Food Allergy Frequently Asked Questions

The primary federal guidelines that are involved in managing food allergies in school nutrition programs relate to allergies qualifying as a disability. Named for section 504 of the Rehabilitation Act, a 504 plan is a legal document that outlines the specific accommodations that will be provided by the school to the allergic child (or any child with a disability). A student whose allergies are determined, as a result of an evaluation, to have a physical or mental impairment that substantially limits one or more major life activity, such as breathing, will qualify for coverage under Section 504 of the Rehabilitation Act. Qualification for Section 504 coverage, as well as for coverage under the Americans With Disabilities Act (ADA), is much broader than that coverage under the Individuals with Disabilities Education Act (IDEA). Section 504 is the primary law governing accommodations for those with disabilities in the educational setting. The definitions and other aspects of Section 504 and the ADA are the same, as are their purposes – to ensure equal access for those with disabilities, as compared to those without disabilities. Since food allergy reactions have the potential to substantially limit the major life activity of breathing even if a student has never had an anaphylactic reaction, they can still qualify under Section 504. Schools can still be required to provide reasonable accommodations for food allergic students who are evaluated as being eligible for Section 504.

A statement from a healthcare provider should be provided for a student identifying the major life activity impacted to be designated as “disabled” according to the ADA guidelines. This statement will be considered as part of the evaluation. Additionally, amendments adopted in 2009 to the ADA prohibit consideration of mitigating measures when making a determination regarding disability. Measures such as avoidance of a particular allergen qualify as a mitigating measure and a disability determination must consider whether a disabling condition exists without considering the effects of the mitigating measure. Additionally, the 2009 ADA amendments clarified that disability determinations involving episodic conditions, such as severe food allergies, must consider whether the condition is disabling during the episode itself. Even if a student looks healthy, the decision regarding disability should be made considering what would occur in the event that the allergen was ingested.

Section 504 accommodations are meant to ensure equal access for students. Examples of accommodations that can help ensure equal access to education for students with food allergies include:

• Ensuring access to non-allergenic foods during times when foods are being provided to all students.
• Designating “allergen-aware” tables in the cafeteria where the top eight allergens are not allowed.
• Creating “food free” classrooms and shared spaces, such as computer rooms and libraries, where food is not allowed – to reduce the risk of accidental ingestion. This is also a more hygienic practice.

What does the Section 504 Plan look like?

A Section 504 plan is often a simple document of a few pages that is mostly checklist in format. It is completed by school staff, such as a school nurse and administrator, together with a child’s parents. Documented decisions represent collective decision-making where all parties’ input is considered and everyone has a seat at the table. It is helpful for school nutrition staff to participate in Section 504 planning for students with allergies to ensure that the 504 plan represents something that the school nutrition team can reasonably accomplish. An Allergy & Anaphylaxis Emergency Action Plan can also be a part of the Section 504 Plan which will also include nondiscrimination statements. Although many Section 504 Plans contain checklists, these plans should also include spaces to handwrite in relevant directions when checklists would be ineffective.

For some students, a more simplified health plan may be adequate to meet their needs. Every child should have an Emergency Action Plan on file.

One other relevant law is the Family Educational Rights and Privacy Act (FERPA). FERPA protects the privacy of student education records and ensures parental access to student records. Unless an exception applies, and there are many exceptions, FERPA requires schools to acquire prior written parental consent before disclosing the contents of a student education record, including a health record created and maintained by the school. To ensure compliance, a student’s food allergies should not be disclosed to anyone except those with specific interaction and responsibility for the care of the child without prior written parental consent. Unless specifically requested and/or approved by the parents, the child’s food allergies should never be discussed with other parents, students, or staff unnecessarily.

