New guidelines call for schools and child-care centers to have staff training on anaphylaxis, allergy action plans, and epinephrine available to manage food allergies. But they conclude that school-wide food bans and allergen-free zones and even free-from tables are not necessary.
The recommendations to do away with food bans and allergen-free zones are meant to help remove the stigma for students often associated with those, says allergist Dr. Susan Waserman. The professor of medicine at Canada’s McMaster University chaired the international panel that developed the guidelines.
An analysis of research did not show those protocols make schools safer in reducing the risk of allergic reactions, the panel’s study findings say.
School-wide bans often have been disputed because of a false sense of security, and research shows that reactions still happen in those situations, notes Dr. Scott Sicherer, director of the Jaffe Food Allergy Institute at Mount Sinai in New York.
The panel acknowledges that managing food allergies at school is a controversial topic, and early response to their findings shows that. There is concern among some experts that school leaders might follow the recommendations regardless of individual situations or special circumstances.
Age Factor, Special Situations
For instance, Sicherer (who wasn’t on the panel), says that whether areas free of allergens are helpful depends a lot on children’s ages and development.
Longtime food allergy educator Gina Clowes agrees. She participated in the international panel, but chose not to be listed as an author. “I do believe that some of the guidelines could be helpful. I strongly disagreed with others and have concerns for what they would mean in the day-to-day management of food allergies in schools,” says Clowes, who formerly was the program director for the CDC’s voluntary food allergy guidelines for schools and daycares.
The panel references the need to prepare students with food allergies to live in the world where allergens aren’t prohibited. But Clowes notes: “We protect our young ones from dangers: We don’t give young children knives, matches or access to prescription medication, even though they must learn to deal with all of these as they grow up.”
Age is a factor when considering the guidance to avoid allergen-free zones. For example, a busy classroom of 30 5-year-olds with one adult in charge would be a case where it is appropriate to restrict food from certain areas to protect the children with food allergies, Clowes says.
Panel’s Key Recommendations
Inconsistencies in procedures and protocols regarding food allergy management were the impetus behind creating guidelines based on a systematic review of the best-available literature, Waserman says. Healthcare experts, school personnel, and parents studied scientific evidence for the recommendations, which were published in the Journal of Allergy and Clinical Immunology (JACI, May 2021).
The panel evaluated low-quality evidence, due to research gaps in the areas studied, so the recommendations are conditional, Waserman says. The recommendations, which allow for special circumstances, include:
- Food allergy training for teachers and staff.
- An allergy action plan for each student with a diagnosed food allergy.
- Protocols to manage suspected allergic reactions in students without an allergy action plan.
- Not banning specific allergenic foods site-wide.
- There should not be allergen-restricted zones or classrooms except in special circumstances, such as with very young children or when a child lacks the capacity to self-manage.
- Use of epinephrine only when someone is suspected of experiencing anaphylaxis.
- Personnel should not preemptively administer epinephrine when no signs or symptoms of an allergic reaction have developed, “even if a student has eaten a food to which they have a known allergy or history or anaphylaxis”.
- Having stock unassigned epinephrine auto-injectors on site, where laws permit, instead of requiring students to supply the school with their own auto-injectors.
“We’re here to report on the science, not to tell people what to do,” Waserman notes. “How schools choose to implement the guidelines is up to them.”
Stock Epi and School Size
Local circumstances must come into play when considering the guidelines, especially because of the huge variations across countries, communities, schools and age groups, says Dr. Michael Pistiner, who served as a reviewer for the guidelines.
“There are many different ways to implement the pillars of food allergy management, which are preventing an allergic reaction and emergency preparedness,” notes Pistiner, director of food allergy advocacy, education and prevention for the MassGeneral Hospital for Children Food Allergy Center in Boston.
For example, the recommendation that epinephrine auto-injectors should be stocked on site, instead of requiring personal auto-injectors from students, could vary depending on resources and size of the school. While having so-called “stock epinephrine” is essential in case of first-time allergic reactions, giving the option to provide a student’s own epinephrine can relieve some costs for schools.
Not requiring each student to provide auto-injectors would help some families financially. However, the idea could make parents nervous, and Sicherer notes that it’s important to ensure that students can quickly get to the epinephrine at the school. For example, that might not be feasible in a big school where a child would have to go to a different building or three floors away to get to the epinephrine, he says.
Individuals’ Disability Rights
“I am grateful for laws in the U.S. that require school districts to evaluate a student’s individual needs. I don’t believe a one-size-fits-all approach is appropriate,” Clowes says.
Federal disability laws in the United States, including the Americans with Disability Act (ADA) and Section 504 of the Rehabilitation Act, form the legal basis fo accommodations for students with food allergies. They focus on the rights of individual students, says Amelia Smith, general counsel and vice president of civil rights advocacy for Food Allergy & Anaphylaxis Connection Team (FAACT).
Smith says the new guidelines could create friction when parents go into a 504 plan meeting. For instance, school officials might use them to push back on requests for accommodations that fit a student’s individual needs.
Since U.S. students with disabilities have a legal right to education accommodations, she suggests parents focus on their child’s individual needs when working with school. “It is important to stress that these guidelines are not mandates,” she says.
In the bigger picture, Pistiner says the new guidelines can help everyone start thinking about their approach to food allergy management and where to prioritize. He views staff training as the key to ensuring the success of any guidelines implemented. Proper training provides everyone with the tools to know the role they play and to properly carry out each school’s protocols.
“Training is essential to successful food allergy management, especially in schools without a nurse or in countries with limited resources,” Pistiner says.
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