Food Allergies in Schools: Overview

Introduction

The growing prevalence of allergies among the pediatric population poses a challenge to school officials concerned about promoting the physical health and academic well-being of their students. For reasons scientists cannot definitively explain, the numbers of school-aged children with allergies has continued to increase steadily around the globe, including the United States, since researchers began monitoring the trend in 1991. Some studies have suggested that the rate of peanut allergy, in particular, tripled in the first decades of the twenty-first century, with about 1 to 2 percent of children having a peanut allergy by 2020.

Common allergens, irritants capable of triggering an allergic reaction, in a school setting include dust mites, animal dander or pet hair, pollen, mold, mildew, pesticides, paint fumes, perfumes, chalk dust, scented markers, and cleaning chemicals. Experts estimate that allergic and asthmatic reactions to such stimuli are to blame for millions of American student absences annually.

But food allergies, which in a typical year cause 30,000 emergency medical visits, have created the most pressing worries for children, parents, and school officials. By 2021, food allergies affected an estimated 6 percent of children, about half of whom are at high risk of experiencing anaphylaxis, the most severe and potentially fatal type of allergic reaction.

While allergies to any edible item can and do exist, the majority of food allergy episodes are caused by just nine items: peanuts, tree nuts (such as walnuts, pecans, almonds, cashews), milk, eggs, fish, shellfish, wheat, soy, and sesame. While 80 percent of children outgrow milk, egg, wheat, or soy allergies by their mid-teens, only 20 to 25 percent outgrow peanut allergy and fewer than 15 percent outgrow tree nut allergies, according to the Allergy and Asthma Foundation of America. Many schools have focused their allergy awareness and prevention efforts on peanuts and tree nuts for this reason—and also because these two foods alone account for the majority of all severe-to-lethal reactions.

Understanding the Discussion

Allergen: A substance that can trigger an allergic reaction in certain people whose immune systems are predisposed to interpreting the substance as harmful to the body.

Anaphylaxis: A sudden, severe, potentially life-threatening, systemic allergic reaction. Symptoms may include a tingling sensation, itching, or burning in the mouth; hives; swelling; watery eyes; runny nose; cough; vomiting, diarrhea, and stomach cramping; a drop in blood pressure; loss of consciousness; bluish lips; breathing difficulties.

EpiPen: An emergency device used to inject epinephrine (a synthetic version of the naturally-occurring hormone adrenaline) into the thigh of a person experiencing an anaphylactic reaction. The drug works quickly to offset cardiovascular and respiratory distress by reducing swelling in the throat and relaxing lung muscles. The device’s convenient design (anaphylaxis-prone patients can easily inject themselves using an EpiPen if the need arises) is of military origins; armed forces researchers developed the device as a means for soldiers in the field to self-administer nerve gas antidote.

Food allergy: An immune system response that occurs after the body has created specific (most commonly immunoglobulin E) antibodies to a particular food item that, for unknown reasons, the immune system has identified as harmful. In an effort to protect the body, the immune system secretes a flood of chemicals called mediators. When these mediators, which include histamine, come in contact with the ingested food, they trigger an allergic reaction. The symptoms can be respiratory, gastrointestinal, skin-related, and/or cardiovascular in nature.

Food intolerance: An adverse food-induced reaction that, unlike a true food allergy, does not trigger an immune system response. A person with lactose intolerance, for example, lacks a digestive enzyme necessary for the body to break down the sugar found in milk products. The gastrointestinal discomfort that typically results when a lactose-intolerant person consumes such products results from this deficiency and does not involve the body’s immune system.

Background

While scientists have yet to offer a definitive answer to what has caused the sharp, worldwide increase in allergies and asthma among school-aged children over the past few decades, they have put forth a number of theories. One of the leading theories, the so-called hygiene hypothesis, speculates that, with the popularity of antimicrobial cleaning agents, home environments have become so pristine that young children are no longer exposed to the same levels and varieties of bacteria, thus depriving their immune systems of the opportunity to learn how to assess and fight potential threats.

While the cause of the phenomenon remains a subject of debate, school officials have scrambled to respond to the consequences of steadily increasing numbers of allergy-prone children in the classroom. The motivation to accommodate students with food allergies has been spurred both by the concerns of parents, teachers, and school officials for the health and safety of children as well as by obligations to comply with the law. A food allergy that may result in anaphylaxis (as determined by a physician) meets the definition of disability and is covered under the federal Americans with Disabilities Act of 1990 (ADA) and Section 504 of the Rehabilitation Act of 1973. Such a disability may also be covered under the Individuals with Disabilities Education Act (IDEA), first passed in 1975, if the allergy management affects the student’s ability to make educational progress.

