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Emerging Epidemic: Latest Research on Childhood Food Allergies Shows Troubling Trend

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We like to follow research in the food allergy world closely—after all, many of our team members are as personally vested as we are professionally in the advancement of food allergy research! Several of our senior team members either have food allergies or have children with food allergies. 

Last month at FABlogCon, we learned that Dr. Ruchi Gupta and her team at Northwestern University were soon releasing a new study in PediatricsThe Public Health Impact of Parent-Reported Childhood Food Allergies in the United States.

The study was published this month, and we wanted to share some key findings with you: 

  • Food allergies continue to affect a significant number of children in the United States—7.6 percent, or nearly 6 million kids, have a food allergy. Of those, 40 percent report having multiple food allergies.

  • Food allergies have a meaningful impact on families—42 percent reported a severe allergic reaction to their food allergen, and nearly 1 in 5 reported that their child had visited the emergency department for a food-allergic reaction in the past year!

  • Not everyone has emergency medicines at the ready—less than half of parents reported that their child has a current prescription for an epinephrine auto-injector, the only treatment for anaphylaxis. 

This study is a continuation of the work carried out by Dr. Gupta and her team in 2011. Their objective was to better assess the public health impact on childhood food allergies. They surveyed over 40,000 households using advanced statistical modeling to ensure they captured a representative sample of children in the United States. 

One noteworthy feature of this study was a “stringent symptom” methodology, which looked at the frequency, type, and severity of allergy symptoms as part of a diagnosis. This approach helped filter out those who did not likely have a food allergy, as several parents reported a food allergy when the symptoms were more characteristic of a food intolerance or oral allergy syndrome (OAS).

Even after applying the stricter criteria, food allergies are still a significant problem for American children. Today, 1 in 13 kids has a food allergy, which translates to 2 in every classroom. Peanut (2.2%) and milk (1.9%) are the most commonly reported food allergies, affecting 1.6 million and 1.4 million children, respectively. African American children are also more likely to have a food allergy than non-Hispanic white children and are more likely than other children to have multiple food allergies. 

Dr. Gupta (second from the left on the bottom row) and her SOAAR research team (Science and Outcomes of Allergy and Asthma Research) at Northwestern University.

Dr. Gupta (second from the left on the bottom row) and her SOAAR research team (Science and Outcomes of Allergy and Asthma Research) at Northwestern University.

We appreciate the work of Dr. Gupta and her team to increase awareness of the public health implications of food allergies. To quote from the study: “With the growing epidemic and life-threatening nature of food allergies, developing treatments and prevention strategies are critical.” 

We couldn’t agree more!

- Susannah & the Allergy Amulet Team 


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Managing Food Allergies at the Gym and Yoga Studio

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Food allergy management is not reserved for the kitchen, dining room, cafeteria, and restaurants. Food allergies follow you everywhere, from airplanes to offices, to places you would least expect—like yoga studios.

My favorite yoga teacher, who has a peanut-allergic son and maintains a peanut-free house, uses the yoga studio as her place to eat all the peanuts she can’t at home. I only learned about her son’s allergy because I spotted her spooning peanut butter right out of the jar and directly into her mouth before class one day. As a regular, there’s a good chance of her assisting me, and it is not unusual for her to lie right on top of students during a seated forward fold. 

Since we may be getting “intimate,” I knew I would have to tell her about my allergy. I explained that I was allergic to peanuts and would appreciate it if she either washed her hands or not assist me that day. Since she’s an allergy mom and understands the struggle, she was embarrassed that she had never thought of this as an issue when teaching. 

Yoga studios aren't the only place I’ve encountered my food allergies. They have shown up in locker rooms, the swimming pool, and on a marathon race course. I bet I’m not the only one who has spotted an allergen during a workout! 

As someone with many food allergies (peanuts, tree nuts, sesame, soy, and sunflower seeds, to name a few), I’ve gotten pretty good at managing them in public workout spaces. Below are my top tips! 

Your auto-injector is your number one workout buddy.

Having your epinephrine auto-injector with you at all times is a best practice no matter where you are or what you are doing. This is especially true for the gym. The last thing you want is someone scrambling to your locker—perhaps not knowing or forgetting the lock combo—and then rummaging through your things to find your auto-injector. Keeping it in a small bag with you is a convenient way to carry it from machine to machine. Activities in extreme temperatures, like hot yoga, may require an exception to this rule.

