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Food-Allergic Reactions in Schools and Preschools
Anna Nowak-Wegrzyn, MD;
Mary Kay Conover-Walker, MSN, RN, CRNP;
Robert A. Wood, MD
Arch Pediatr Adolesc Med. 2001;155:790-795.
ABSTRACT
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Background Food allergies may affect up to 6% of school-aged children.
Objectives To conduct a telephone survey to characterize food-allergic reactions
in children (defined as those aged 3-19 years in this study) with known food
allergies in schools and preschools and to determine mechanisms that are in
place to prevent and treat those reactions.
Design The parents of food-allergic children were contacted by telephone and
asked about their child's history of food-allergic reactions in school. The
schools the children attended were contacted, and the person responsible for
the treatment of allergic reactions completed a telephone survey.
Results Of 132 children in the study, 58% reported food-allergic reactions in
the past 2 years. Eighteen percent experienced 1 or more reactions in school.
The offending food was identified in 34 of 41 reactions, milk being the causative
food in 11 (32%); peanut in 10 (29%); egg in 6 (18%); tree nuts in 2 (6%);
and soy, wheat, celery, mango, or garlic in 1 (3%) each. In 24 reactions (59%),
symptoms were limited to the skin; wheezing occurred in 13 (32%), vomiting
and/or diarrhea in 4 (10%), and hypotension in 1 (2%). Also, 15 (36%) of the
41 reactions involved 2 or more organ systems, and 6 (15%) were treated with
epinephrine. Fourteen percent of the children did not have a physician's orders
for treatment, and 16% did not have any medications available. Of the 80 participating
schools, 31 (39%) reported at least 1 food-allergic reaction within the past
2 years and 54 (67%) made at least 1 accommodation for children with a food
allergy, such as peanut-free tables, a peanut ban from the classroom, or alternative
meals.
Conclusions It is common for food-allergic children to experience allergic reactions
in schools and preschools, with 18% of children having had at least 1 school
reaction within the past 2 years. Thirty-six percent of the reactions involved
2 or more organ systems, and 32% involved wheezing. Every effort should be
made to prevent, recognize, and appropriately treat food-allergic reactions
in schools.
INTRODUCTION
FOOD ALLERGIES may affect up to 6% of preschool- and school-aged children.1 While the only available therapy for these children
is strict avoidance of the offending foods, accidental reactions are common
and occur in up to 50% of food-allergic children despite their best efforts
to avoid the offending foods.2 It is also known
that up to 50% of anaphylactic reactions in children are due to food allergies
and that some of these reactions occur in the school.3, 4
However, to our knowledge, the incidence of food-allergic reactions in schools
has not been previously described. We, therefore, conducted a telephone survey
to determine the frequency, symptoms, treatments, and outcomes of food-allergic
reactions in children (defined as those aged 3-19 years in this study) with
known food allergies in schools and preschools and the mechanisms that are
in place in schools to prevent and treat these reactions.
PATIENTS AND METHODS
One hundred sixty food-allergic children aged 3 to 19 years were recruited
among the patients seen at The Johns Hopkins Hospital Pediatric Allergy Clinic,
Baltimore, Md, from April 1, 1999, to April 30, 2000, and from private pediatric
offices in the Baltimore metropolitan area and in Virginia. Twenty-eight children
were not enrolled in school and, therefore, were not included in the analysis.
Of the remaining 132 children, a diagnosis of food allergy in 106 examined
at The Johns Hopkins Hospital Pediatric Allergy Clinic was based on a convincing
history of food-related reactions, with supportive laboratory data such as
positive prick skin test results to the suspected food allergen, food-specific
IgE measured by immunoassay (CAP System FEIA; Pharmacia Diagnostics, Uppsala,
Sweden) (>0.35 kU/L), and/or food challenge. In the remaining 26 patients,
food allergies were reported by the parents, and 23 (88%) of these patients
had undergone an examination by an allergist that included skin testing and/or
serum IgE testing to the relevant foods.
