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Food Allergies: A Recipe For Success At SchoolInformation, Recommendations and Inspiration for Families and School Personnel
By JAN HANSON
AuthorHouseCopyright © 2012 Jan Hanson, M.A.
All right reserved.
Chapter One"We must remember that we cannot separate health from the ability to learn. The two must go together."
Surgeon general Antonia Novella, US Department of Health & Human Services, 1992
Understanding Food Allergies
Food allergy. These two words, said together, were rarely spoken in everyday conversation just twenty years ago. Not so today. It seems that everyone knows at least one person with a food allergy, whether that person is a neighbor, a friend's child, a student in your son or daughter's class, a niece or a nephew, or perhaps it is your own child. Food allergies are a growing phenomenon with no sign of abating. Food allergies have become, directly or indirectly, a part of the world in which we live. These two words, when spoken, rarely evoke a response of indifference. They do, however, often provoke many questions. Although there is much we still need to learn about food allergies, the information provided in this chapter will give an overview of what is known today about this complex health issue.
Research studies looking at the epidemiology of food allergies became more prevalent during the 1990's, and they have continued worldwide since that time. The information revealed as a result of these studies allows us to develop a better understanding of what exactly food allergies are, and how we might be affected by them. A look at statistics over recent years demonstrates that the number of children with food allergies in the United States is growing at an alarming rate. A 2004 study in the Journal of School Nursing found that there was a 44% increase in the number of children at school with food allergies over the previous five years. In Massachusetts, an Essential School Health Services report demonstrated that from June 2007 to September 2008, there were a total of 16,365 students with a food allergy enrolled in 102 school districts. A recent study published in the July, 2011 issue of the medical journal, Pediatrics, reported that in the United States today, food allergies affect 6 million children under the age of 18. For school-aged children in the U.S., that means 8%, or one out of every thirteen children, will be diagnosed with some type of a food allergy. These statistics reflect a significantly higher number of children who have food allergies than were reported previously in similar studies.
Children are not only developing food allergies, they are also experiencing allergic reactions to food while at school. In a 2001 study by noted allergists and researchers Scott Sicherer, M.D. and Hugh Sampson, M.D., it was reported that 84% of students with a food allergy had an allergic reaction while in a school setting. Further evidence of this is found in the results of a 2005 study reported in Pediatrics, which demonstrated that 16-18% of children who had a food allergy experienced a food-allergic reaction during the school day. Data from the US Peanut and Tree Nut Allergy Registry indicate that 79% of allergic reactions to food occurred in the classroom, and 12% occurred in the cafeteria. Children are also having severe and life threatening reactions to their food allergens. In a Data Health Brief published by the Massachusetts Department of Public Health, it was revealed that from August, 2007 to July, 2008, 44% of anaphylactic reactions requiring epinephrine at school were caused by food. Tragically, children are also experiencing fatal reactions to their food allergens while at school. In a groundbreaking study by Dr. Hugh Sampson in 1992, it was determined that four out of six deaths from food-induced anaphylaxis occurred in the school setting. Another disturbing study in 2007 found that 50% of fatal food-allergic reactions among college-aged students occurred on the college campus. To view food allergies as a significant health concern would be appropriate.
Food allergy Defined
We know that it can take only an infinitesimal amount of food to which we are allergic to cause an allergic reaction. It was reported in a 2008 study published in the Journal of Allergy and Clinical Immunology that over a two month period of time, 20,821 individuals visited a hospital emergency room due to a food-allergic reaction. This is an astounding number of people who experienced a traumatic, physical event. What exactly happens to someone when a food is eaten to which that person is allergic? The following information is intended to provide a basic understanding of the body's physiological response during a food-allergic reaction.
A True Food Allergy
Our body's immune system is designed to keep us healthy by protecting us from such things as harmful bacteria and viruses. For a person with a true food allergy, the immune system, in essence, misreads the information it receives. In other words, it mistakenly identifies the protein in the food to which the person is allergic as being harmful. For example, if someone is allergic to peanuts, the first time that individual ingests a peanut, the body red flags peanut protein as a foreign protein and in response, produces proteins called "IgE antibodies" that will recognize peanut protein if it enters the body again. These IgE antibodies attach themselves to mast cells, located in tissue found throughout the body, such as in the nose, throat, skin, lungs and gastrointestinal system, and to basophils, found in blood which circulates throughout the body, resulting in what is called "sensitization". These sensitized mast cells and basophils are now ready to recognize peanut protein when it enters the person's body again. If the person does eat peanut a second time, these sensitized mast cells and basophils spring into action by attaching to the food protein, in this case peanut protein. This action triggers the mast cells and basophils to release chemicals, such as histamine, which in turn causes the symptoms of an allergic reaction. The release of histamine happens very quickly, usually within five minutes of when the food protein (allergen) binds to the IgE antibodies located on these mast cells and basophils, and can continue for thirty minutes to an hour. Whatever food a person is allergic to, whether it is peanuts, tree nuts, shellfish, milk, mustard, sesame seeds, mango, etc., the second time that food is ingested, the process of an allergic reaction as described above, will be put into motion.
