Food Fight:

Back to School with

Food Allergies
Ashley Ellsworth, MD
Ben Wright, MD
Morning Report
May 27, 2011
 Personal Accounts
• http://www.youtube.com/watch?v=B-47w1Jz
lRE
• http://www.foodallergy.org/section/video-
gallery
 Case
• 13 y/o female from Illinois with a history of
peanut allergy
• Class Party – teacher ordered Chinese
cuisine. Teacher called restaurant multiple
times to ensure peanut containing foods
would not be served
• Developed anaphylactic shock
• Died on the scene

Ahmed-Uilah, Noreen. Seventh-grader dies of food allergy at Chicago school. Chicago Tribune. 20 Dec.
2010. Online. 24 May, 2011. http://articles.chicagotribune.com/2010-12-20/news/ct-met-allergic-death-
cps-1221-20101220_1_food-allergy-epipens-allergic-reaction>.
 Overview
• Epidemiology
• Common Allergens
• Clinical Manifestations
• Treatment
• Advocacy
– Airplanes
– Labeling
– Research
 Epidemiology
• In 2007, affected ~3 million children
• 8% of children < 3 years old
• Prevalence in children < 18 increased 18% percent
from 1997 to 2007
• 2-4x more likely to have conditions such as asthma
and other allergies

Branum AM, Lukacs SL. Food allergy among U.S. children: Trends in prevalence and hospitalizations. NCHS data
brief, no 10. Hyattsville, MD: National Center for Health Statistics. 2008.
 Epidemiology
• Anaphylaxis occurs in 20% of allergic reactions to
peanuts and tree nuts1
• ~150 to 200 fatalities/year 2
• Risk factors for fatal anaphylaxis 3, 4
– failure or delay in administration of epinephrine,
– history of asthma
– teenagers

1. Sicherer SH, et al. Clinical features of acute allergic reactions to peanut and tree nuts  in children. Pediatrics
1998;102(1) e6.
2. Sampson HA. Anaphylaxis and emergency treatment. Pediatrics 2003;111:1601-08.
3. Bock SA, et al. Fatalities due to anaphylactic reactions to food. J Allergy Clin Immunol 2001;107:191-3.
4. Sampson HA, et al. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. New
Engl J Med 1992;327: 380-4.
 Common Allergens
• The most common food allergens are
– cow's milk
– eggs
– peanuts
– wheat
– soy
– fish, shellfish
– tree nuts
• Children frequently “outgrow” allergies to milk and
eggs.
– 68% of egg allergy outgrown by 161
– 80% of milk allergy outgrown by 162
1. Savage JH, et al. The natural history of egg allergy. J Allergy Clin Immunol  2007;120:1413-7
2. Sicherer SH, Sampson HA. Food allergy. J Allergy Clin Immunol 2006;117:S470-5.
 Signs of a food allergy
• A rash, or red, itchy skin
• Stuffy or itchy nose, sneezing, or itchy
and teary eyes
• Vomiting, stomach cramps or diarrhea
• Angioedema or swelling
 Anaphylaxis
• Acute onset of symptoms involving
skin/mucosal tissue + respiratory distress or
reduced BP
• 2 or more of the following rapidly after
exposure:
– Skin/mucosal involvement
– Respiratory compromise
– Hypotension/associated symptoms
– Persistent GI symptoms
• Hypotension after exposure to a known
allergen
Sicherer, Scott H., Mahr, Todd. Management of Food Allergy in the School Setting.
Pediatrics 2010; 126; 1232.
 Treatment
• Avoiding Triggers
• EPINEPHRINE
– Most deaths 2/2 delayed administration
– If in doubt, better to give than not
– 24% of the time, >1 dose of epinephrine is
required1
• Activate EMS
– 1/3 of patients with severe anaphylaxis will
have a biphasic reaction 2
1. Young, Michael C., Munoz-Furlong A, Sicherer SH. Management of food allergies in schools: A
perspective for allergists. J Allergy Clin Immunol. 2009; 124(2): 175-182.
2. McIntyre, C. Lynne, Sheetz AH, Carroll CR, Young MC. Administration of Epinephrine for Life-
Threatening Allergic Reactions in School Settings. Pediatrics. 2005; 116(5): 1134-1140.
 School Risks
• Exposure
– 79% of cases in classroom
– Playground is important site
– Only 12% in cafeteria
– Failure to read food labels
– Cross-contamination
– Food sharing
• Social stigma of carrying a
medication/notifying teachers if ill
• Lack of trained responders
• Lack of epinephrine

