Tips to help families navigate food allergy policies at school

What are some of the common food allergens?

Allergic reactions from foods are typically triggered when the food is ingested. Contact with a food allergen may lead to a local allergic response (e.g., hives at the site of contact), but systemic reactions from contact are rare. Inhalation of an aerosolized food protein could lead to an allergic reaction, but this is uncommon unless an allergic individual is exposed to steam from a food while it is being cooked in a poorly ventilated space (e.g., milk, finned fish, shellfish).

Foods such as peanuts and tree nuts are not easily aerosolized, and airborne reactivity is unlikely for most patients. Common food allergens include:

• Milk is a ubiquitous allergen found in the diets of most cultures. It can be very challenging to avoid milk and milk protein in all forms, including dairy products such as cheese, yogurt, ice cream, and butter.
• Peanut allergies are common, and reactions may be severe. Patients must read labels very closely to avoid accidental ingestion of peanuts, which may be found in a variety of foods, most commonly in candies, snack bars, and in many sauces, such as mole. Patients allergic to peanuts are reactive to peanut protein; therefore, highly refined peanut oil, a fat derived from peanut, is safe – it is often used in fast food restaurants. Other kinds of peanut oil (e.g., cold pressed or expeller pressed peanut oils) do contain peanut protein and should be avoided.

• Shellfish includes crustaceans such as shrimp, lobster, and crab and mollusks such as oysters and clams. Patients must be mindful of cross-contact, since restaurants may use the same fryers to cook shellfish and other foods. We typically advise families to prepare their child’s lunch at home on days when the cafeteria is serving shrimp since it is not uncommon for fried shrimp to end up in other foods being served behind the food counter.
• Finned fish such as catfish, codfish, salmon, or tuna can cause allergies that commonly develop in childhood. Patients should be aware of cross-contamination, since finned fish is commonly prepared in a fryer. Patients should stay out of the kitchen cooking these foods on a stovetop since aerosolization of fish protein may trigger respiratory symptoms that can be severe, particularly in patients with pre-existing asthma.
• Soy protein is an allergen most frequently encountered in plant-based products as a source of protein. Soy is easily recognized in products such as soy milk or soy-based yogurts. It is also important to remember that tofu and edamame are cooked forms of soy. Patients will see soy listed in a number of packaged products. However, the soy derivative used often is soy oil or soy lecithin, which are fat derivatives that do not contain soy protein. Soy protein is often listed as soybean or soy flour.
• Wheat is the most common grain used in breaded products. White bread contains wheat protein, so patients must carefully read the labels of all bread products to make sure wheat is not included as an ingredient.
• Tree nuts, which includes almonds, cashew, pistachios, hazelnuts, pecans, and walnuts, belong to a different botanical family than peanuts, which are legumes. Patients allergic to one tree nut may not be allergic to all; however, it is difficult to differentiate one from another, and families often request schools avoid all tree nuts to minimize the risk of accidental ingestion.
• Egg allergies are common among young children and are often outgrown with age. Most patients can tolerate eggs in baked goods; however, if they are not already eating baked goods at home, it would be recommended to avoid egg in all forms at school.
• Sesame seed has recently been added to the list of allergens required on ingredient labels. Sesame seed may be found in breads as a flour or additive, and it is also commonly found in products like hummus. Tahini is made from ground sesame seed.

How can families help keep kids safer at school?

Individual accountability is key to protecting children with food allergies. Studies show that simply having a peanut-free school policy does not eliminate peanuts or tree nuts from the school environment since these foods are often brought in unregulated lunch or snack foods. Importantly, these policies have not demonstrated a lower incidence of anaphylaxis.

Families, students, and educators must follow the policies and take them seriously. We recommend these strategies to reduce the risk of serious allergic reactions at school:

• Keep open, frequent communication. Do not be afraid to ask for direct communication with school administrators and teachers to discuss policies and precautions.
• Do not trade or share food. Lunch and snack swaps can introduce allergens.
• Read food labels carefully. Allergens legally required to be listed on food labels include milk, egg, fish, crustacean shellfish, tree nuts, peanuts, wheat, sesame seed, and soy. Teach your child where allergens are listed on nutritional labels and what to look for.
• Teach your child to set boundaries. Remind them to ask for allergen information before they accept food. Reassure them that it’s OK to refuse to eat anything that might be unsafe. Teach kids without food allergies that their friends might not be able to eat like them and to never be pushy about food.
• Act quickly at the first sign of a reaction. Teach your kids the signs of an allergic reaction in themselves and in others. Remind them to get an adult to help right away. Make sure supervising adults are aware of the signs and symptoms of an allergic reaction and proper use of self-administered epinephrine. Self-administration of epinephrine is typically reserved for teens, though occasionally older children may be capable in the presence of a supervising adult. When age-appropriate, begin transitioning responsibility to the child to carry epinephrine.