Helping Families Manage Food Allergy in Schools

Tips and Tools for the Allergist and Nonallergist

Matthew J. Greenhawt, MD, MBA


July 25, 2011

In This Article

How Common Are Reactions at School?

What Are the Chances That a Reaction Will Occur at School or a Child Care Center?

Reactions do occur at school and can be severe under certain circumstances; however, their overall occurrence is still rare. There are no exact data detailing how often reactions occur in school.[5] One study found that they occurred more frequently in younger children, particularly those in preschool and kindergarten.[6] The reasons for this are not entirely clear, although a contributing factor may be that food allergy commonly first presents at that age, and therefore some initial reactions may occur in the school or child care setting. Another potential contributor is that common allergenic foods (eg, peanut butter) may be used in class projects, which increases the potential for exposure. In addition, older children may be more experienced and better trained in knowing what they can and cannot eat, explaining the lower rate of reactions in the older age range.

Sadly, there is a growing trend among some parents to “home-school” their food-allergic children out of fear that their child is at high risk for a reaction that will not receive adequate protection at school. This misperception diminishes quality of life for these families. There are no data to support the need for home-schooling to provide protection and decrease risk.[5]It is important to understand that the vast majority of even severely food-allergic children can and do attend school safely every day, and there seems to be little risk in attending school for food- allergic children.[5,6,7]

What Route (eg, Oral, Contact, Inhalation) Is Most Likely to Cause a Reaction at School or Child Care?

The highest risk for any food-induced reaction stems from direct ingestion of the food. Moreover, the risk for a severe allergic reaction from an unintended environmental exposure, such as contact with a contaminated surface or inhalation of air-borne particles, seems to be extremely low. Unfortunately, a common misperception held by many persons in the food-allergic community is that these are realistic risks. This belief causes unnecessary alarm and anxiety and may lead to requests for unwarranted precautions to be taken at school or child care, or may influence the decision to home-school.[8,9] However, the evidence to the contrary is quite clear.

Peanut and tree nut particles are commonly believed to have the potential to provoke a reaction from air-borne inhalation.[5,6,10] In a study from Johns Hopkins, researchers failed to detect measurable quantities of peanut in air filters around the necks of volunteers who danced on peanut shells scattered on the floor of a poorly ventilated room.[8]Similarly, in a study from Mount Sinai, blinded participants inhaling from a jar of peanut butter at very close range did not experience significant allergic reactions from the exposure.[9] This same study also did not find detectable levels of peanut on surfaces first smeared with peanut butter then cleaned with commercial products. Detectable levels were also not found on hands coated with peanut butter and then washed with soap and water, nor after cleaning with liquid hand sanitizer.

Skin contact as a route of exposure may be of particular concern in younger children who are more prone to touch contaminated items and not wash their hands before placing them in their -- or someone else's -- mouth. This is why a policy supporting strict handwashing after food contact in young children is important (to prevent both allergic reactions and infections). Nonetheless, these children still need to ingest the food to cause severe symptoms, although cases of contact urticaria can occur from certain foods in allergic children. Contact urticaria is generally self-limited to a cutaneous reaction that causes some mild discomfort without further generalization to other organ systems.[11] Wiping down the skin area of allergen contact often resolves the reaction. However, contact urticaria could be misinterpreted by a frightened observer unfamiliar with the child's reaction history as a sign of a more severe reaction.

Inhalation reactions are frequently reported anecdotally, although again, evidence to support this as a reaction-inducing mechanism is limited.[6,7,8,9] What most likely occurs in these cases is that dust or particles are briefly released into the air but settle quickly, and unnoticed contact between the skin -- and subsequently the oral mucosa -- and the now-contaminated surface occurs, introducing unrecognized ingestion. (For example, a hand might touch a contaminated counter, and then is brought to the mouth.) Alternatively, anxiety in this situation may induce subjective symptoms like wheezing or shortness of breath attributable to paradoxic motion of the vocal cords, pharyngeal tightening, a globus sensation, itching, and even urticaria.

To summarize a point that is often misperceived: The greatest risk for a reaction at school or child care in a food-allergic child is from direct ingestion of the allergen and not from other routes of exposure. This is essential to keep in mind when making any classroom or facility recommendations.


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