Young, Michael C., Munoz-Furlong A, Sicherer SH. Management of food allergies in schools: A perspective for
allergists. J Allergy Clin Immunol. 2009; 124(2): 175-182.
 Back to School Tips

• Provide a list of foods to avoid and safe alternatives

• Complete a "Food Allergy Action Plan"
– (available at www.foodallergy.org/
actionplan.pdf)
• Inform the school cafeteria workers, teachers and
other staff of child's allergies
• Provide a picture of child for the cafeteria cooks
and cashier
• Pack bag lunches if cafeteria options are limited
• Work with the school to establish a peanut-free
lunch table, if necessary

Sicherer, Scott H., Mahr, Todd. Management of Food Allergy in the School Setting. Pediatrics 2010; 126; 1232.
 Back to School Tips
• Offer safe snacks
• Advocate "no eating" policies on buses and
other settings where students aren't
supervised
• Keep medication, such as antihistamine or
auto-injectable epinephrine, in the child's
classroom or backpack
– Check with school administrators on their
medication policies
 Barriers to safety
• School unaware of allergy
– Student has an allergy, but school not notified
– No prior reaction (24% cases of anaphylaxis)
• No emergency plan in place
• Lack of training of school employees
– No school nurse
– Inadequate training of non-medical personnel
• No epinephrine
– 64% of students with nut allergy had no meds available
– Only 26% had epinephrine
– When available at school, location can be difficult

Young, Michael C., Munoz-Furlong A, Sicherer SH. Management of food allergies in schools: A perspective for
allergists. J Allergy Clin Immunol. 2009; 124(2): 175-182.
Advocating for your patient
• Emphasize to parents the importance of
notifying school
• Assist parents and school in developing an
Individualized Health Care Plan along with
an Emergency Action Plan
• Provide a prescription for epinephrine to
be carried in backpack (if allowed) AND
readily available at the school
• Be available for education of school staff
Advocating for general population
• Emphasize impact and mortality associated with
food allergies
• Encourage availability of school nurses
• Work on making IHCP standard paperwork for
children with allergies
• Availability of unassigned epinephrine
– 25% of patients were not previously known to have an
allergy
– In many states EMTs are NOT allowed to carry and
administer epinephrine.
• Importance of transport to a hospital for further
management
– 24% of patients require >1 dose of eipnephrine
– Biphasic reactions

Young, Michael C., Munoz-Furlong A, Sicherer SH. Management of food allergies in schools: A
perspective for allergists. J Allergy Clin Immunol. 2009; 124(2): 175-182.
 Food Labeling
• Food Allergen Labeling and Consumer P
rotection Act (FALCPA)
, Jan. 1, 2006
• Mandates that the labels of foods
containing major food allergens declare
the allergen in plain language.
• Such ingredients must be listed if they
are present in any amount, even in
colors, flavors, or spice blends.
 Airplanes
• Severe, or anaphylactic, reactions caused
by peanuts -> ingestion of peanut-
containing meals or snacks.
• Air Canada, Air Tran, American,
Continental, Frontier, Jet Blue, Midwest,
United, US Airways don’t serve peanuts
in coach
• If you are peanut allergic, DO NOT EAT
AIRLINE MEALS OR SNACKS!
 Future Therapies
Food Allergen Specific Non-specific
• Oral Immunotherapy • Humanized monoclonal
• Sublingual therapy anti-IgE
• Peptide immunotherapy • Traditional Chinese
• Engineered recombinant medicine (TCM)
protein immunotherapy • Blockade of vasoactive
• Immunomodulatory mediators
adjuvants
 Conclusion
• Impact of food allergies
– >150 deaths/year
• Most common triggers
• Dangers in school environment
• How to make a difference
– Decrease the risk of anaphylaxis and
death
• Further research
 Resources
• Food Allergy and Anaphylaxis Network
(FAAN) http://www.foodallergy.org
• Food Allergy Initiative
http://www.faiusa.org
• American Academy of Allergy, Asthma
and Immunology (AAAAI)
http://www.aaaai.org
• Utah Food Allergy Network (UFAN)
http://www.utahfoodallergy.org