1. Managing Food Allergies in School Nutrition Programs Beth Foland, MS, RD July 21, 2014

2.  An Overview of Food Allergies,  Reading and Managing Food Labels,  Accommodating Students with Food Allergies,  Avoiding Cross Contact, and  Food Allergy Awareness/Resources.  An Overview of Food Allergies,  Reading and Managing Food Labels,  Accommodating Students with Food Allergies,  Avoiding Cross Contact, and  Food Allergy Awareness/Resources. Topics for Today

3. Pre-assessment: Test your food allergy knowledge

4.  Describe a food allergy, and its symptoms and treatments.  Distinguish between food allergy and food intolerance.  Identify the “Big 8” food allergen  Review reading food allergens on a food label. All About Allergies Objectives

5. What is a Food Allergy? Food Allergy An immune-mediated adverse reaction to a food protein Body’s Immune System Body identifies a food protein as dangerous creates antibodies (Immunoglobulin E (IgE)) against the protein EVEN A BITE can result in an allergic reaction.

6. This food is too spicy. There’s something stuck in my throat. My lips feel tight. It feels like something is poking my tongue. My throat feels thick. My tongue (or mouth) is tingling. My mouth feels funny. There is a frog in my throat. My tongue (or mouth) itches. My tongue is hot (or burning). It feels like there is a bump on the back of my tongue. How a Child Might Describe Symptoms

7. One or more symptoms can occur within minutes up to 2 hours and can be MILD to SEVERE Trouble swallowing Shortness of breath Repetitive coughing Voice change Nausea & vomiting Diarrhea Abdominal cramping Drop in blood pressure Loss of consciousness Death may occur Swelling Hives Eczema Itchy red rash Allergic Symptoms

8. Anaphylaxis-rapid onset; can cause death An epinephrine auto- injector is used to treat anaphylaxis. Most commonly heard trade name is EpiPen (but there are others, e.g. Auvi-Q, Twinject..)

9. Team Discussion With School Nurse Should Include:  Where are the devices kept in the school; are they accessible?  Do you need to be trained to administer an autoinjector?  What if it inject the person, and they are not really having an allergic reaction?  How do substitutes know how to respond?  Do the phones near you get an outside line to call 911?  Will local EMTs have epinephrine when they arrive?

10. What is a Food Intolerance? Food Intolerance An abnormal physiological response to eating Involves the Gastrointestinal System  Food intolerance presents with symptoms affecting the skin, respiratory tract, and gastrointestinal tract; individually or in combination. Detrimental reaction (nausea, diarrhea, vomiting).  Come on gradually, not life threatening, affect the body’s organs  Symptoms are often confused with food allergies. Medical name: Non-allergic Food Hypersensitivity

11.  Absence of an enzyme to digest food  Irritable bowel syndrome  Food poisoning  Sensitivity to food additives  Recurring Stress  Celiac Disease Treatment is determined between the Licensed Physician and the patient. Causes of Food Intolerance

12. Food Allergy Background  More than 3 million children have some type of food allergy.  Food allergies affect an estimated 4%–6% of children in the United States. 1 (1, 2)  Children with food allergies are 2-4 times more likely to have other related conditions such as asthma and other allergies, compared with children who do not have food allergies.  Reactions primarily caused by food used in class projects and celebrations; – 79% Classroom – 12% Lunchroom 25% of reactions in those with no known allergy!

13. The “Big 8” Food Allergens Eggs Milk Peanuts Tree Nuts Fish Shellfish Soy Wheat Prevention: Strict Avoidance of Known Food Allergens

14. Food Allergen Labeling and Consumer Protection Act (FALCPA) Food labels must declare major food allergen in plain language: Milk, eggs, fish, shellfish, peanuts, tree nuts, soy, and wheat Either in the ingredient list by either of these two methods: “Contains” followed by the name Example: “Contains: milk and wheat” Parenthetical statement in the list of ingredients Example: “albumin (egg)”

15. Label Samples Contains….. Parenthesis…

16. Subscribe to food allergy recall notices and a have system to take action if you serve the product being recalled www.foodsafety.gov Recall Notifications

17. Not regulated Not safe for people with known food allergies “May Contain” statement “..made on equipment that also makes….” Precautionary Labeling

