Food Allergy Awareness and Management University of Wisconsin Jo Hopp hoppj@uwstout.edu 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

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

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)

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

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)

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

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) www.foodallergy.org

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. www.foodallergy.org Bock, et. al J Allergy Clinical Immunol 2001

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

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

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

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

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

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

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

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).

Managing Food/Peanut Allergies in Schools

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

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

Good Attitude Setting an example Teaching Empathy Good Communication with Families

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.

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

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)

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

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

“Contains” Statements

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

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

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

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

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

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

A New School Year…new faces, new information

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.

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

Possible Exposures Ingestion Contact Inhalation Eating, Mucus Membranes, Eczema

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

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

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

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

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.

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.

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