1. Food Allergy Awareness and Management
University of Wisconsin
Jo Hopp
Give BOTH activities as students are walking in.
Introduction
Who you are
Why you do this
Trece’s story
Why talking to DAP classes
UW-Stout CFSC
Future advocates for children
Schools are becoming more aware
accommodations have to be made
nut-free schools

2. Food Allergy Awareness Agenda
Introduction
Food Allergy Basics
Peanut Allergy Basics
Managing Peanut Allergies at School
Reactions and the Epi-pen

3. Resources and Information
Food Allergy and Anaphylaxis Network (FAAN)
American Academy of Allergy, Asthma and Immunology
National Institute of Allergy and Infectious Disease
FEAST of Seattle, WA
Various websites dedicated to food allergy advocacy (e.g. peanutallergy.com)

4. THANK YOU, THANK YOU (we can’t say it enough)
Wakanda Elementary School Administration and Teachers
Menomonie School District
Wisconsin
Recipients of 3 Mariel C. Furlong Awards (2006)
Contributions of food allergy awareness, education and advocacy
Trece’s thank you story
Other kids thank yous
Emapthy teaching to the kids – comments from kids to me

5. What is a Food Allergy?
Immunological response to food (allergic reaction)
Body protecting itself – release of histamine
Affects multiple body systems: GI
Respiratory
Skin
Cardiovascular
Exposure can cause serious problems or death
Some affects are visible (hives, coughing, vomitting) and some are not (drop in blood pressure)

6. Intolerance vs. Allergy
Reaction to the chemicals in food
No immune system response
No serious (life-threatening) side-effects
Bloating, gas, abdominal discomfort
Public impression
Parental interaction
Many people believe that food allergies and food intolerances are the same thing

7. Food Allergy Facts What the experts say
Doubling of food allergy over the past 10 years, particularly peanut allergy.
Latest statistics show continual increase with peanut allergy as the leading cause
~12 million Americans affected (4%)
~ ½ are peanut and/or tree nut
~3 million school aged children (~8%)
Onset at any age
Not clear why there is a rise of food allergies. Many theories exist including the emphasis on sanitization. In the case of peanut allergy, one train of thought is due to the way peanuts are processed (roasting process)
Onset at any age: Melissa Mihali (32)

8. Food Allergy Facts What the experts say
Food allergy is the leading cause of serious allergic reaction (anaphylaxis) outside the hospital setting.
over 30,000 ER visits per year
~ 175 deaths annually
reactions caused most often outside the home and by products believed to be safe
Asthma increases risk of fatal reaction
Adolescents and young adults are at the highest risk
Final point: studies have suggested that fatal reactions are most often caused by peanut allergies when epinephrine was not administered early enough.
Bock, et. al J Allergy Clinical Immunol 2001

9. Food Allergy Facts What the experts say
Sensitivity to the allergen can vary
For some, a speck of allergen can have the same effect as eating a large quantity
For some, skin contact with the allergen is enough to cause a reaction
For some, inhalation of the allergen can cause discomfort
Sensitivity is truly ‘unknown’
Affected systems can vary between individuals AND reactions
College student who ate a cookie from the vending machine, allergist who ate a ‘peanut free’ cookie at a Christmas party, but the spatula used to remove the peanut butter cookies was also used to remove the ‘peanut-free’ cookie
Trece and her dad playing. Trece being licked by a dog. Cases of reactions occurring after being kissed If PB is on a surface and an allergic child touches that surface, potential problem, and then if they puts their hands in their mouths or handles their lunch/snack a problem can happen
Trece experiences on the airplane.
In fact, such small amounts of protein like those found in breastmilk can trigger a reaction (Trece’s first)
Eliminating the allergen not only reduces the risk of fatal reactions, but even if the individual does not ingest the protein, mild, uncomfortable reactions can occur and linger. Furthermore, unfortunately when dealing with young children, they often either put their hands in their mouths or do not wash well before eating, so skin contact can lead to ingestion

10. Food Allergy Facts What the experts say
No Cure
Strict avoidance is the only way to prevent allergic reactions
No desensitization techniques like there is with environmental allergies

11. Food Allergy Facts What the experts say
Eight foods account for 90% of all reactions

12. Peanut Allergy Specific
1/250 of a peanut is enough to trigger a reaction (cutting a peanut in half 125 times!) Hourihane, J. J Allergy Clin Immunol 1997
Severe allergies are typically life-long
High cross-reactivity to tree nuts (almonds, walnuts, etc.)
Although some do outgrow peanut allergies, those individuals tend to have meticulous avoidance, no history of anaphylaxis, smaller skin/blood test results, fewer food allergies in general.
Peanut allergic individual are strongly recommended to avoid all tree nuts as well