For more information:

• USDA Guidance for Accommodating children with special dietary needs in the school nutrition program. Available at:
https://www.fns.usda.gov/sites/default/files/special_dietary_needs.pdf
• FAACT’s Civil Rights Advocacy Resource Center. Available at: http://www.FoodAllergyAwareness.org/civil-rights-advocacy/
• American Academy of Pediatrics Website. Allergy & Anaphylaxis Emergency Action Plan Available at: https://www.aap.org/en-us/Documents/AA-EmergencyPlan.pdf 

Eight foods are responsible for 90% of food allergy reactions in the U.S. These include milk, egg, peanut, tree nuts, fish, shellfish, wheat, and soy. Milk and egg are the most common allergens for children, followed by peanut. However, more than 160 foods have been implicated in food allergy reactions. Any food has the potential to cause anaphylaxis, so every food allergy should be treated with care and consideration.

While food allergies seem common, they affect a small percentage of the population. About 5% of adults and teens have food allergies, and between 6-8% of children have food allergies. Because awareness of food allergies has increased over the past decade, food allergies may seem more common than they are. Moreover, many people confuse food allergies with other conditions, such as intolerances, or may self-diagnose without getting proper diagnosis from a physician. Some experts estimate that 50-90% of self-diagnosed food allergies aren’t actually allergies at all. If you think you or someone you love may have a food allergy, you should see your healthcare provider for a proper diagnosis.

While many individuals are afraid of the potential of allergic reactions due to smelling peanut foods, research does not support airborne exposure to peanuts as a cause of anaphylaxis. In a study of children with peanut allergy, smelling peanut butter at close range and having peanut butter applied to the skin did not elicit systemic reactions.1 No respiratory reactions occurred, although the skin contact did cause localized reactions.

In a recent study, researchers reported using proximity challenges – whereby they sought to reduce anxiety in peanut allergic individuals by opening a jar of peanut butter near those who are peanut allergic to show that the smell would not cause a reaction – have caused no recorded allergic responses.2 Other studies have shown that peanut protein is not well aerosolized, because it is very heavy. It settles quickly and becomes undetectable in the air almost immediately in simulated situations where peanuts were eaten.

Experts agree that there is very little risk posed to those with peanut allergies simply by being near someone eating peanuts or peanut butter. It is ingestion that may cause anaphylaxis. Children should not share foods, but can sit in the same room with or even next to others eating peanut foods without fear. Still, some children and their parents feel better when allergic students are separated from students who are eating their food and one study found that having “peanut-free” tables was associated with lower use of epinephrine.³

Ingestion has the potential to cause reactions, some of which could be severe and even life-threatening. It is important for people with peanut allergies to use caution to prevent accidental ingestion. Since reactions are unpredictable, every allergic individual should maintain a food allergy action plan to help keep them safe.

You should always consult an allergist if you have concern about a food allergy. Working with an allergist who is familiar with your health history can assist in managing food allergy risk.

Section References:

1. Simonte SJ, Ma S, Mofidi S, Sicherer SH. Relevance of casual contact with peanut butter in children with peanut allergy. J Allergy Clin Immunol. 2003;112(1):180-2. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12847496

2. Dinakar C, Shroba J, Portnoy J. The transforming power of proximity food challenges. Annals of Allergy, Asthma, & Immun. 2016;117(2):135-137. Available at: http://www.annallergy.org/article/S1081-1206(16)30339-8/fulltext

3. Bartnikas L, Huffaker M, Sheehan W, Kanchongkittiphon W, Leibowitz R, et al. Impact of school peanut-free policies on epinephrine administration. J of Allergy & Clin Immunol. Article in Press. 2017

Preparing foods that contain allergens is not hard, but does require careful attention. The two primary keys are to ensure that allergens are clearly communicated both in the back of the house and in the front, and to prevent cross-contact. School nutrition professionals should ensure that allergenic foods are always clearly labeled – in storage, during preparation, and when serving students. Communicating allergens on menus and on the serving lines helps prevent a student from accidentally selecting and eating the food they are allergic to. Using separate tools and equipment, and cleaning before and after preparation helps prevent cross-contact during preparation. Using separate serving utensils also helps prevent cross-contact during service. Washing hands and changing gloves frequently, particularly when moving from handling one food to another, are also keys to preventing cross-contact.