Have a water bottle that stands out.

Just like the yoga studio was my teacher’s go-to place for snacking on peanut butter, the swimming pool is where my husband eats peanut M&Ms. Besides not kissing, we do not share water bottles when he eats peanuts! 

While unlikely, you might share the same water bottle as someone else at the gym, and you don’t want to accidentally sip from the wrong spout! When it comes to your water bottle, make sure it stands out and that you always know where it is. If you bring along a bag for your epinephrine auto-injector, you can pop your water bottle in there! Or add stickers, a name label, or tie a ribbon around your bottle to ensure it’s unique. 

Clean what you can.

Wiping down surfaces at the gym is always a good practice—food allergies or not. 

Sometimes this isn’t always an option—take bouldering, for instance. I recall one time watching people shell pistachios and then going right back to the climbing wall. In these cases, you just have to use your best judgment.

Specialty equipment at a yoga or boxing studio can also have questionable cleanliness. In these cases, it is best to bring your own mat, props, and gloves. If you’re there for the first time, or can't bring your equipment, it’s a good idea to ask how they clean their equipment or request a newly-cleaned item. You may want to wipe it down yourself just in case 😁.

Let someone know about your allergy.

When working out alone, it helps if someone knows about your food allergies. Before any yoga class, I always say something to the instructor because I’ve experienced teachers lathering students with essential oils. 

Don't be embarrassed by saying something. I used to be, but really who is it harming? Nobody! 

Managing food allergies means you have to be a little more diligent when engaging in extracurricular activities, even ones that aren't food related. Taking simple precautions to mitigate risk is all part of life with food allergies and shouldn't stop you from hitting the gym!

What tricks do you use when navigating public workout spaces? I’d love to know! 

 

Kortney Kwong Hing is the allergy girl behind the blog Allergy Girl Eats. She has multiple food allergies (peanuts, tree nuts, sesame, soy, sunflower seeds and more), but does not let them stand in the way of enjoying food and exploring the globe. On the blog Kortney shares stories of life as an allergic adult, tips on managing everyday life with food allergies, and a few favorite allergy-friendly recipes. 

Kortney is also one of the co-founders of Allergy Travels, a website and online community that shares travel insights and inspiration for those managing allergies. 

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Sesame: More Than Just a Street

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Sesame allergy has been all over the news lately. Last year, a teenage girl tragically died at Heathrow Airport after eating a Pret a Manger baguette containing sesame—the ingredient was not listed on the packaging. This incident drew attention not only to the severity of sesame allergies, but also to deficiencies in food allergy labeling. 

A growing body of research indicates that sesame allergy is on the rise. A recent study published in Pediatrics estimates that 0.2% of the U.S. population has a sesame allergy, making it the ninth most common food allergy. 

The spike in sesame allergy has triggered a closer look at the way sesame is labeled on food packaging. This past October, the FDA released a statement indicating that it was considering sesame for mandatory allergen labeling on food packaging pursuant to the Food Allergen Labeling and Consumer Protection Act (FALCPA). Enacted January 1, 2006, FALCPA imposes special labeling requirements for the top eight most common food allergens: peanuts, tree nuts, fish, shellfish, wheat, eggs, milk, and soy. As you can see, the list does not currently include sesame. That could soon change. Notably, Canada, the European Union, Australia, and Israel currently require allergen labeling for sesame. 

For those out there managing a sesame allergy, know that you are amazing. Sesame is insidious, and because it does not fall within FALCPA labeling laws, it is infinitely harder to manage. 

If you’ve followed us for a while, you know that I have a daughter with serious food allergies to peanuts and tree nuts. She was diagnosed with these food allergies at one and is now six (and crushing Kindergarten!). What I haven’t mentioned is that from ages two through three we avoided sesame like the plague because of an anaphylactic reaction she’d had to hummus just before her second birthday.

She’d eaten hummus multiple times previously, but one day, while eating hummus at lunch, her lips began turning blue and she started coughing. One epinephrine auto-injector, several hours at our children’s hospital, and some IgE blood testing later, she was home safely with a new food allergy added to the list: sesame. 

