By Dr. David Stukus
I couldn’t believe it had come to this. I was the first allergist this family had seen for their 10-year-old son, who had a peanut allergy. They came to see me as a last resort before pulling their son out of school. He had attended public schools since Kindergarten, all of which were “nut free.” However, he was about to start fifth grade at a new school, which was not. Both parents were extremely anxious about his peanut allergy and potential for life-threatening reaction at school, where he was outside of their watchful eye. They requested that I “force” the school to ban all nuts to allow their child to safely attend. After much discussion, it turned out that they had never received counseling about food allergy management, risks, and expectations. I’ll spare the details, but after a productive discussion (and several subsequent visits), they decided to allow their son to attend his new school, without changing its policy. You’ll be happy to learn that he has done great ever since.
Nowhere is the epidemic of food allergies more contentious than in our nation’s schools. This is where the health problems of an average of two children per classroom run headlong into the “right” of children to eat “America’s favorite food” or other staples of the typical diet, where education professionals must learn emergency medical skills and school nurses are becoming a luxury, and so on.
Current estimates are that 5-8% of children have at least one food allergy, with roughly 2% having allergies to peanut or tree nuts. But while these are the battleground allergens, milk, egg, wheat, soy, fish, and shellfish collectively account for > 90% of all food allergy reactions. Many people do not realize that any food allergy can cause a severe allergic reaction. Although milk, egg, wheat, and soy allergies tend to improve or go away with age, 80% of children with nut or seafood allergies will never outgrow their allergy. The severity of reactions can progress over time and cannot be predicted based upon any test result, or even prior history.
Compounding the school dilemma is the fact that food allergens can represent a threat even when they are not ingested. Because even trace amounts of peanut protein introduced through cross contamination from a shared baking sheet or utensil can provoke a life-threatening allergic reaction in some children, management of food allergies requires constant vigilance at every snack and meal to ensure the food doesn’t contain or didn’t contact any food allergens. Casual contact through touching the food or a surface where the food previously touched can also cause reactions, although these are rarely life threatening, and mostly cause localized hives or swelling. However, transfer of the food from hands to the eyes or mouth can trigger a more severe reaction. Food allergy reactions can occur to some foods through inhalation as well, but the majority of these are when the food is being cooked on the stove top and releases vapors into the air, such as frying fish. It is exceptionally rare for a food such as peanut to cause a life-threatening allergic reaction by merely being in the same room or vicinity without ingestion occurring, but minute amounts may travel on hands and clothing. The exact route these proteins travel may never be known in each case.
Given the prevalence of peanut and tree nut allergies, risk for reaction with every exposure, and multiple routes of exposure, some schools have adopted nut-free policies to try to minimize the risk with their students. This can be a highly charged political and emotional discussion from both sides, and may provoke strong sentiments from families who don’t have children with food allergies. The decision to make a school nut-free affects everyone. Below are some of the things to consider for both sides of this argument.
Given the large number of students spread throughout multiple different classrooms and moving through various locations throughout the school day, it can be extremely challenging for school personnel to provide constant supervision for students with food allergy. Younger children in particular naturally explore their environments more with their hands and even mouths. Having peanut/nut containing products in the classroom increases the risk that they will accidentally touch or ingest these foods. Having a policy in place that is communicated to all students and school personnel about being a nut-free facility can reduce the number of potential exposures and risk for reaction. This can also bring about a sense of community and promote well-being for all students, acknowledging the challenges that children with nut allergies face every day.
Each school differs in regards to their physical layout and meal preparation/lunchrooms. It may make a lot of sense for a school that serves lunch in the classroom to restrict all nuts to minimize risk of exposure. However, schools that have separate cafeterias and do not allow snacks/meals in the classroom may prefer to implement nut-free cafeterias instead. Each circumstance is different and the age of the students, specifics to the school, and understanding/preparation from the school personnel all must be taken into consideration when deciding whether to go nut-free.