For more information:

• PeanutAllergyFacts.org is a resource for schools and others who want to learn more about peanut allergies, provided by the National Peanut Board.
• Best Practices for Handling Food Allergens in School Foodservice – a blog and video series on how to manage food allergens, particularly peanut in schools. Available at http://peanutallergyfacts.org/blog/schools-can-serve-peanut-products-while-managing-food-allergy-risks
• Additional resources are listed below, see #10 

Food allergy reactions can be mild or life-threatening and are unpredictable. Even if an individual has never had anaphylaxis before, they can still have a life-threatening reaction. Two keys to safety for protecting those with food allergies are being able to identify a reaction and responding appropriately and fast.

Symptoms of a food allergy reaction can include any organ system:

• Mouth: swelling of the lips, tongue, or palate (roof of the mouth)
• Eyes/Nose: runny nose, stuffy nose, sneezing, water red eyes, itchy eyes, swollen eyes
• Skin: hives or other rash, redness/flushing, itching, swelling
• Gut: abdominal pain, vomiting, diarrhea, nausea
• Throat: hoarseness, tightening of the throat, difficulty swallowing, hacking cough, stridor (a loud, high-pitched sound when breathing in)
• Lungs: shortness of breath, wheezing, coughing, chest pain, tightness
• Mental: anxiety, panic, sense of doom
• Circulation/Heart: chest pain, low blood pressure, weak pulse, shock, pale blue color, dizziness or fainting, lethargy (lack of energy)

When a food allergy reaction happens, time is of the essence. Responding quickly and appropriately can save a life. Every child should have an Emergency Action Plan/Emergency Anaphylaxis Plan that tells caregivers how to respond based on symptoms. Based on the reaction and EAP, caregivers should give emergency care that may include administering medication (including epinephrine) and calling 911. In the event of anaphylaxis, epinephrine should be administered as quickly as possible and 911 should always be called after epinephrine administration. A second wave of reaction is also possible, called a bi-phasic response, whereby the allergic individual may recover and then become ill again. Additional doses of epinephrine may be necessary, which is one of the reasons emergency medical services (EMS) should always be called.

For more information:

• FAACT Website. Food Allergy & Anaphylaxis: Signs and Symptoms of Anaphylaxis. Available at: https://www.foodallergyawareness.org/food-allergy-and-anaphylaxis/signs-symptoms/signs-symptoms/
• FAACT Website. Food Allergy & Anaphylaxis: Anaphylaxis. Available at: https://www.foodallergyawareness.org/food-allergy-and-anaphylaxis/anaphylaxis/anaphylaxis/
• FAACT Website. Food Allergy & Anaphylaxis: Treatment of Anaphylaxis. Available at: https://www.foodallergyawareness.org/food-allergy-and-anaphylaxis/treatment-management/anaphylaxis-treatment-and-management/ 

It is stressful for parents to send their allergic student to school, where they will not be able to directly watch over them every day. Because they fear a life-threatening reaction, they may request restrictions such as removing peanut products from the menu.

Schools should take care to not make promises that cannot be kept or that provide a false sense of security. A parent’s request that a particular food should be banned from the school menu should be considered, but the Section 504 Committee need not do that if other accommodations can be made to allow the student equal access to educational opportunities.

Food bans take the focus off education and onto enforcement, when all resources are needed to provide education. Claiming to be “allergen free” gives food allergic students a false sense of security. Allergic children and school officials can become lax about the precautions needed, potentially increasing the risk for allergic reactions.