Sesame often hides under the guise of “natural flavors” or “spices” on food labels. I used to keep a spreadsheet of every manufacturer I called knowing the ingredient could be lurking behind these vague categories. To make matters worse, some manufacturers won’t share this information, citing trade secret protection. I quickly learned that I had more success if I asked if sesame was included as an ingredient in any of these proprietary categories, as opposed to asking for the whole ingredient list. Sesame also lurks under different names like tahini, a paste made from sesame seeds. If you’re managing a sesame allergy, here’s a great list of food and non-food items that may contain sesame or any of its derivatives. 

It’s been over four years since my daughter’s anaphylactic reaction, and I can joyfully say that she’s outgrown her sesame allergy. But it was no walk in the park to manage, and I still vividly remember my sesame spreadsheet and the tears of frustration that went along with tracking all of the different food ingredients. 

For those managing a sesame allergy, the struggle is real, and FALCPA labeling for sesame would make things a LOT easier! Interestingly, the Pediatrics study we referenced earlier cited that the highest rates of epinephrine auto-injector prescriptions were found for children with peanut, tree nut, and SESAME allergies.

We’ll be following the regulatory deliberations closely, and will be sure to keep you all updated on social media as the discussion unfolds. Do you or does your child have a sesame allergy? What’s your experience been like?

 - Meg and the Allergy Amulet Team 

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Ming Tsai’s Food For Thought

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My journey with food allergies began when I opened my first restaurant, Blue Ginger, in 1998. I felt it was important that our kitchen be mindful of food allergies to ensure that all customers could safely dine with us. Little did I know that soon enough food allergies would become an enormous part of my everyday life. 

Just a few years after opening Blue Ginger, my oldest son was diagnosed with multiple food allergies; in fact, he was born severely allergic to soy, wheat, peanuts, tree nuts, dairy, shellfish, and eggs. At first, as a chef, I thought it was an unfunny joke from upstairs. But I soon realized it would be an invaluable lesson and opportunity. I quickly learned that trying to eat at restaurants with food allergies was a much larger task than I imagined. Even though I had established protocols in my restaurant for those with food allergies, most other restaurants didn’t take the same care. I can recall a few times where my family and I were turned away because the chef or restaurant did not want to accommodate us. There were a few occasions where my son was accidentally served a dish containing a small amount of one of his allergens, and within minutes he began exhibiting symptoms of an anaphylactic reaction. As a parent, it’s one the scariest experiences. Thankfully, my wife is a trained nurse, and we were able to spot the signs quickly and administer epinephrine right away. 

First implemented at Blue Ginger, and later at Blue Dragon (which is 100% peanut and tree nut free), we created a book that includes every dish on the menu and a comprehensive list of ingredients separated by dish components (i.e. proteins, starches, vegetables, sauces, and garnishes). This way, the patron and restaurant staff can easily determine which part of the dish has the allergen and omit the item from their order. For example, a customer with a peanut allergy would still be able to have the Chicken Satay with Peanut Sauce by opting for an alternate (and equally delicious) dipping sauce. 

Additionally, any ingredient processed and received from outside vendors is starred and the ingredients are indexed in our system (e.g., dried *egg* pasta). A highlighted ingredient indicates that it is one of the top eight food allergens: peanuts, tree nuts, wheat, soy, shellfish, fish, milk, or egg. Our protocols also ensure proper lines of communication between the front of house staff and the kitchen. Every manager, server, and bartender is trained to ensure all customers can safely dine with us. You can find an example of our documentation here.

My family’s experiences, and the knowledge that comes with being a restaurant owner and chef, inspired me to champion the first bill in Massachusetts to require all local restaurants to comply with food allergy awareness guidelines. It took four years working with the Massachusetts legislature to write Bill S. 2701, which was eventually signed into law in early 2009.  

I’m incredibly proud of the work that we’ve done in Massachusetts to help those with food allergies have a more positive restaurant experience. As a chef, restaurateur, and a food allergy parent, I’ve experienced this issue from multiple sides. From the customer perspective, it’s important to notify the restaurant when making the reservation, triple-check that the server understands the severity of the allergy, and do a final check when the food arrives at the table for any visible cross-contact with your allergen or mistakes. Food allergies are a two-way street. From the restaurant perspective, we need to have procedures in place to make sure customers can safely eat, but we also need to be made aware of any allergies and understand the severity so that we can accommodate. Over the years, I’ve developed a useful and effective way to better determine the severity of people’s food allergies. I ask, “Is using the same fryer okay?” The point we are getting at here is if shrimp is fried in a fryer, could the customer eat fries out of that same fryer? Depending on the answer we then have a better understanding as to the severity of the food allergy, which we use as a directive to the kitchen staff. 