The parents of these children were contacted by telephone by 1 of 2
trained interviewers (A.N.-W. or M.K.C.-W.) after informed consent was obtained
by mail. The parents and teenaged patients answered a standardized questionnaire
detailing food-allergic reactions in the past 2 years. The 2-year period was
used as a cutoff for more reliable recall. The schools that the children attended
were contacted by the same interviewers, and the person in charge of treating
food-allergic reactions completed a structured questionnaire by telephone.
The study was approved by the institutional review board of The Johns Hopkins
University School of Medicine, Baltimore.
RESULTS
PARENTAL SURVEY
One hundred sixty parents or patients responded to the survey. Four
school-aged children were homeschooled, 2 because of food allergies. Twenty-four
preschool-aged children were not enrolled in preschool, 15 (63%) because of
a food allergy. One hundred thirty-two subjects completed the entire study
questionnaire and were included in the final data analysis. In 89%, the person
responding was the child's mother; in 9%, the child's father; and in 2%, the
patients themselves. Eighty-two were established patients in The Johns Hopkins
Hospital Pediatric Allergy Clinic, 24 were new patients, and 26 were identified
through private pediatricians. The characteristics of the 132 participants
are provided in Table 1.
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Table 1. Description of the 132 Study Participants
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Fifty-eight percent of the children were reported to have had food-allergic
reactions in the past 2 years. Parents recalled a total of 219 reactions in
these children (median, 2 reactions; range, 1-12 reactions). As detailed in Table 2, 24 of these children experienced
1 or more reactions in school. A total of 41 reactions were reported in these
24 children (median, 1 reaction; range, 1-7 reactions). Twelve children had
19 reactions in schools, and 12 had 22 reactions in preschools. There were
an additional 3 children with multiple food allergies who had frequent (>30)
benign cutaneous reactions at school that were attributed to foods. However,
the offending foods and detailed descriptions of the reactions were not available,
and these patients were, therefore, not included in the reaction analysis.
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Table 2. Food-Allergic Reactions in Schools and Preschools*
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Data presented in Table 3
further characterize food-allergic reactions. The causative food was clearly
identified in 34 of the 41 reactions. Milk was most commonly implicated, followed
by peanut, egg, and tree nuts. Most reactions took place in classrooms with
eating areas, but regular classrooms were the second most common location.
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Table 3. Details of the 41 Food-Allergic Reactions in School
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In 59% of the reactions, symptoms were limited to the skin and mucous
membranes. Wheezing was noted in 32%, and vomiting and/or diarrhea in 10%.
Thirty-six percent of the reactions involved 2 or more organ systems. One
child was treated immediately with an antihistamine on the ingestion of the
incriminated food and developed no symptoms.
Sixty-five percent of the reactions were treated with oral antihistamines,
while 15% were treated with epinephrine (6 episodes in 3 children) and 10%
were treated with inhaled bronchodilators. In 1 child, the administration
of epinephrine was attempted but was not successful, and by the time the ambulance
arrived, her symptoms (wheezing and vomiting) had resolved. In 2 other children,
3 cutaneous reactions also resolved without treatment.
The treatment provided for the reactions is detailed in Table 3. Most reactions were treated by either a school nurse or
a teacher. An ambulance was called for 3 reactions. In the reactions that
were treated with medication, treatment was initiated within 10 minutes of
the onset of symptoms in most cases.
Eighty-six percent of the children had a protocol for the treatment
of food-allergic reactions in place at school, provided by an allergist in
60% and by a pediatrician in 40%. Fourteen percent of the children did not
have a written protocol in place. Parents reported good adherence to the protocol
in 80% of the children who experienced reactions at school. Eighty-four percent
of the parents provided medications to be used at school in case of an allergic
reaction. Eighty-one percent provided at least 1 self-injectable epinephrine
device, 64% provided oral antihistamines, and 20% provided inhaled bronchodilators.
Medications were kept in a health room for 58% of the children, in the classroom
for 28%, and in the front office for 18%. Seventeen percent of the children
carried their medications with them. Five percent of the children also had
medications in other locations, such as the cafeteria, the school bus, or
with a coach. Nineteen percent of the children had medications in more than
1 location. Sixteen percent of the children did not have any medications at
school for the treatment of food-allergic reactions.