Instead, it is recommended that schools model their programs after the CDC Voluntary Guidelines for Managing Food Allergies in Schools and Early Child Education.1 Schools should provide annual training for school staff on safe allergen handling practices and how to recognize and respond to allergic reactions, internal and external communication, and plans for minimizing the risk of accidental ingestion. The guidelines do not recommend food bans in schools as a means to prevent reactions. In fact, recent research indicates that bans do not necessarily prevent allergic reactions. In a cohort study of Canadian children with peanut allergy, only 8% of reactions that occurred were at schools or day-cares, and there was not a significant difference between the percentage of reactions that occurred in schools that claimed to be peanut free versus those allowing peanuts.2 Another study showed that there was no difference in the frequency of epinephrine (a treatment for severe allergic reactions) use to treat allergic reactions to nuts in schools that banned peanuts as compared to those that do not.³

It’s also important to remember that schools are charged with meeting the nutritional needs of all children. More than 98% of children can enjoy peanuts without any issue. In fact, most children love peanut butter and it is an affordable food for school nutrition programs. A 2014 survey by the University of Michigan of 816 parents of children 5-12 years old, of which 5% reported having a child with peanut or tree nut allergy, showed that most parents are not in favor of banning pean Centers for Disease Control and Prevention. CDC Voluntary Guidelines for Managing Food Allergies in Schools and Early Child Education. Available at https://www.cdc.gov/healthyyouth/foodallergies/pdf/13_243135_A_Food_Allergy_Web_508.pdf uts in schools - including parents of allergic children.⁴

Section References:

1. Centers for Disease Control and Prevention. CDC Voluntary Guidelines for Managing Food Allergies in Schools and Early Child Education. Available at https://www.cdc.gov/healthyyouth/foodallergies/pdf/13_243135_A_Food_Allergy_Web_508.pdf
2. Cherkaoui S, Ben-Shoshan M, Alizadehfar R, Asai Y, Shand G, St-Pierre Y, et al. Accidental exposure (AE) to peanut in a large cohort of Canadian children with peanut allergy. Allergy Asthma Clin Immunol. 2014;10(Suppl 1):A32
3.Bartnikas L, Huffaker M, Sheehan W, Kanchongkittiphon W, Leibowitz R, et al. Impact of school peanut-free policies on epinephrine administration. J of Allergy & Clin Immunol. Article in Press. 2017
4. C.S. Mott Children’s Hospital. Nut-free lunch? Parents speak out. Available at http://mottnpch.org/reports-surveys/nut-free-lunch-parents-speak-out

Not every adverse reaction to food is a food allergy. Foodborne illness, intolerances, sensitivities and other reactions can all present symptoms that are like food allergies. It is important to know the difference, although a diet modification and accommodations may still be required for some of these other conditions.

• A food allergy is an immune-mediated reaction. The body’s immune system mistakenly identifies a food (usually proteins) as foreign and dangerous, and then creates antibodies (IgE) that mount an allergic response by triggering the release of chemicals in the blood. These chemicals travel throughout the body and cause the symptoms of food allergy. View the Signs and Symptoms Infographic.

• A foodborne illness is caused by pathogens (such as bacteria and viruses) in foods. Symptoms may include fever, vomiting and diarrhea, and most people will recover on their own, however foodborne illness can be especially dangerous for children, older adults, and those with compromised immune systems.

• An intolerance is usually caused when the body does not make any or enough of an enzyme that is needed to break down certain constituents of food (usually a sugar). One common example is lactose intolerance, whereby an individual may not be able to tolerate a common sugar in cow’s milk. Reactions to lactose may include bloating, diarrhea, and discomfort, but are not life-threatening.

• Sensitivities to foods are commonly reported. Like intolerances, they may cause discomfort, but symptoms may be more general and harder to pinpoint. Also like intolerances, food sensitivities are not life-threatening.

• Other conditions that may cause food allergy-like symptoms include Celiac Disease, Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (Crohn’s and Colitis). These are distinct conditions that may require modifications and restrictions in the diet. For instance, individuals with Celiac Disease should avoid all sources of gluten, which includes wheat, barley, rye and anything made from these grains or which could have come into contact with gluten (i.e. cross-contaminated). While eating gluten can harm people with Celiac Disease, their reactions are not acutely life-threatening.

Accurate diagnosis is important, because food allergies can be a life-threatening situation. To learn more about accurately diagnosing food allergy as well as treatment and management of allergies, speak with your healthcare provider and visit http://www.FoodAllergyAwareness.org/campaignhome.