Today, most schools have in place policies designed to minimize risk for students with life-threatening allergies. Their efforts have focused primarily on food anaphylaxis, with particular emphasis on peanut allergy. These policies are based on prevention and preparedness, with a strong focus on the former. Since avoidance of the offending allergen represents the most effective means of protecting children, many schools have instituted bans on the sharing or trading of food or utensils.

Some have designated “peanut-free” tables in the cafeteria. Others have banned peanut butter and other tree nut products altogether from the cafeteria, the school bus, or sometimes even the entire school building (some children are so hypersensitive to peanut products that even tactile exposure, say by touching a desk or table surface with peanut residue, can trigger a violent reaction).

In recognition, however, of the reality that accidental exposures inevitably occur despite the best precautions, schools have also invested resources in awareness training for students, faculty, and staff. The allergies of very young students are sometimes (with parental consent) posted on classroom walls or imprinted on bracelets worn by the children as a clear reminder to teachers and visitors.

Many schools require older children who have an epinephrine prescription to disclose this information to all school personnel, including teachers, nurses, and food service workers. Some also require teachers of severely allergic children to receive instruction about potential reactions and proper emergency treatment; the American Academy of Pediatrics recommends that schools be fully equipped and trained to treat anaphylaxis in allergic students due to the associated mortality risk.

Schools that have made education and supervision cornerstones of their allergy management programs have witnessed promising results despite the overall rising numbers of allergic children. The incidence of adverse reactions in such settings has declined. At the same time, studies have shown that the prompt administration (ideally, within 20 minutes) of epinephrine to a child experiencing anaphylaxis can reduce the fatality rate to nearly zero.

In September 2005, Illinois became the first state in the nation to offer a free statewide food allergy education program to every school, preschool, and childcare center in Illinois.

On the federal level, in 2011, President Barack Obama signed into law the Food Allergy and Anaphylaxis Management Act, which calls on the federal government to develop uniform, voluntary guidelines for managing the risk of food allergy and anaphylaxis in schools. Accordingly, in 2013 the Centers for Disease Control and Prevention released the CDC Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs. Also in 2013, Obama signed the School Access to Emergency Epinephrine Act, encouraging schools to plan for severe asthma attacks and allergic reactions.

Food Allergies in Schools Today

In 2021 an international panel of experts led by Dr. Susan Waserman issued preliminary guidance recommending against school-wide bans or even restricted areas or tables, except for daycare settings serving infants and toddlers who lack self-management skills. They noted that such bans or restricted areas were difficult to enforce and could lead to laxness on the part of staff as well as social harm for the children affected. They instead advocated for maintaining management plans, close adult supervision, and unrestricted stocks of epinephrine versus requiring student-supplied autoinjectors as first-time allergic reactions do happen at school. Indeed, federal statistics show that in one-quarter of food allergy reactions at school, it was the student's first reaction.

By the early 2020s, the US Department of Agriculture was offering voluntary food allergy training to school cafeteria workers involved in some but not all federally funded food programs. In 2023 the Protecting Children with Food Allergies Act was introduced in Congress to address gaps in that training program, most notably by making it mandatory and extending it to other food programs.

That same year, the US Food and Drug Administration added sesame to its list of the top allergens that food manufacturers are required to disclose. The move, intended to aid those with sesame allergies, backfired as many manufacturers began adding sesame flour to products rather than risk inadvertent cross-contamination. Consequently, the change made it more difficult for sesame-allergic schoolchildren and their parents to identify safe foods, particularly in congregate settings such as schools.

As increasing numbers of children who do not outgrow their food allergies have become young adults with food allergies, the debate over how to handle food allergies in school has reached higher education as well. While some colleges and universities provide allergy-free menu options, dedicated facilities for allergic students, or at least ingredient lists, mistakes still occur and many campuses lack of staff training and general awareness of the problem. Moreover, the round-the-clock nature of on-campus living and required meal plans complicate matters for both students and the institutions. Nonprofit organizations such as Food Allergy Research & Education (FARE) and Food Allergy & Anaphylaxis Connection Team (FAACT) have sought to ameliorate conditions for allergic college students by offering trainings and resources to food staff at various institutions. Food-service staff, for their part, struggle with the ever-changing needs and demands of the student population and how much and how best to accommodate them.

These essays and any opinions, information or representations contained therein are the creation of the particular author and do not necessarily reflect the opinion of EBSCO Information Services.

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