13. Peanut Allergy Specific
Peanut allergies tend to cause the most severe reactions
Peanut or tree nut allergies and asthma appear to increase the risk for fatal reactions
A study (2001) of 32 cases of fatal food-allergy induced anaphylaxis showed >90% had peanut and tree nut allergies, most had asthma and emergency medication (epinephrine) was not given or not given soon enough. Bock, et al. J Allergy Clin Immunol 2001
A more recent study (2007) also showed a large majority of fatalities due to peanuts/tree nuts and asthma.
Estimated that at least ½ of deaths are result of peanut/tree nut

14. Allergic Reactions - facts
Severity of reaction can vary from mild to serious and potentially fatal
Previous reactions DO NOT indicate future reactions
An unpredictable physiological change occurs after each exposure
Within a couple minutes to 2 hours after exposure (and in rare cases longer)
Once reaction starts, progression can vary
Not just a lunch-time event!
Can be biphasic
Biphasic: could be more serious or less serious

15. What is anaphylaxis? Most severe allergic reaction
Involves multiple systems at the same time
Potentially fatal, especially if medication is not given promptly (at first signs)
Most severe
Hives and vomiting, difficulty breathing and swelling, any combination
Most fatalities that occurred when medication was given was the result of medication not being given soon enough. If you suspect a child is having a reaction…you must give medication. You can not wait to see if the reaction will get worse or bad enough. In fact, for some children, if you suspect they have ingested an allergen, even if signs of a reaction have not yet been seen (you saw them eat a bite of PB&J), medication should be administered. Although each individual plan may differ, in general you do not want to see if a reaction will progress before you make a decision about medication. It can progress to quickly and time is precious
Why is this important for you to understand: some schools require medication be kept in the nurses station or a locked cabinet. People feel kids should NOT be allowed to carry medication with them…THIS IS S PROBLEM…6 minutes to run to the nurse’s station, find the key, ect.
FEAST story of changing the Epi-pen due to expiration

16. What is anaphylaxis?
Can occur within minutes of exposure (death can occur within as few as 6 minutes)
Pattern can vary among individuals
Peanut/Tree nut allergies in combination with asthma is the highest risk
Most severe
Hives and vomiting, difficulty breathing and swelling, any combination
Most fatalities that occurred when medication was given was the result of medication not being given soon enough. If you suspect a child is having a reaction…you must give medication. Furthermore, for some children, if you suspect they have ingested an allergen, even if signs of a reaction have not yet been seen (you saw them eat a bite of PB&J), medication should be administered.
Although each individual plan may differ, in general you do not want to see if a reaction will progress before you make a decision about medication. It can progress to quickly and time is precious
Some will start out slow and steady, some will develop quickly and become life-threatening within minutes. The later is most often caused by peanuts and tree nuts. Trece’s first reaction, and how amazingly quick the initial symptoms came (thank God it slowed down).

17. Managing Food/Peanut Allergies in Schools

18. Strict Avoidance No cure for food allergies
Key is helping children avoid allergens
Good attitude
Careful handling
Cross-contamination
Label reading
Expecting the Unexpected

19. Good Attitude Nothing is 100% safe
‘peanut free’ environment only reduces the risk of exposure, it does not eliminate risk
Even food from home is a risk
Food and food consumption IS NOT the only risk
Exposure can occur in non-food items
Exposure can occur on surfaces, in projects, outdoors
Vigilance is key
When Trece asks if a food is safe, we always say, “I think so”
Peanut butter is a problem for this as it is so sticky and stays on…protein remains intact

20. Good Attitude Setting an example Teaching Empathy
Good Communication with Families

21. Careful handling Allergic children can react through
Ingesting
Contact
Inhaling
Everyone has to be aware, as reactions can occur at varying times after exposure
Just because you aren’t around during lunch doesn’t mean that you won’t be needed for a reaction
Reminder: reactions can occur a few minutes to 2 hours after exposure (even 4 hours). If you are the music specialist three hours after lunch, you STILL have to be competent to handle a reaction. A reaction could occur due to something the child ate OR a reaction could occur because the kid sitting next to the allergic child ate something and it is still on his/her hands.