18. 18  “Peanut-free” may create a false sense of security  FOCUS: STRATEGIES TO REDUCE ACCIDENTAL EXPOSURE Allergen-safe tables/classrooms are options to school- wide bans. Banerjee, D. K., Kagan, R.S., Turnburr, E., et al. Peanut-free guidelines reduce school lunch peanut contents. Arch Dis Child. 2007 Take Caution When Making Statements! Allergy ALERT We appreciate your cooperation DO NOT Bring peanut/tree nut products Into this classroom

19. Barilla Whole Grain Spaghetti, Thin 19 Made with 51% whole wheat, Ingredients Whole Grain Durum Wheat Flour, Semolina (Wheat), Durum Wheat Flour, Oat Fiber. Warnings Contains wheat ingredients. This product is manufactured on equipment that processes products containing eggs.

20. Hamburger Buns 20 Enriched wheat flour, B vitamins, water, yeast, high fructose corn syrup or sugar, soybean oil contains 2% or less of wheat gluten, salt,calcium sulfate, vinegar, vitamin D, cornstarch,wheat starch, dough conditioners, soy flour, calcium propionate, whey, soy lecithin. What allergens are in the hamburger bun?

21. A very common ingredient used in making salad dressing, coleslaw and potato salad. Do I contain allergens? 21 My ingredients include: Water, soybean oil, vinegar, high fructose corn syrup, modified food starch, sugar, salt, enzyme modified egg yolks, mustard, flour, artificial color, potassium sorbate, paprika, spice, natural flavor, dried garlic, beta carotene.

22. Reminder: 10% allergies are NOT the Big 8  Read ingredient statements  SOP for handling bulk  Prevent cross contact: Multiple Lots Scooping out of bulk Cleaning bulk containers  Examples:  Sesame  Strawberries  Mustard

23. Strategies to Manage Labels and Ingredient Lists

24. Communicating Food Allergy Label Information School Nutrition Staff School Nurse Students, Parents or Guardian Website, handouts, other How? Notebook of Labels Software/website When? Start of school, arrival of new products What method? (face-to-face, phone, e-mail) Establish procedures with team

25. Accommodating Students with Food-Related Disabilities: The Law

26. Respect and Protect Children with Food Allergies  Civil rights and privacy must not be violated  Prevent a child with food allergies from being singled out  Be alert to prevent and address bullying from other children and/or adults

27. Federal Laws Prohibits discrimination against qualified persons with disabilities in programs or activities of any agency of the federal government’s executive branch or any organization receiving federal financial assistance. Programs receiving federal assistance: National School Lunch Program, School Breakfast Program, Fresh Fruit & Vegetable Program, After School Snack Program Rehabilitation Act of 1973

28. Federal Laws (continued) Individuals with Disabilities Education Act (IDEA) 1975, Part B 2006 Requires a free and appropriate public education be provided for children with disabilities aged 3-21. Americans with Disabilities Act (ADA) 1990 and 2008 Amendments Broadens and extends civil rights protections for approximately 50 million Americans with disabilities.

29. Respect Privacy Laws HIPAA The Health Insurance Portability & Accountability Act (1996) - Requires all medical records disclosed be kept properly confidential. - Gives the patient rights control how health information is used. FERPA Family Educational Rights and Privacy Act (1974) - Protects the privacy of health information entered into a student’s record

30. http://origin.www.fns.usda.gov/cnd/Guidance/special_dietary_needs.pdf Accommodating Children with Special Dietary Needs in the School Nutrition Programs Guidance from USDA

31. School Meal Requirements  Schools must make substitutions in the reimbursable meal for disabled students whose disability prevents them from consuming the school meal as prepared.  No extra charge  A disability determination can only be made by a licensed physician.

32. Disability VS Non-Disability  Diet Order components o Specify disability o How restricts diet o Major life activity affected o Foods to omit o Foods to substitute  Menu substitutions required 32 Diet Order components o How restricts diet o Foods to omit o Foods to substitute Signed by licensed MD Signed by recognized medical authority Option to provide menu substitutions

33. Food Allergy Action Plan 1 (5) Recommended for each child with a known food allergy  Completed by student’s MD or MD designee  Use by nursing AND school personnel  Outlines care in emergency situation  For the student’s safety  Do you have a formal plan written for your school?