Research suggests that many children with food allergies experience bullying at school. In fact, in a survey of 251 families, 45.4% of children report bullying, with 31.5% of the children having been bullied specifically because of their food allergy.1 Bullying can negatively impact quality of life and create an unsafe environment for children with food allergies.

From a legal perspective, if an individual is subjected to a hostile environment because of a disability (such as a food allergy) that prevents the student from participating in educational opportunities, then that environment may be in violation of Section 504. Bullying based on a disability that is not effectively addressed by school administration and is so severe and pervasive that a student is unable to participate in educational opportunities can be considered discrimination and is a Section 504 violation. A complaint to the Office of Civil Rights can be made online at: https://www2.ed.gov/about/offices/list/ocr/docs/howto.html.

Section References:

1. Shemesh E, Annunziato R, Ambrose M, Ravid N, Mullarkey C, et al. Child and parent reports of bullying in a consecutive sample of children with food allergy. Pediatrics. 2013;131(1)

• For more information:

FAACT Website. Education: Bullying General Information. Available at https://www.foodallergyawareness.org/education/bullying/bullying-general-information/.

There are many excellent resources for schools to use to learn more about managing food allergens in schools. Here are some great places to start:

1. CDC Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs, available at https://www.cdc.gov/healthyschools/foodallergies/index.htm.
• Centers for Disease Control and Prevention’s Food Allergies in Schools Toolkit is available at https://www.cdc.gov/healthyschools/foodallergies/toolkit.htm . The toolkit was developed to help schools implement the guidelines. It includes information for all members of the school community, such as handouts and power point presentations that can serve to educate and provide guidance for specific areas of the school environment.

2. USDA offers Resources for Schools with links to a variety of food allergy related training and informational resources. These free tools are available from the Team Nutrition website at https://www.fns.usda.gov/food-safety/food-safety-resources

3. FAME Toolkit is a resource developed by St. Louis Children’s Hospital to help schools manage food allergies. This downloadable PDF provides instruction for all members of the school community and is available at http://www.stlouischildrens.org/health-resources/advocacy-outreach/food-allergy-management-and-education.

4. Institute for Child Nutrition (ICN) available at https://theicn.docebosaas.com/learn.
ICN has two eLearning modules available, or you can request Food Safety Face-to-Face training: https://theicn.org/training-2/ .
• Food Allergies in SNPs – General Food Allergies https://theicn.docebosaas.com/learn/course/external/view/elearning/118/FoodAllergiesinSNPs-GeneralFoodAllergies
• Managing Food Allergies in SNPs https://theicn.docebosaas.com/learn/course/external/view/elearning/14/ManagingFoodAllergiesinSNPs

5. Food Allergy &Anaphylaxis Connection Team (FAACT) is available at www.foodallergyawareness.org and serves as a resource for families managing food allergies. FAACT also provides information and education for schools and others looking to better understand food allergies.
• FAACT’s Food Allergy Curricula Programs for Schools is an age-appropriate education program that includes lesson plans and materials to educate students and others about food allergies. Find it at https://www.foodallergyawareness.org/education/school-curricula-program-for-students/ .
• “FAACTs for Schools” Program is a comprehensive program to raise awareness of food allergies in schools and is free to download at https://www.foodallergyawareness.org/education/education-resource-center/schools/

• Food Allery Research & Education (FARE) is a research, education and advocacy organization for food allergies. FARE provides information and education for parents, schools and universities, and others interested in learning more about food allergies. FARE is online at www.foodallergy.org

6. National Restaurant Association offers ServSafe Allergens® program online. This short training is available on-demand and for a fee. Learn more at https://www.servsafe.com/allergens.

7. PeanutAllergyFacts.org is a website with videos, links, and news about peanut allergies. Provided by the National Peanut Board, it serves as a resource for those who want to learn more about peanut allergies. Available at www.peanutallergyfacts.org.