A Food Intolerance
For people who have a food intolerance, as opposed to a true food allergy, the body's immune system is not involved and IgE antibodies are not produced. Rather, this is a metabolic disorder which does not allow the body to properly digest the food being consumed. Lactose intolerance is an example of a food intolerance. For someone who is lactose intolerant, the person is unable to break down lactose, which is a sugar present in milk products. If milk enters the body, the person would most likely experience an adverse physical reaction which can cause considerable discomfort, such as an upset stomach, abdominal bloating and other gastrointestinal symptoms.
Diagnosis of a Food Allergy
Consultation with a board-certified allergist is an important step to take when food seems to cause unwanted, adverse reactions, and our health, or that of a loved one, is being compromised. Your allergist will take a thorough medical history which will allow him or her to gather important information in order to make a diagnosis. During this appointment, you will be asked to describe: the symptoms being experienced, how long after eating the food do symptoms appear, if there are any specific foods which seem to trigger the reaction, and whether or not any family members have been diagnosed with an allergic disease, such as hayfever, eczema or asthma. Often, in conjunction with a medical history, diagnostic tests such as skin tests and blood tests will be performed to help diagnose a food allergy. In the skin prick test, a tiny amount of food extract is placed on the skin and then is gently "pricked" to allow it to reach below the top layer of the skin. The person will develop a red itchy hive on the area of the skin being tested if he is allergic to the food being tested. For blood tests, such as the ImmunoCAP test, blood is drawn and then examined in a laboratory to determine if IgE antibodies are being made to a specific food protein. Because it is possible to have a false positive result from either of these types of testing, your allergist may recommend that an oral food challenge test be performed in a medical setting in order to confirm whether or not the food, when eaten, causes an allergic reaction.
An excellent resource to further understand the diagnosis of a true food allergy is a publication issued by the National Institute for Allergy and Infectious Disease (NIAID), entitled, "Guidelines for the Diagnosis and management of Food Allergy in the United States. Summary for Patients, Families, and Caregivers".
Symptoms of an Allergic Reaction
When a person with a food allergy is exposed to one of his allergens, there are many different symptoms which may occur. The symptoms which develop during an allergic reaction will depend on which body system(s) has become involved, such as the skin, the gastrointestinal system (stomach and intestines), the respiratory system, and/or the cardiovascular system. A person having an allergic reaction will experience some of the symptoms listed below, but not necessarily all of them. It is also important to understand that the symptoms you have during one allergic reaction may be different than those you experience during a subsequent reaction. Similarly, while one reaction may be mild, your next reaction might be severe and life-threatening. Symptoms may start off very mild in nature but could progress to a severe reaction very rapidly, sometimes within minutes. Unfortunately, at this point in time, there is no way to predict which symptoms will develop after exposure to an offending allergen, or how severe or mild the reaction will be. Therefore, having the knowledge required to 1.) recognize symptoms of an allergic reaction, and 2.) understand that the symptoms being observed may progress rapidly to anaphylaxis, becomes critical, because it will promote better decision making in response to this type of an emergency, and help to insure that the appropriate medical intervention will be accessed quickly.
When the skin is involved during an allergic reaction, symptoms might include itchy, red hives, and swelling (called edema) of the area of the skin that has come in contact with the allergen—most commonly in the lips, tongue and/or eyelids. If the person has a pre-existing condition of eczema, then he might experience an eczema flare during the allergic reaction. If you eat a food to which you are allergic, some of the first symptoms you may notice might be an itchy mouth and lips, and redness and swelling in that area. Although most allergic reactions begin with skin symptoms, this is not always the case. It is interesting to note that during some food-induced allergic reactions, skin symptoms do not develop at all.
The Gastrointestinal System
The gastrointestinal system refers to the stomach and intestines. When a food allergen has reached these areas of the body, a person may experience abdominal cramps, gas, nausea, vomiting and diarrhea.
The Respiratory System
During an allergic reaction, the respiratory system may produce symptoms such as a stuffy or runny nose, and sneezing or coughing, often repetitively. In addition, a person may have difficulty swallowing. Children may describe this sensation as feeling like there is something caught in their throat. It is also possible to hear a change in the way the person's voice normally sounds, such as being either higher or lower or perhaps "squeaky". Symptoms of asthma, such as wheezing or shortness of breath, may develop. The onset of respiratory symptoms often signals that the allergic reaction is becoming more severe.
The Cardiovascular System
When the cardiovascular system is involved, the reaction has become severe and is life threatening. Symptoms may include paleness, a bluish tint of the skin, dizziness, feeling faint, confusion, a weak pulse and a drop in blood pressure. It is also possible for a person to lose consciousness when blood circulation is affected. People who have experienced these types of symptoms have described feeling a sense of impending doom.