Restaurants should care about food allergies not only because it keeps their patrons safe, but also because it’s smart business. The hospitality industry can be challenging, and meeting customer’s demands is always of the utmost importance. At the end of the day, we are all fighting for loyal customers. 

I guarantee you, if you serve a food allergy customer a delicious and safe meal, and they leave smiling, you’ll have a customer for life.

Peace and Good Eating, 

Chef Ming Tsai

 

Ming Tsai holds an equity stake in Allergy Amulet.

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Killer Beauty Regimens

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When we think about managing food allergies, we don’t tend to consider lipstick or lotion. But we should.

Walking down the aisle of my local co-op recently, I grabbed a tub of moisturizer labeled “tester” and applied a dab to my hand. I tried placing the scent, and when I couldn’t, turned the jar around and saw almond oil listed as the first ingredient. My stomach clenched, and a variant of “shoot” slipped from my mouth. I’m deathly allergic to tree nuts. I washed my hands immediately, and fortunately, I was fine. Historically, my worst skin exposure outcome is hives. However, given the unpredictability of allergic reactions, it’s still hard not to panic. 

You’d think after all these years and several close calls I’d be more careful; but when it comes to skincare and beauty products, I routinely let down my guard. I shouldn’t.

Did I sufficiently give you a fright? 

Good. Sometimes a little fear is a good thing. Especially when you’re talking about something as serious as an allergic reaction! 

For the food allergic, even moderate skin exposure can be serious. Creams, soaps, oils, make-up, lipstick, and balms can also lead to small amounts of ingestion, so it’s important for those with food allergies and their loved ones to vet these items with the same diligence they do foods. Don’t forget vitamins, teas, and herbal supplements, too! 

Beware the two S’s: spas and salons. 

Planning a massage, manicure, or haircut? Make sure you tell your massage therapist or stylist to avoid products containing your allergen. This is especially true if you’re allergic to nuts—you’d be surprised how many spas and salons use nut oils. Just last month while getting my haircut I was surrounded by advertisements for the salon’s newest cherry almond shampoos and conditioners. Suffice it to say, I steered clear of this product line. 😉 

FDA labeling laws and cosmetics.

Skincare and beauty products are not regulated in the same way that foods are for allergens—even if they contain a common allergenic ingredient! 

The Food Allergen Labeling and Consumer Protection Act (FALCPA), which we explore in an earlier blog, applies to FDA-regulated food products, not cosmetics and beauty products. Accordingly, these products do not need to adhere to FALCPA labeling requirements, although many brands list these ingredients anyway. Regardless, it’s worth taking note.

We hope this information hasn’t spooked you, although it is Halloween season! Rather, we hope this knowledge helps you stay informed and safe when managing your food allergies. So before you slather on some blood-red lipstick this All Hallow’s Eve, check that label!

Wishing you all a BOO-tiful Halloween! 👻🎃

- Abi and the Allergy Amulet Team 

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Take Two: The Importance of Carrying Two Epinephrine Auto-injectors

With Halloween around the bend, we wanted to share a quick PSA on the importance of carrying two epinephrine auto-injectors in case of an allergic reaction. 

Why? Let’s look at the facts.

In cases of severe anaphylaxis, one dose of epinephrine is often not enough. Up to 20% of people who receive an initial dose of epinephrine for anaphylaxis require a second injection. This can happen even without further exposure to the allergenic trigger! A second allergic reaction called biphasic anaphylaxis can occur between 1 to 72 hours (typically eight hours) after the initial reaction.

Despite these harrowing stats, most individuals do not carry two auto-injectors.

In a study of roughly 1,000 US patients and caregivers with epinephrine prescriptions, 82% said they do not carry two auto-injectors. Meanwhile, 75% of respondents reported previously administering epinephrine. Of those that sought emergency care, 45% did so because a second dose of epinephrine was unavailable. 