There is no evidence that demonstrates nut-free schools protect against allergic reactions. In fact, the opposite may be true. At least one study has shown ongoing reactions to peanut/tree nuts in nut-free schools! How can this be? If you discuss with school nurses and administrators, many of them will tell you that nut-free policies are not enforceable. Despite repeated notifications to families and provision of policy statements, children without allergies may still unintentionally bring nut containing foods to school for lunch. Unless you search every single bag every single day, there is no way to enforce this rule with 100% certainty. Peanut butter is a great source of relatively inexpensive protein and many families rely on peanut butter and jelly sandwiches to feed their children at lunch.
In addition, having a policy about being nut-free may inadvertently cause students with food allergies and school personnel to have a false sense of security and let their guards down. One study shows that accidental exposures happen at higher rates than in schools that allow nuts (and both are far below the rates at home). Labels may not be read every time. Perhaps the students forget to ask about ingredients in the lunch line. Perhaps parents neglect to send injectable epinephrine with their child, feeling secure that they will not be exposed to nuts. One must always consider unintended consequences, which in this instance includes potential for being unprepared to recognize or treat an allergic emergency.
Many who advocate against nut-free schools discuss the need to prepare children with food allergies for living in the ‘real world’. They will always need to follow all standard precautions when visiting public places, other people’s homes, or when traveling. Implementation of nut-free policies within schools may hamper their ability to practice and learn critical self-management strategies that will help them navigate their way through the rest of the world. Counseling the family in the anecdote with which I began this post taught me as much as I taught them about the responsibilities that fall on every food allergy family. Fortunately, they learned and their son has benefited.
Parents of children without food allergies may not understand the real risks involved or the serious nature of living with a food allergy. They may not understand that there is no safe amount and every snack or meal needs to be scrutinized. Poor awareness and recognition of these facts can lead to intentional or unintentional emotionally charged exchanges with families living with food allergies. Animosity may grow towards the select few who force a policy that affects all. Occasionally, conflict erupts that brings out the very worst in parents, who view new restrictions in a political context of ever-more intrusion on personal liberties.
In addition, making a school nut-free does not protect children with other potentially life-threatening food allergies such as milk, egg, wheat, soy, or seafood. Parents of these children may feel as though their child’s needs are not being met and excluded from the communal feeling of the school banding together to protect some children, but not others. This can turn into a slippery slope very quickly.
Lastly, several studies have shown that 25-30% of children with food allergies are subjected to bullying at school. While having nut-free policies won’t change the fact that a student may already have food allergies, it may bring their allergies to the forefront for those with bad intentions to exploit.
Regardless of a school’s decision to adopt nut-free policies or not, everyone within the school should receive annual training and education regarding the recognition and management of food allergies. The Centers for Disease Control published excellent free guidelines in 2014 that provide in-depth discussion of many of the issues raised in this article, in addition to recommendations for ways schools can best accommodate and protect students with food allergies.
You may note that this article does not make any recommendation one way or the other whether schools should adopt nut-free policies. You may also note that no professional medical organizations, including the allergy specialties, have made formal recommendations regarding this topic either. It is simply too complex to apply blanket statements that should be adopted by everyone. While debate can carry on regarding the merits of nut-free policies, no one can argue that there is a lack of evidence for both sides of the argument. Individual 504 plans for children with food allergies can help provide thorough, written communication regarding provisions the school can make to ensure the safest environment possible.
The approaches by schools and families with food allergic children may vary. However, at the end of the day, what matters most is that children with food allergies be able to attend school with their peers, not be secluded from any activities, and learn in a safe environment while minimizing risk of accidental ingestion of their food allergens.
David Stukus, MD, is board certified in Allergy/Immunology and is an Assistant Professor of Pediatrics at Nationwide Children’s Hospital and The Ohio State University in Columbus, Ohio. His clinical and research interests focus on asthma and food allergies, especially improving education and adherence for patients and families. As part of his research, Dr. Stukus has created novel technology and educational tools using mobile health apps to improve the care of patients, for which he was recognized with the Nationwide Children’s Hospital Department of Pediatrics Junior Faculty Award in November 2013. Dr. Stukus has been an active member of the medical advisory team for Kids with Food Allergies since 2009 and was elected to the Board of Directors for the Asthma and Allergy Foundation of America in 2014. Lastly, Dr. Stukus actively engages with food allergy support groups and participates in social media on twitter through @AllergyKidsDoc.