The most severe form of an allergic reaction is called "anaphylaxis". A reaction of this nature can be life threatening and cause death. The symptoms of an anaphylactic reaction usually appear within five to thirty minutes after someone has been exposed to the allergen. It is possible for symptoms of an anaphylactic reaction to subside after treatment, only to reappear with a vengeance four to eight hours later. This is referred to as a biphasic reaction and statistically, 5-20% of all cases of anaphylaxis are biphasic. For a very long time there was no consensus on exactly how anaphylaxis should be defined. As a result, there is speculation that incidences of anaphylaxis have been under-recognized and under-reported. In July, 2005, the National Institute of Allergy and Infectious Disease (NIAID) and the Food Allergy & Anaphylaxis Network (FAAN) convened for a second time in order to define anaphylaxis in a way that would be agreed upon across organizations and specialties of medicine. As a result of the concerted efforts of these two organizations, a definition was finally agreed upon at this second symposium. The definition that is to be used by both medical professionals and the non-medical community is:
"Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death."
This group also agreed upon specific DIAGNOSTIC CRITERIA to be used. They are:
ANAPHYLAXIS IS HIGHLY LIKELY TO OCCUR WHEN ANY ONE OF THE FOLLOWING OCCURS (WITHIN MINUTES TO HOURS):
1. An individual has acute onset of symptoms (minutes to several hours) involving the skin (generalized hives, pruritis or flushing) and/or swelling of the lips, tongue or uvula, and at least one of the following:
a. Respiratory difficulty (eg. Dyspnea, wheezebronchospasm, stridor, reduced PEF, hypoxemia)
b. Reduced BP or associated symptoms of end-organ dysfunction (eg. Hypotonia (collapse), syncope, incontinence)
2. An individual was exposed to a suspected allergen and two or more of the following occur within minutes to several hours:
a. Involvement of the skin-mucosal tissue (eg. Generalized hives, itch-flush, swollen lips-tongue-uvula)
b. Respiratory difficulty (eg. Dyspnea, wheezebronchospasm, stridor, reduced PEF, hypoxemia)
c. Reduced BP or associated symptoms (eg. Hypotonia (collapse), syncope, incontinence)
d. Persistent gastrointestinal symptoms (eg. cramping, abdominal pain, vomiting)
3. An individual has had a known exposure to an allergen and experiences a reduced blood pressure within minutes to several hours:
a. Infants and children: low systolic Blood Pressure (age specific) or greater than 30% decrease in systolic Blood Pressure
b. Adults: systolic Blood Pressure of less than 90mmHg or greater than 30% decrease from that person's baseline
Epinephrine should be given immediately when the above criteria are met or for an individual with a history of life-threatening reactions who has had exposure to an allergen and begins to have symptoms quickly, even if they are mild.
(Source: 2nd National Institute of Allergy and Infectious Disease/FAAN Anaphylaxis Symposium July, 2005)
Please refer to the Supplemental Materials for a printable version of the NIAID Anaphylaxis Diagnostic Criteria.
An anaphylactic reaction should be regarded as a serious medical event. Current data indicates that the incidence of anaphylaxis in the United Sates is occurring in numbers that justify great concern. In an editorial printed in a recent Journal of Allergy and Clinical Immunology, titled, "Anaphylaxis epidemic: Fact or fiction?" the authors concluded that the rate of anaphylaxis in the U.S. has increased so much in recent years, that the term "epidemic" may be appropriately applied. Support for this conclusion is found in the 2008 study referenced earlier in this chapter which looked at the incidence of food-allergic reactions seen at a hospital ER over a period of two months. This study also found that there were 2,333 ER visits for anaphylaxis over that same two month period of time. In yet another study, it was determined that food allergies, primarily peanut and tree nut allergies, account for 150-200 deaths annually. School-aged children are not immune to these morbid statistics, as was evidenced by the 2012 death of a first grade student in a Virginia school due to food-induced anaphylaxis. Current data indicates that teenagers and young adults experience the greatest number of fatalities due to anaphylaxis caused by food allergy.
Excerpted from Food Allergies: A Recipe For Success At School by JAN HANSON Copyright © 2012 by Jan Hanson, M.A.. Excerpted by permission of AuthorHouse. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
CHAPTER ONE UNDERSTANDING FOOD ALLERGIES....................1
CHAPTER TWO GOING TO SCHOOL WITH FOOD ALLERGIES: A 3-STEP PLAN FOR FOOD ALLERGY MANAGEMENT....................45
CHAPTER THREE THE NEED FOR SCHOOL DISTRICT LIFE-THREATENING FOOD ALLERGY POLICIES....................161
CHAPTER FOUR THE LAWS AND HOW THEY RELATE TO FOOD ALLERGIES....................189
CHAPTER FIVE THE IMPACT OF FOOD ALLERGIES: WORKING THROUGH THE EMOTIONS....................239
CHAPTER SIX ANALYSIS OF A SCHOOL NURSE SURVEY ON FOOD ALLERGY MANAGEMENT....................263
REFERENCE BOOKS FOR FOOD ALLERGY MANAGEMENT....................307
REFERENCE LIST OF BOOKS & VIDEOS FOR CHILDREN....................311
LIST OF RESOURCES....................315
ABOUT THE AUTHOR....................319