Education and awareness is also lacking. Only a quarter of respondents reported that they were advised to carry two auto-injectors.

But epinephrine is expensive.

We hear you. Epinephrine auto-injectors are not cheap, which can make it difficult to have multiple epinephrine auto-injectors on your person at all times.  

Fortunately, that’s starting to change. Increased market competition and PR scandals like the one that rocked Mylan have helped drive down the price. 

Additionally, below are some cost-saving options worth checking out. 

-      Check for discount codes and savings plans on manufacturer websites. 

-      Purchase generic epinephrine alternatives.

-      Explore mail-order pharmacy options (you may be able to receive a larger supply of medication at a lower co-pay amount if these benefits apply).

-      Price shop between local pharmacies—prices vary, especially between large chains and small pharmacies.

-      Ask your doctor about patient assistance programs. 

-      Switch to your insurance carrier’s “preferred” auto-injector (if applicable).

-      Double check that your pharmacy has applied all possible coupons at check out.

-      Ask your company’s HR department if they offer financial assistance to employees to cover prescriptions.

We hope you all have a SWEET and SAFE Halloween! And don’t forget to TAKE TWO!

-      Meg and the Allergy Amulet Team

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Food Allergies + Natural Disasters… A Different Kind of Storm

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As torrential floods from Hurricane Florence ripped through the Carolinas earlier this month, Madison, Wisconsin—home of the Allergy Amulet headquarters—was still reeling from record rainfall levels and flash floods. 

These events got us thinking: How should the food allergy community prepare for a natural disaster? 

First, there are great emergency kit checklists available through the American Red Cross and FEMA websites, which advise on supplies to have at the ready in case of an emergency. If you or your loved one has a food allergy, however, you have a few extra things to consider.

Tell me more.

At a minimum you should plan to have several days’ worth of allergy-friendly foods on hand that don’t require refrigeration, heating, and that don’t spoil easily. This might include canned vegetables, granola, or dried fruits and meats. Don’t forget several days’ worth of water, too! 

The American Red Cross recommends having a seven-day supply of any necessary medications. For food allergy families this could include your antihistamines as well as epinephrine, or any other doctor-recommended medications (e.g., inhaler). Depending on where you live, and what type of emergencies are most common, you may want to have these items already packed and stored in a convenient location. For example, if you live in an area prone to tornadoes, it’s likely that you have a basement, so you may want to store your emergency supplies down there.  

What if I need to evacuate?

Evacuating in the wake of a natural disaster can present unique challenges for those with food allergies. Shelters may not serve allergy-friendly meals, and even if they do, families may need to manage for cross-contact. Having allergy-friendly foods on hand and disinfectant wipes for hands and surfaces can help mitigate exposure risk. Make sure to also pack emergency action plans for children if you have them, insurance cards, and an emergency contact list with your medical providers!

Check expiration dates!

Don’t forget to review and update your emergency preparedness kit at least once a year, and make sure to check the expiration dates on your epinephrine and antihistamines. Spokin recently offered a feature on its app that helps you to manage epinephrine expiration dates.

We all hope that you never need your emergency supplies, but it’s a good idea to be prepared! 

- Susannah and the Allergy Amulet Team 

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Scientists Find Link Between Antacid & Antibiotic Exposure and Food Allergies & Asthma

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As someone who remembers (with disgust) that pink goo as a child (also known as the antibiotic amoxicillin), I read this headline in shock. Did that chalky bubble gum syrup make me more susceptible to developing food allergies and asthma?

Here’s what the scientists found. 

In a recent study published in JAMA Pediatrics, researchers looked at approximately 800,000 infants that had ingested antibiotics or antacids in their first six months of life. They found that those exposed were more likely to develop food allergies or asthma. 

Babies are routinely prescribed antacids for regurgitating food or experiencing acid reflux after a feeding. This is very common in infants, so you can appreciate why this study is sending shockwaves throughout the parenting community!

The research hones in on how antacids and antibiotics affect an infant’s microbiome—that place where trillions of bacteria help aid in digestion, fight infection, and regulate the immune system. We know that antibiotics kill the bad bacteria that make us sick, but they also wipe out the good stuff that keeps us healthy. Antacids similarly can help ease digestion, but a less acidic stomach can alter the bacterial composition of the intestine and reduce protein digestion

The microbiome has been a hotbed of research lately—especially in the food allergy field. As we’ve discussed in a previous post, one of the leading theories behind the rise in food allergies is the impact that chemicals and medications are having on our microbiome and gut health—especially at a young age. We’ve also previously written on gut health and the important role the microbiome plays in healthy immune function.  