22. Avoiding Cross-Contamination
Food proximity (same plate, same bag, same platter)
Using the same utensil
Using the same area/surface
Not cleaning the area/plate/utensil thoroughly
Using the same cooking material/machine (toaster)
Transfer of allergens (nut falling into a plate, but plate not getting clean)
Notice sources of cross-contact here… NAME SOME
Cross-contamination at risk foods: NAME SOME

23. What to do
Require thorough hand washing and teeth brushing especially if you suspect a student has eaten peanuts/nuts
Clean eating and working areas carefully
Discourage food sharing
Have “safe” snacks and treats from family
Do not allow homemade goodies or home prepared foods (e.g. apples cut at home)

24. Label Reading
Food Allergen Labeling and Consumer Protection Act (FALCPA)
As of January 1, 2006, labels must list common language for the top 8 allergens
Reading labels carefully can save a child’s life
Foods can be analogous to poison
Top 8 allergens must be clearly stated in ingredient list.
May have Contains statement
May have cross-contamination statement

25. Standard Label
From the picture on the box, it does not appear that there are nuts in this product. Is it safe?

26. “Contains” Statements

27. “Contains” Statement Policy
Only required for allergens not clearly stated in the ingredient list.
Chef Boyardee Pizza

28. Warning Labels
May also say “manufactured in a facility that also processes peanuts”

29. “safe” based on warning labels
NOTE: level of concern is family dependent…comfort level

30. Ingredients: ENRICHED FLOUR (WHEAT FLOUR, NIACIN, REDUCED IRON, THIAMINE MONONITRATE {VITAMIN B1}, RIBOFLAVIN {VITAMIN B2}, FOLIC ACID), SUGAR, PARTIALLY HYDROGENATED SOYBEAN AND/OR LIQUID SOYBEAN OIL AND/OR PARTIALLY HYDROGENATED COTTONSEED OIL, HIGH FRUCTOSE CORN SYRUP, GRAHAM FLOUR, BROWN SUGAR, COCOA (PROCESSED WITH ALKALI), BAKING SODA, CORNSTARCH, SALT, CHOCOLATE, MILK (ENZYME MODIFIED), NATURAL AND ARTIFICIAL FLAVOR, SOY LECITHIN (EMULSIFIER).
Peanut counter-part

31. What NOT to give If label is ambiguous as to presence of peanut
If no label present
Homebaked items
Ice cream
Bakery Items
Imported Foods

32. Expecting the Unexpected
What might contain peanuts/tree nuts?
It’s NOT ONLY in the food!!!
Activity ANSWERS
Two examples of unexpected places:
Jen’s wedding – hazelnuts in grounds
Pacific Science Center in Seattle – Mancala game with brazil nuts

33. A New School Year…new faces, new information

34. Your Students and Families
Education and Support is critical to keep ALL children safe at school
Hand out
Constant reminders are necessary, especially around birthdays and holidays
Be consistent in policies
Be an advocate and an example – avoid confusion
Engage the students in awareness
Likely not understand necessity of peanut-free environment
Educate the students
Teach empathy
Take bullying seriously
PAL Program
Parents are often resistant at first because they are not aware of the issues. Education generally eases all concerns.
If you let the cookies from home or the bakery be served just once, then it will be more difficult to prevent it in the future.
Teach the students about allergies and the importance of safety. Explain why keeping all kids safe is important
Children don’t understand how something so benign can be lethal. They would never pick up a gun or knife and threaten another classmate, however to a peanut allergic child, for example, peanut butter is no different than a gun or knife. Bullying based on the child’s food allergy can cause more than hurt feelings and has to be dealt with appropriately.

35. Management in the school and classroom
Nothing is 100% safe
Cross-contamination is a serious threat
Label reading is critical
Peanuts/nuts can be in unusual items (not even food related)
Know the students – know the plan
Locations of medication
How to recognize reaction
How to use medication

36. Possible Exposures Ingestion Contact Inhalation
Eating, Mucus Membranes, Eczema

37. Signs of an Allergic Reaction
Hives
Difficulty Breathing
Vomiting
Diarrhea
Eczema Flare
Lightheadedness
Swelling

38. What a Child May Say I think I am going to throw up
Food Allergy News, Vol 13, No 2; 2003
I think I am going to throw up
My mouth/tongue itches
My chest feels tight
I feel itchy
My tongue feels hot/burning/tingling/heavy
There’s something in my throat
My lips feel tight
My tongue feels like there is hair on it
Feels like bugs are in my ears

39. What can be done???
GIVE EPINEPHRINE!!! (Epi-pen)

40. Administering an Epi-pen
Remove grey activation cap
Jab black end into outer thigh
Use enough force to make a bruise
This can be done through clothing
Hold 15 seconds
VERY easy to give.
Keep patient lying down

41. Call 911 After injection, call 911 right away
Tell them that you have a child who is experiencing anaphylaxis, you have administered the epi-pen, and to bring more epinephrine!
THIS is a must. The child will look better, feel better and want to sit up. BUT recall the reaction may not be over. Biphasic reactions and Epi only lasts 15 minutes.

42. Emergency Action Plan Varies for individual child
Action plan should be in place that is SPECIFIC for each allergic child
Know the plan
Know where the medication is located
Require that your allergic students have an action plan and familiarize yourself with that plan.

43. THANK YOU
You can make a difference in the life of a food allergic child. Please be an advocate.