The treatment in school of children who have food allergies

The treatment food allergies

in school of children who have

Committee report from the Adverse Reactions American Academy of Allergy and Immunology

Although the exact prevalence of food allergy in school-age children is unknown, conservative estimates suggest that at least one food-allergic student attends most schools.’ The symptoms and signs attributable to allergic reactions to foods vary among affected individuals but commonly involve the gastrointestinal tract and/or the skin, less frequently involve the respiratory tract, and rarely involve the cardiovascular system.* Although most of these reactions are self-limited and/or respond to appropriate early medical intervention, fatal anaphylactic reactions to foods in exquisitely sensitized individuals have been documented.’ Simply stated, the key to the prevention of allergic reactions to foods is antigen avoidance, that is, ensuring that the food-allergic child is not exposed to an offending food. Attainment of this goal often proves more elusive in practice than might theoretically be predicted and requires the development of a heightened awareness of the potential risks associated with allergic reactions to foods and increased commitment and cooperation among several parties, including teachers, physicians, parents, and sensitized children. If, while these children are at school, all children with food allergies ate only foods carefully prepared at home, it would theoretically be possible to prevent food-induced reactions. However, many children with food allergies prefer to consume meals in the school cafeteria, share or swap foods with classmates, or participate in classroom activities that involve the ingestion of various snacks. Since it is impossible for parents to inspect everything eaten by their children at school, instruction of these children concerning which foods are safe and which foods must be avoided is important. Physicians should review potential sources of inadvertent exposure to offending foods with their patients and their parents and, when this is necessary, teach them how to read labels. In turn, parents need to inform the appropriate teachers about their children’s sensitivities. Bracelets or necklaces identifying the children as having food allergies should be worn to school. Cooperation among parents and teachers about providing safe snacks for the foodallergic child at classroom activities without drawing undue attention to the child is sometimes necessary. The unambiguous advance listing of ingredients used in the preparation of foods served in the school cafeteria provides the food-sensitive child, either alone

to Food Committee

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or with the aid of a responsible adult, the information needed to select a safe meal. In addition, steps should be taken in the kitchen of the school cafeteria to avoid inadvertent contamination of nonallergenic foods with allergenic foods by preparing these foods with separate utensils. Unfortunately, long-term studies of food-allergic subjects suggest that the frequency of adverse reactions resulting from the accidental ingestion of offending foods by allergic individuals is alarming. For example, in one study, 16 of 32 peanut-sensitive individuals contacted had experienced an accidental ingestion within the previous year.4 Clearly, discussions between teachers, physicians, parents, and foodallergic children concerning the prevention of reactions should also include both a review of symptoms and signs that might aid in early recognition of a reaction and a detailed treatment plan. A study reviewing seven cases of fatal allergic reactions to foods revealed that the ingestion of milligram to gram (5000 mg equals 5 grams or 1 teaspoon) amounts of food allergen by exquisitely sensitized individuals may prove fatal and raised important points regarding the treatment of individuals during allergic reactions to foods.3 The rapidity with which life-threatening reactions developed in these individuals suggests that the availability and early appropriate administration of epinephrine followed by immediate transport to an emergency room is indicated at the first sign of a severe allergic reaction. Parents, food-allergic children who are old enough to be trained, and school nurses or another designated responsible individual, such as the child’s teacher, need to be trained to recognize the symptoms of impending anaphylaxis and promptly institute the proper therapy, including the oral administration of an appropriate dose of antihistamine and the early use of aqueous epinephrine by injection. It is strongly recommended that aqueous epinephrine in a form that can easily be administered by injection (EpiPen Jr. and EpiPen; Center Laboratories Division, Port Washington, N.Y.; Ana-Kit; Hollister-Stier Laboratories, Spokane, Wash.) be available and that a responsible individual be designated to administer the injection in the event of an allergic reaction to a food. The dosages and indications for the use of other medications, such as antihistamines and/or inhalers needed for the treatment of brochospasm, should be clearly delineated (Fig. 749

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I). Furthermore, a plan for safe transport of a foodallergic child during a reaction to the closest medical facility capableof treating anaphylaxis should be developed. REFERENCES 1. Anderson JA, Sogn DD, eds. American Academy of Allergy and Immunology and the National Institute of Allergy and In-

of children

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751

fectious Diseases: Adverse reactions to foods. Washington, DC.: U.S. Government Printing Office. Publication no. 017044-0045-l), 1984. 2. Bock SA, Sampson HA, Atkins FM, et al. Double-blind, placebo-controlled food challenge (DBF’CFC) as an office procedure: a manual. J ALLERGY CLIN IMMUNOL 1988;82:986-97. 3. Yunginger JW, Sweeney KG, Stumer WQ, et al. Fatal foodinduced anaphylaxis. JAMA 1988;260:1450. 4. Bock SA, Atkins FM. The natural history of peanut allergy. J ALLERGY CLIN IMMUNOL 1989;83:900-4.

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