according to the parents, it is important to first confirm the diagnosis. This may require the assistance of an allergist. Once the diagnosis is confirmed, the family can be provided with a written plan of action that includes instructions on how to avoid exposure and manage an acute reaction, which can be given to the child’s teachers.
How common is food allergy? Over the past 10 to 20 years, food allergy has been diagnosed in an increasing number of children. From 1997 and 2007, the prevalence of reported food allergy increased 18% among children younger than 18 years.1 In the United States, 8 foods account for 90% of all food-allergic reactions. These include milk, egg, peanuts, tree nuts, fish, shellfish, wheat, and soy. Peanut allergy affects approximately 1% of children younger than 5 years.2
Food allergy is estimated to affect 1 in 25 school-aged children and is the most common cause of anaphylaxis treated in emergency departments.1,2 About 16% to 18% of children with food allergy had a reaction while in school.3 Fortunately, the majority of reactions in preschools and schools are not severe.4 In general, fatality caused by anaphylactic reactions to food is primarily a result of significant delay in administering epinephrine.5
What is peanut allergy? Peanut allergy is an IgE-mediated immune reaction that usually occurs within seconds and up to 2 hours after ingestion. Reactions can be mild, with symptoms of rash, hives, itching, and swelling, or more severe, with symptoms of vomiting, voice changes, trouble breathing, cough, wheeze, and laryngeal edema. Anaphylaxis may manifest as any of these symptoms; however, its initial manifestation may be hypotension, arrhythmia, or loss of consciousness.
In about 20% of fatal or near-fatal reactions, a biphasic or secondary late-phase allergic response occurs within 1 to 4 hours after the initial reaction.6 The only way to prevent a reaction is strict avoidance of peanuts. There is currently no cure for peanut allergy. It is important to note that about 80% of children will not outgrow their peanut allergy, especially if they have high levels of serum peanut-specific IgE antibodies.7
How to prepare the child with peanut allergy for school. It is recommended that the clinician work in collaboration with an allergist to develop a treatment approach that is individualized for the child. Before this is done, the following questions need to be answered:
•Has the diagnosis of peanut allergy been confirmed?
•What was the nature of the initial reaction?
•Is the patient at risk for a fatal reaction?
A definitive diagnosis of peanut allergy is made with either a clear clinical history and confirmatory test (skin test or radioallergosorbent test) results or an oral food challenge conducted by an allergist after a positive test result.
The initial allergic reaction to a food usually indicates the potential nature and severity of any subsequent reactions. For example, if the child had anaphylaxis after ingesting peanut, then anaphylaxis is likely to develop after subsequent exposures. However, caregivers need to be aware that subsequent reactions may be severe even when the initial reaction was very mild. For children in school, caregivers should provide a list of potential symptoms based on their child’s initial reaction but make sure that teachers are prepared for the worst possible reaction.
Asthma is one of the risk factors for near-fatal or fatal food allergy reactions. Other risk factors include previous history of anaphylaxis and allergy to peanut, tree nut, egg, fish, or shellfish. Teenagers with food allergies are at higher risk for fatal or near-fatal anaphylaxis than children with food allergies.6
Approach to schoolchildren with peanut allergy. This involves education and an emergency action plan. Education of the child, family, and school personnel addresses:
•How to avoid accidental peanut exposure.
•How to recognize and manage the early symptoms of an allergic reaction.
The importance of reading food labels and advisory labels that indicate possible cross-contamination with peanuts should be stressed. Families and teachers should be able to anticipate reactions to nonfood sources, such as materials used for crafts.
A basic rule is that food sharing or trading foods among children is not allowed in school. The child should eat only food prepared at home and avoid cafeteria food as well as food brought into school for birthdays or holidays. When old enough, the child can be taught how to read food labels and ask a teacher or school staff member whether a food item is safe for them to eat. All children in the classroom should wash hands after eating, make sure surfaces are cleaned, and store lunches in a designated location.
Although life-threatening reactions to peanuts usually result from ingestion, allergic reactions may result from inhalation or contact with surfaces that have been exposed to peanuts. Commercial sanitizing products, such as Formula 409, Lysol Sanitizing Wipes, and Target Brand Cleaner with Bleach, have been shown to effectively remove peanut allergen from surfaces, whereas dishwashing liquid left traces of allergen.8 For removing peanut allergen from hands, liquid or bar soap and sanitizing wipes for skin were more effective than antibacterial hand sanitizer.
Highly processed peanut oils (acid-extracted, heat-distilled oils) do not contain peanut protein and can be consumed by peanut-allergic patients; however, cold-pressed or extruded peanut oils should be avoided.8 It is usually advised that children who are allergic to peanuts also avoid tree nuts because of cross-contamination concerns.
An emergency action plan, also known as an anaphylaxis action plan, provides specific instructions for the child, family, and school personnel in the event of an acute reaction. Self-injectable epinephrine, 2 doses for the school and 2 doses for the family, is prescribed. The treatment regimen is listed in the Table.
The family must notify the school about the child’s food allergy and share a copy of the action plan with the child’s teachers and the school nurse. The action plan should be as simple as possible and include the child’s name and preferably his or her photo, allergic foods, symptoms of anaphylaxis, and treatment regimen (including the doses of epinephrine and diphenhydra-mine). The doses will need to be updated annually as the child grows. The action plan should also include instructions to call 911 immediately when epinephrine is administered.
A sample Food Allergy Action Plan can be downloaded from the Food Allergy & Anaphylaxis Network at foodallergy.org/files/FAAP.pdf. Other educational materials for families and schools are available at foodallergy.org.