Recommendations developed by an international panel for the prevention and management of food allergies in children and youth aim to provide "evidence-based guidance" for what has become a confusing and, at times, contentious issue in schools and childcare centers. The guidelines, published in the May Journal of Allergy and Clinical Immunology, are intended for global implementation and can be adapted to local conditions and resources.
Among the recommendations are that schools and childcare facilities implement training for staff in the recognition and treatment of allergic reactions; administer epinephrine only to treat suspected anaphylaxis rather than as a preventative; stock unassigned epinephrine autoinjectors in schools rather than require students to supply their own; and eliminate site-wide food prohibitions and allergen-restricted zones (such as "nut-free classrooms" and "milk-free tables").
The panel-consisting of allergy specialists, primary care and nursing professionals, school administrators, parents, and methodology researchers-said it strove to balance the quality of life needs of allergic children with those of the larger school community. It also classified most of the recommendations as "conditional," owing to the "low quality of available evidence," and called for more focused research into, for example, whether training school personnel to recognize and respond to allergic reactions yields benefits.
According to the Centers for Disease Control and Prevention, food allergies affect about 8% of children in the United States. The most serious allergies are caused by milk, eggs, fish, crustacean shellfish, wheat, soy, peanuts, and tree nuts. The panel noted that "most allergic reactions to food are mild to moderate," and that anaphylactic or life-threatening reactions are rare. Still, its recommendation against ongoing efforts to eliminate allergy-triggering foods such as nuts from the school environment is likely to spark debate, according to Robin Cogan, a school nurse in Camden, New Jersey, legislative cochair for the New Jersey State School Nurses Association, and AJN editorial board member.
"Doing away with food bans is contentious," Cogan told AJN, adding that there are many misunderstandings about which foods pose danger. "People think tree nuts are the primary sources of food allergies. But milk allergies are actually more prevalent." According to the American College of Allergy, Asthma, and Immunology, more than 2% of U.S. children under age five have a milk allergy, although most tend to outgrow it.
Susan Kelly, coleader of Friends Helping Friends Food Allergy Support Group, believes every school-and every child within it-has unique needs that must be taken into consideration. "There are not a lot of data to support the panel's recommendations," she commented in an interview with AJN.
Still, both Cogan and Kelly said they support the panel's focus on training and education of school staff as well as the proposal to have epinephrine autoinjectors available in schools, especially in light of a recent study of schoolchildren showing that although food-related anaphylactic events are rare, 25% occurred in youngsters without a known allergy. But this recommendation, too, is likely to be controversial, according to Cogan and Kelly, because of the high cost of autoinjectors, such as the EpiPen, which may make stocking them unaffordable for some school districts.
The COVID-19 pandemic complicated ongoing discussions about how best to protect children with food allergies. Many schools seeking to prevent transmission of the disease required students to eat in their classrooms rather than the cafeteria where they would be exposed to more children. "There is a psychological component to all this," Cogan said. "Sitting next to something that might cause a visit to the hospital can create a lot of anxiety for kids." On the other hand, she added, the pandemic brought new awareness of the importance of universal precautions, which can also protect people with food allergies: wash hands, and respect others' need for social distance.-Dalia Sofer