“This does not mean that infants should never get antacids or antibiotics,” Dr. Claire McCarthy notes in response to the study. “Antibiotics can be lifesaving for infants with bacterial infections, and there are situations when antacids can be extremely useful.” She adds though that both medications are often overprescribed and encourages doctors to “ask if it is truly necessary [to prescribe these medications]—and whether there are any alternative treatments that might be tried.” The lead author of the study, Dr. Edward Mitre, also recommended in light of the findings that “antibiotics and acid-suppressive medications should only be used in situations of clear clinical benefit.”

The recent surge in research surrounding gut health and the microbiome is a welcome trend, and one that will hopefully lead us to more concrete answers surrounding the origin of food allergies and how to mitigate or eliminate them altogether. 

- Abi and the Allergy Amulet Team

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The 411 on the 504: School Allergy Plans Decoded

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Last month we covered the basics of kids and epinephrine. This month we’re bringing you the skinny on school management plans for your child’s food allergies.

Are you wondering about a 504? An IEP? Have we lost you? 

Don’t worry, we’ve got you covered. 

Setting Up the Plan

Most school districts have district-wide plans for food allergy management, treatment, and reaction prevention. Many states also offer suggestions for school districts on managing food allergies based on guidelines from the Centers for Disease Control and Prevention. To date, there is no federal regulation that standardizes these policies and procedures, so these policies vary between states (and often between school districts within each state). 

The first step in setting up an allergy management plan for your child is to reach out to your child’s school. Many schools will ask you and your child’s doctor to fill out an allergy and anaphylaxis emergency plan form, although this form can go by different names. This form covers what steps school staff should take in case the child is exposed to an allergen or if he/she exhibits symptoms of a reaction. The American Academy of Pediatrics published this template form for reference. Once submitted, the school nurse typically prepares an Individualized Healthcare Plan (IHP): an internal document that outlines the processes the school should follow in the event the child experiences an allergic reaction. 

Some parents go one step further and request a 504 plan. Section 504 is part of a federal civil rights law that protects individuals with disabilities and health conditions, including life-threatening food allergies. The law applies to all schools and programs that receive financial assistance from the U.S. Department of Education (so all public schools and some private schools). A 504 plan lays out how the school should prevent and respond to allergic events. If a 504 plan protocol is not followed, there are several dispute resolution options available for parents. 

To secure a 504 plan, a parent must contact the school district’s 504 coordinator, who works with school officials to determine if the child qualifies. This determination is based in part on medical history, so your doctor may need to provide the school with this information. If the child qualifies, the team will work together to determine what special accommodations and protocols must be followed. 

Notably, if your child has a disability and qualifies for an Individualized Education Plan (IEP), a separate 504 plan is not necessary. The child’s food allergy accommodations may be joined under their IEP. Also of note, in some non-religious private schools where 504 plans do not apply, parents may rely on the Americans with Disabilities Act (ADA) to ensure that the school implements a food allergy management plan for the child. 

School Policy Options

Since there are no national standards for food allergy protocols, policies vary widely between schools. 

According to a recent study surveying school nurses across the country, the most frequently reported policies include: training school staff to respond to allergic reactions and anaphylaxis, using epinephrine autoinjectors, and managing for cross-contact in cafeterias. Other policies commonly implemented include: community food allergy awareness events, designated lunch areas for children with food allergies, and food guidelines for classroom celebrations.

The least frequently reported policies were: allergen labeling information in cafeterias, food management policies for after-school activities, and school-provided stock epinephrine for field trips and off-campus outings. In light of the differences between school policies, parents should understand their school’s protocols before developing their child’s plan.

Words of Wisdom

Finally, we talked with a few food allergy parents in different school districts and asked them to share a few words of wisdom on these management plans:

- “Plans may be different within the same school system—as your child goes from elementary to middle to high school, you will want to revisit your plan. For example, once a child moves to a different school building, new protocols may be appropriate. Older children may also be allowed to self-carry epinephrine or antihistamines.”