34. Team Approach 34 Leaders  Administrators  School RN  Foodservice Director  Teachers Others need to be informed: Classroom Aides, Janitors, Bus Drivers, Coaches, Foodservice personnel, After-School Staff, Substitute Teachers, anyone working in the building CURE

35. Strategies to Accommodate Students with Food Allergies  Menu planning, label reading, follow HACCP principles  Know the requirements for serving food to students with special dietary needs.  USDA FNS Guidance for serving children with disabilities and special dietary needs in child nutrition programs www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf STEP 1 STEP 2

36. Child’s Safety Licensed Healthcare Professional School Administrator Nurse School Nutrition Faculty Others Family Parents Child Communication / Education The Partnership Communication / Education Step 3

37.  Implement the directives in the Special Dietary Form signed by a licensed physician.  If the form indicates the student has a DISABILITY, School Nutrition Services is required to make the accommodation.  If there is no disability, the accommodation is optional. Step 4: Accommodating Students with Food-Related Disabilities Step 4

38. Licensed Physician Provides  5 Key Elements  What the disability is  How it restricts the diet  Major life activity affected  Food(s) to be omitted  Food(s) to be substituted

39. Accommodating Students with Other Food-Related Disabilities Food Related Disabilities  Diabetes  Phenylketonuria (PKU)  Food Anaphylaxis  Celiac Disease Other Accommodations  Texture  IV  Tube Feeding

40.  Work with distributors, brokers, and manufacturers to purchase foods to meet the needs of students with allergies.  Get specifications, ask for clarification, develop a relationship with your key partners (includes RN).  TIP: When getting information for USDA Foods, call the manufacturer, not USDA or the State Agency. Communication with Key Partners

41. 41 Secure, Accessible Location

42. Cross Contact vs. Cross Contamination Cross Contact  Allergen accidentally transferred from a food containing an allergen to a food or surface that does not contain the allergen.  Cooking does not reduce or eliminate allergen. Cross Contamination  Microorganisms from different sources contaminate foods during preparation and storage.  Cooking does reduce or eliminate microorganisms.

43.  Sabrina Shannon : teen had fatal anaphylactic reaction during her first year of high school, 2003.  Reaction triggered by dairy protein - likely due to cross- contamination from tongs used for poutine (potatoes topped with curd cheese and a tomato- based sauce) after ordering French fries from school cafeteria  "A Nutty Tale“ first-person radio documentary http://www.anaphylaxis.ca/flash/ http://www.anaphylaxis.ca/flash/ Cross Contact Can Be Deadly

44. Avoid Cross Contact – Potential Sources  Food handling and preparation  Insufficient handwashing  Insufficient cleaning  Shared equipment and utensils  Cutting boards, counters  Griddles  Splatter or steam from cooking  Salad bars, buffets, serving stations

45.  Color Coding  Isolate ingredients containing allergens  Individual preparation of menu items with allergens  Sticker or color code wrapped food  Standard Operating Procedures for handwashing and cleaning  Include allergen risk assessment in the Food Safety Plan based on HACCP Avoid Cross Contact – Prevention Ideas

46. Standard Operating Procedures Clean and Sanitize Clean with soap, hot/warm water, and friction; WILL REMOVE ALLERGEN RESIDUE Sanitize to reduce microorganisms that cause disease; WILL NOT REMOVE ALLERGEN RESIDUE

47.  Examples:  NFSMI’s HACCP-based Cleaning and Sanitizing Food Contact Surface SOPs  NFSMI’s Serving Safe Food to Student with Food Allergies SOP  NOTE: remember food sources outside café (BIC, FFVP, classroom projects/ASP) Sanitation SOPs are important for managing food allergens.

48. General Tips – In the Cafe  Offer designated allergen-friendly tables for young students (? optional for students with parental and physician authorization to sit at “regular” table)  Clean tables carefully  Prevent food trading  Encourage students to wash hands  Provide supervision to ensure orderly behavior  Be prepared for an emergency (know role in FAAP) 48

49. RESOURCES USDA CDC

50. RESOURCES (continued) National School Boards Association National Education Association (NEA) Health Information Network

51. Post-assessment-on your own Questions??? Beth Foland efoland@doe.in.gov efoland@doe.in.gov