Managing Life-Threatening Food Allergies in Child Care:

A Guide for Parents[*]

Food allergies are a growing problem among children attending preschool and day care. The parent of a food-allergic child must work with the child care facility to assure that the setting is as safe as possible for the child.

Background:

· Food allergies affect up to 8% of infants and pre-school children. Half of them are at risk for anaphylaxis.

· Food allergic reactions can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions.

· A delay in the administration of life-saving emergency medication, particularly epinephrine, is a major factor in death from food allergy.

· It is essential that child care facilities have detailed plans for both (1) avoiding accidental exposures to food allergens and (2) promptly treating reactions for all food-allergic children.

What Is Anaphylaxis?

Anaphylaxis is an allergic reaction affecting multiple systems in the body. Upon contact with a food allergen, the body releases chemicals into the tissues of the heart, lungs, digestive system, or skin. Blood vessels widen so much that blood pressure plummets.

Every reaction is different; not all reactions show the same symptoms. Symptoms may include:

· Inconsolable crying, listlessness, looking scared, or pointing to the throat, ears, chest, etc., particularly if the child can’t verbalize symptoms.

· Flushed, tingling, or itchy skin; swelling of lips or joints; hives or rash; sweating; paleness.

· A lump, itch or tickle in the throat; throat tightness; hoarseness; difficulty swallowing

· Nasal congestion; runny nose; a feeling of “fullness” in the ears.

· Chest tightness; wheezing or high-pitched sounds from the lungs; shortness of breath.

· Nausea; abdominal cramps; bloating; vomiting; diarrhea.

· Sense of impending doom.

· Lightheadedness; faintness; irregular or rapid heartbeat; confusion; passing out.

Patients who do not have life-threatening symptoms initially may progress to life- threatening anaphylaxis. Adequate warning signs, such as hives, are not always present before serious reactions develop. The first warning signs may be only “a funny feeling in the mouth” or abdominal discomfort.

Foods that most commonly cause anaphylaxis are:

· Peanuts · Tree nuts · Shellfish · Fish · Milk · Eggs · Soy · Wheat

· However, ANY food can cause an allergic reaction

Exposures to food allergens occur most frequently through eating and tasting. However, less commonly, reactions can occur as a result of merely touching or inhaling the food.

Protecting a child from exposure to an offending food is the most important way to prevent life-threatening anaphylaxis. Most anaphylactic reactions occur as a result of accidental exposure to the allergen.

Parents’ Responsibilities:

Parents should provide:

Ø Documentation and description of the food allergy signed by a doctor.

Ø Instructions on steps that need to be taken to avoid that food.

Ø A detailed Allergy Action Plan to be implemented in the event of an allergic reaction, including the names, doses, and methods of administration of any medications that the child should receive, including symptoms that would indicate the need to administer those medications.

Ø Doctor’s order for epinephrine by auto-injector (or EpiPen®) and any other medications needed.

Ø Parent’s signed consent to administer all medications.

Ø A sufficient supply of necessary up-to-date medications (including EpiPens®).

Ø Arrangements for proper storage of such medications in an unlocked cabinet always accessible to staff.

Ø SAFE foods for their children, as agreed upon with the facility.

(Parents can obtain a Child Care Asthma/Allergy Action Card for documenting such information by calling AAFA/NE at (617) 965-7771 or toll-free at 1-877-2-ASTHMA.)

Child Care Facility’s Responsibilities:

Ø Facility must develop policies and procedures to prevent anaphylaxis and manage food allergy emergencies and must train staff in these procedures.

Ø Facility staff should be trained by a health care consultant to prevent and manage anaphylactic reactions, even if no food allergic child is enrolled. A first reaction can happen at child care, and it can be severe.

Ø Facility must decide with parents how to handle food. Three basic options are:

o The facility may give the child only foods provided directly by the parent.

o The facility may give the child foods approved by the parent in advance.

o The facility may give the child foods approved by a trained staff.