Fifty-nine percent of the children were not allowed to eat any food
at school or preschool not provided by their parents, 22% ate regular school
food, and 19% were allowed to have some of the foods and snacks provided by
the school. Most parents were proactive in approaching the issue of a food
allergy at school. Ninety percent talked to teachers, 58% talked to the school
nurse, and 47% talked to the school principal. Thirty-five percent of the
parents distributed written educational materials, 21% talked with parents
of other children in the classroom, 15% made a formal presentation for the
school staff, and 14% showed a videotape from the Food Allergy Network. Eight
percent arranged for self-injectable epinephrine device training for school
personnel, 4% asked their child's pediatrician or allergist to call the school,
and 7% used other resources. Most (83%) applied more than 1 strategy to ensure
their child's safety at school. Eighty-six percent of the parents rated school
receptiveness toward food allergy as good to excellent, 9% deemed it satisfactory,
and 5% thought that there was inadequate school receptiveness. Forty-one percent
of the parents belonged to 1 support group, 10% belonged to 2 support groups,
and 3% belonged to 3 or more support groups; 46% of the parents did not hold
any support group membership. Fifty percent of the parents belonged to the
Food Allergy Network, 8% belonged to the Asthma and Allergy Foundation of
America, and 4% belonged to other support groups.
SCHOOL SURVEY
We attempted to contact 89 schools; 3 declined the interview, and in
6 we were unable to reach the school nurse or the director. Fifty-nine schools
and 21 preschools participated in the survey. As shown in Table 4, most (90%) of the schools and preschools reported more
than 1 allergic child among their students. Thirty-nine percent of the schools
reported at least 1 food-allergic reaction within the past 2 years, including
71 reactions in 22 schools and 14 reactions in 9 preschools. Most of the schools
had a health professional; there was no health professional in 5%. None of
the preschools had a nurse on the premises. In more than 90% of the schools,
the nurse or health technician was responsible for the treatment of food-allergic
reactions, while in the preschools, teachers and administrative staff were
in charge of treatment. In 78% of the schools and in 62% of the preschools,
there was at least 1 backup person trained in the use of the self-injectable
epinephrine device.
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Table 4. Characteristics of Schools and Preschools Participating in
the Survey*
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In 97% of the schools, medications for the treatment of food-allergic
reactions were kept in the health room, and 31% of the schools had medications
available in more than 1 location. In 19% of the schools, students were allowed
to carry epinephrine with them. In the preschools, medications were located
in the classroom in 48%, in the front office in 43%, and in the kitchen in
14%, with 5% of the preschools having medications for the treatment of food-allergic
reactions available in more than 1 location. Fifty-one percent of all schools
used a special form for the orders for treatment of food-allergic reactions,
and 49% used a standard medication form. Sixty-seven percent of all schools
made at least 1 accommodation for children with a food allergy, such as peanut-free
tables, a peanut ban from the classroom or from the entire school, separate
eating areas, and alternative meals.
COMMENT
Although food allergies may affect up to 6% of school-aged children
and are the most common reasons for nutritional modifications in school, little
is known about food-allergic reactions in schools and preschools.1, 5, 6 The almost universal
presence of the most common food allergens, such as milk, egg, soy, wheat,
and peanuts, makes their avoidance extremely difficult.7
In fact, in one study2 focusing specifically
on peanut allergy, 50% of the children had experienced an accidental exposure
in a 1-year period. This risk is especially important, because food-allergic
reactions in children have the potential to be life threatening or even fatal.8, 9, 10 In case series3, 4, 11, 12, 13
of anaphylaxis, food allergy was the major identifiable trigger in 34% to
57% of the reactions. A time trend study14
of hospital admissions for acute anaphylaxis reported that food was a causative
factor in 15%, and that in addition to an overall increase in anaphylaxis
incidence there was an increase in the incidence of food-related anaphylaxis.
In other studies,3, 4 it was found
that food allergy was the most common cause of anaphylaxis in children outside
of the hospital setting and that 1% to 2% of all anaphylactic reactions occurred
in schools.
