The American Academy of Pediatrics (AAP) has issued an updated clinical report on the management of food allergies in schools and childcare settings. Published in Pediatrics, the report updates the AAP’s 2010 guidance and emphasizes a proactive role for pediatricians and primary care physicians in collaborating to manage student food allergies.

“Food allergy affects as many as 10% of school-age children, whose reactions may be severe. About 42% of reactions go beyond severe to life-threatening anaphylaxis,” first author Scott H. Sicherer, MD, a professor of pediatrics and director of the Jaffe Food Allergy Institute at Icahn School of Medicine at Mount Sinai in New York City, told Medscape Medical News.

“Thus, it is extremely important for families, schools, and doctors to work together to keep children safe. Staying safe at school takes a village, and doctors can help by educating families about what is important to know and to relay this to the school.”

In the 15 years since the last AAP clinical report, protective laws have changed to encourage schools to make unassigned stock epinephrine available. “The Centers for Disease Control and Prevention and various professional and lay organizations have created school food allergy management guidelines and recommendations. The psychosocial aspects of food allergy have been increasingly recognized, and advice about anaphylaxis management has evolved. All of these changes are incorporated in this new report,” Sicherer said.

According to the AAP, about 16% of children with food allergies report having had a reaction at school or daycare, with nearly half of the severe reactions starting in the classroom rather than the lunchroom or outdoors in the schoolyard.

The comprehensive report makes several key recommendations to physicians:

• Because food allergy can be misdiagnosed, ensure an appropriate diagnosis through consultation with a board-certified allergist-immunologist who can provide directed treatments and advice.
• Provide children with individualized documentation of allergy and anaphylaxis risks and management using a written allergy and anaphylaxis emergency plan.

Updated written allergy and anaphylaxis plans from the AAP are available. “These important individualized documents are used to let the school know about a child’s allergies and to authorize treatment in the event of an allergic reaction,” Sicherer said.

• Prescribe epinephrine delivery devices for anaphylaxis management.

“There is emphasis that epinephrine is the key lifesaving treatment for anaphylaxis, that it is safe, and, when in doubt, use it to treat,” said Sicherer.

• Act as a resource for patients, families, and schools in providing evidence-based advice on food allergy management.

The report also suggests approaches for young children in childcare settings where extra supervision is needed. “Signs and symptoms of an allergic reaction may be different and more subtle than in older children — for example, crying and tongue scratching,” Sicherer said.

• The report offers extensive advice about ways to reduce unintended ingestion of food allergens, including no-food-sharing policies, careful food preparation, and label reading.
• There is a special emphasis on adolescents. Adolescents may be at a higher risk for fatal food-induced anaphylaxis because of risk-taking behaviors such as not reading ingredient labels or not asking questions about food ingredients.

Education for this age group can focus on identifying safe foods, avoiding unintentional allergen ingestion and food sharing, or kissing after a partner recently ingested the allergen. Adolescents can also be educated about recognizing reactions, prompt treatment of reactions, and notifying others about them.

Fully supporting a proactive role for doctors, even volunteering to go to schools as a speaker, is Gina T. Coscia, MD, an attending physician in the Division of Allergy and Immunology at Northwell Health Physician Partners in Great Neck and an assistant professor of medicine and pediatrics at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, both in New York. “Food allergies are ubiquitous and require a team-based approach that gets everyone in play,” Coscia, who was not involved in the report, told Medscape Medical News. She noted that some people still deny the severe threat posed by food allergy.

Psychosocial Concerns

Food allergy can negatively affect a youngster’s emotional quality of life owing to eating anxiety, teasing, harassment, or bullying. Even teachers can be guilty of humiliating behavior toward students with food allergies. To counteract this, the AAP recommends the reporting of all such incidents as well as general education and sensitivity training.

Legal Support

Both federal and state laws are in place to protect students with food allergies. Section 504 of the Rehabilitation Act of 1973, for example, ensures the rights of all students with disabilities, including food allergies. A Section 504 plan is an enforceable agreement ensuring the implementation of adequate policies, procedures, and protocols to support children with food allergies.

The School Access to Emergency Epinephrine Act of 2013 incentivizes states to pass legislation supporting the availability of stock epinephrine in schools. These states are given preference for federal asthma education grants. State regulations vary, however, on who is permitted to administer stock epinephrine.

“These laws ensure that patients with allergies will not be subject to discrimination and will be provided with timely and appropriate care by trained individuals in potentially life-threatening situations,” Coscia said. As healthcare providers, doctor have a responsibility to underscore the importance of federal and state support so all children can be protected. “Clinicians and school staff can work at the state and federal level to ensure that science, health, and well-being are appropriately incorporated into policy.”

Sicherer made disclosures related to the American Academy of Allergy, Asthma & Immunology; Elsevier; Food Allergy Research & Education; HAL Allergy; the Immune Tolerance Network; the International Association for Food Protein Enterocolitis; the International FPIES Association; Johns Hopkins University Press; the National Institute of Allergy and Infectious Diseases; Pfizer; Regeneron; and Up to Date. Co-authors Sonja O’Leary, MD, and Julie Wang, MD, disclosed having similar ties to government and nonprofit organizations, as well as to private companies. Coscia had no competing interests to disclose.