Preventing Accidental Exposures to Food Allergens

Facility staff must:

• Be trained to recognize the different names by which foods may be identified in a list of ingredients. For example, casein, caseinate, whey, and lactoglobulin are all milk products.
• Read labels EVERY time a food is used. Ingredients of a given food may change. Also Halloween candies and other holiday foods may be made in facilities different from those used at other times of the year.
• Prohibit food sharing among children.
• Prohibit eating on buses or vans used to transport children.
• Wash children’s hands and faces before and after eating, to avoid spreading of food particles.
• Wash all surfaces before and after contact with food.
• Not use foods to which the child(ren) are allergic in art, craft, science, cooking, or other classroom projects, such as peanut butter to make a bird feeder.
• Avoid food allergens in both meals and snacks provided. The safest policy is not to allow peanuts on the premises. Short of that, a peanut-free table or eating area should be established and maintained through frequent cleaning.
• Notify parents of all children in the class to avoid bringing any known allergens in class treats or special foods into the child care setting.
• Avoid the use of food for rewards or celebrations.
• Post individual children’s food allergies (including names and photos of children, with parents’ permission) in a designated area in the classroom and/or wherever food is served. Be sensitive to confidentiality issues.
• Make copies of the Allergy Action Plan to be routinely carried on field trips or transport out of the child care setting.
• Choose field trips carefully to avoid potential allergen exposure. Plan for safe foods ahead of time and bring foods if necessary to avoid meals or snacks that may contain food allergens.
• Not use latex gloves in food service, because latex is also a common cause of anaphylaxis and latex proteins transfer to foods.
• Train staff regarding cross-contamination of food allergens--the cooking, serving, or clean-up of different foods with the same utensils or cleaning supplies. Cross-contamination poses a serious risk to a child with food allergies and can occur very easily. Some examples are:
• Slicing peanut butter and non-peanut butter sandwiches with the same knife
• Cleaning surfaces containing different foods with the same sponge

Preparing for and Managing a Food Allergy Emergency

Facility staff must:

• Be equipped with a cell phone or other communication device at all times for emergencies.

• Contact Emergency Medical Services (EMS) and other first responders to alert them that you have a food-allergic child in your setting. Determine whether they routinely carry epinephrine.
• Train and designate staff to administer the EpiPenÒ in the event of an allergic reaction according to the instructions in the AAP.
• Have epinephrine readily available for all children at risk for anaphylaxis.
• Notify the parents of ANY suspected food allergy, even if a serious reaction does not occur. Sometimes the food allergy reaction may occur at the child care facility for the first time.
• When in doubt about whether a reaction warrants administering epinephrine, it is better to give the EpiPenÒ and immediately seek medical attention. Fatalities occur when epinephrine is withheld.
• Call EMS immediately whenever epinephrine has been administered. DO NOT DELAY.
• Notify the child's parents and physician if the facility has had to treat the child for a food allergic reaction.
• Conduct practice drills periodically.
• Conduct peer education before and after a food allergy emergency.

“Epinephrine is the first drug that should be used in the emergency management of a child having a potentially life-threatening allergic reaction…There are no contraindications to the use of epinephrine for a life-threatening allergic reaction.”

“All individuals receiving emergency epinephrine should immediately be transported to a hospital even if symptoms appear to have resolved… Further treatments may be required, and therefore observation in a hospital setting is necessary. ..Additional epinephrine should be available during transport.”

From American Academy of Allergy, Asthma and Immunology (AAAAI) Position Statement. Treatment Strategies.

© 2003. Disclaimer: This publication is not meant to substitute for responsible professional care to diagnose and treat food allergies or anaphylaxis. AAFA/New England, including all parties to or associated with this publication will not be held responsible for any action taken as a result of this publication.

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[*] Based in part on (1) Caring for Our Children: National Health and Safety Performance Standards, Standard 4.010, National Resource Center for Health & Safety in Child Care, http:\nrc.uchsc.edu; and (2) “Managing Life Threatening Food Allergies in Schools,” guidelines that AAFA/NE helped the Massachusetts Departments of Education and Public Health to develop.