The preferred approach to food-allergic reactions is prevention. Theoretically,
it may be achieved by a high level of alertness and/or complete elimination
of the offending food from the child's environment. In reality, however, food
elimination is difficult, and in the case of basic foods, such as milk, egg,
soy, and wheat, it is virtually impossible. In addition, even foods such as
peanuts and tree nuts, which can be avoided without concern of compromising
the child's nutrition, are also difficult to eliminate because of food contamination
or hidden ingredients. Furthermore, a recent telephone survey15
among the registrants in the National Peanut and Tree Nut Allergy Registry
found that in 25% of the cases, a reaction in school was the first indication
of a peanut allergy. Our survey demonstrates that food-allergic reactions
are common in schools and preschools, as almost 1 of 5 surveyed children experienced
such a reaction in school in the past 2 years. It is possible that this is
an overestimate of the true frequency of such reactions in the general population,
because it represents a referral population with an inordinate number of children
with multiple food allergies. However, it also represents a highly educated
population, most of whom were making use of at least 1 support organization,
which may have helped to reduce the chances of accidental exposures.
Milk was the most commonly incriminated food in the preschool-aged children,
whereas peanut was most common in school-aged children. Fortunately, there
were no fatalities; however, 36% of the reactions involved 2 or more organ
systems and 15% were treated with epinephrine (Table 3). However, 14% of the children did not have a written protocol
in place for the treatment of food-allergic reactions in school and 16% did
not have medications available at school for the treatment of food-allergic
reactions.
Thirty-seven percent of the schools and 43% of the preschools reported
at least 1 food-allergic reaction in the past 2 years (Table 4). All but 1 of the surveyed schools had a person responsible
for the treatment of food-allergic reactions trained in the administration
of epinephrine, although there was no backup person identified in 22% of the
schools and in 38% of the preschools. Sixty-seven percent of all schools reported
at least 1 modification directed at the prevention of food-allergic reactions
(Table 4).
Our survey demonstrates that complete elimination of food-allergic reactions
in schools is extremely difficult. In fact, 10 of the reactions occurred in
schools that made special accommodations designed to prevent food-allergic
reactions. Therefore, it is critical that schools are prepared to recognize
and treat food-allergic reactions even when every effort is made to minimize
the risk of reactions.16 Pediatricians and
allergists have an extremely important role in the education of food-allergic
children and their parents. Physicians should ensure that every food-allergic
child has a clear emergency plan and medications available in school in case
of a food-allergic reaction. They have to educate children and their parents
about when and how to use self-injectable epinephrine devices. Children with
a history of severe anaphylactic reactions to food may benefit from wearing
a medical alert bracelet. Physicians may also provide the parents with the
information about lay organizations, such as the Food Allergy Network, that
are a great source of training materials, helpful strategies, and support.
The schools should identify food-allergic students and request detailed
instructions from the child's physician for the treatment of food-allergic
reactions. A person in charge of treating reactions should be clearly identified
and comfortable with the use of injectable epinephrine devices. There should
always be at least 1 backup person with the same qualifications to recognize
and treat food-allergic reactions.17, 18, 19, 20, 21
Finally, it is essential that epinephrine be immediately available since early
administration of epinephrine for food-allergic reactions can be lifesaving,
with clear evidence that fatal outcomes are associated with a delay in its
administration.9, 10
AUTHOR INFORMATION
Accepted for publication February 26, 2001.
This study was supported by training grant T 32 AI 07007 from the National
Institutes of Health, Bethesda, Md; and by the Eudowood Foundation for the
Consumptives of Maryland, Baltimore.
We thank the private pediatricians who kindly referred patients for
this study: Sara B. Levin, MD; Patricia A. Liszewski, MD; Joshua S. Madden,
MD; and Tom L. Seymour, MD.
From the Division of Allergy & Immunology, Department of Pediatrics,
Mount Sinai School of Medicine, New York, NY (Dr Nowak-Wegrzyn); and the Eudowood
Division of Allergy and Immunology, Department of Pediatrics, The Johns Hopkins
University School of Medicine, Baltimore, Md (Ms Conover-Walker and Dr Wood).
Corresponding author and reprints: Anna Nowak-Wegrzyn, MD, Division
of Allergy & Immunology, Department of Pediatrics, Mount Sinai Medical
Center, Campus Box 1198, One Gustave L. Levy Place, New York, NY 10029-6574
(e-mail: anna_nowak-wegrzyn{at}mssm.edu).
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