- “Make sure your plan or school policies cover transportation to and from school if your child rides the school bus.”

- “Think about after-school plans for your older child, as middle and high school students often have plans with friends after school. For example: can they store their medicine in a school locker during the day–even if the school doesn’t allow self-carry–so that they are prepared to go to a friend’s house or activity directly after?”

We hope this rundown of plan options, food allergy management policies, and parenting wisdom helps you to better advocate for your child’s food allergy needs!

-      Susannah and the Allergy Amulet Team 

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The Nutty Nature of Nuts

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For years, patients diagnosed with a tree nut or peanut allergy have been told to avoid all nuts. But what if I told you that being allergic to one nut doesn’t necessarily mean you’re allergic to another? What if I also told you that avoiding nuts altogether could result in a higher risk of BECOMING allergic to nuts?

Nuts, right?

To make things even more confusing, it’s possible to be allergic to some tree nuts and not others (e.g., a patient could be allergic to all tree nuts except hazelnut and almond). Walnuts and pecans are almost 100% cross-reactive, so if you’re allergic to one, you’re almost certainly allergic to the other. The same is true of cashews and pistachios. But that’s pretty much where the similarities end. 

Often, if a patient has an allergic reaction to a peanut or a tree nut, their allergist will advise the patient to avoid all nuts. Why? The rationale is three-fold: 1) some tree nuts are cross-reactive with others; 2) nuts are often packaged and handled in a shared facility, making cross-contact more likely; and 3) it is often easier for a doctor to advise patients to avoid all nuts (including peanuts, which are technically a legume). 

Doctors have also generally recommended strict avoidance of all nuts after a peanut or tree nut allergy diagnosis because of the challenges in distinguishing between nuts. Otherwise, the patient would be expected to know the difference between all of the different types of nuts: almonds, brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pine nuts, pistachios, and walnuts—both shelled and unshelled. Studies have also shown that allergy patients are only slightly worse at identifying tree nuts than their allergists. 

Patients would also have to trust that kitchen and waitstaff at restaurants could distinguish between the nuts (spoiler alert: many can’t). Additionally, it’s hard to find bags of tree nuts that don’t list warnings of possible cross-contact with other tree nuts or peanuts due to manufacturing practices. In order to determine which nuts a patient is allergic to and which ones are safe, one or more oral food challenges may be necessary. 

Because of this, recommending that a patient avoid all nuts has historically been deemed the more practical—and safer—approach to food allergy management. 

Then came the LEAP (Learning Early About Peanut) study.

The LEAP study suggested that kids who were at risk for developing a peanut allergy were significantly less likely to become allergic if they ate peanuts early and often. The study also showed that if a patient was unnecessarily avoiding peanuts they were more likely to become allergic to peanuts over time. This suggested that unnecessarily eliminating certain allergenic foods could increase a child’s risk of becoming allergic.

This study led to a seismic shift in the food allergy community’s understanding of food allergies and allergy management practices. Suddenly, blanket avoidance of all tree nuts and peanuts came with the potential risk of increasing an at-risk child’s chances of developing a food allergy. For this reason, it is important that allergists talk with their patients and/or the patient’s families after a peanut or tree nut diagnosis about the different approaches to managing food allergies and decide together what is in their best interest. 

The first option is the oldest approach: strict avoidance of all peanuts and tree nuts. Many patients and families feel safe with this approach. Total avoidance may lessen the fear of a reaction due to cross-contact. Accordingly, for many patients and/or families, avoidance is the right choice. Another option is to have the patient continue to avoid the foods they are allergic to (in this example certain tree nuts) and teach families how to safely eat the foods they are not allergic to. This process may involve a food challenge. Deciding to eat certain nuts when allergic to others does involve learning how to read labels to check for potential cross-contact, learning what the different nuts look like shelled and unshelled, and understanding that eating those nuts is something that should be done at home and not in restaurants. 

We still have a lot to learn about food allergies, but hopefully in time we’ll get better at managing, diagnosing, and treating them. In the meantime, for newly diagnosed food allergy patients, candid conversations are a good start. 

 

Brian Schroer, MD is on staff at Cleveland Clinic Children’s Hospital where he sees patients of all ages with allergic and food-related diseases. 

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