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Peanut butter in schools: a tough nut to crack!

Peanut butter, a seeming staple of childhood, affects an increasing number of children who have adverse physical reactions that may even result in death. Alarmingly, according to Sicherer, Munoz-Furlong, and Sampson (2003), the number of children with peanut allergies, tree nut allergies, or both doubled over a five-year period. American, French, and British researchers are particularly concerned about this serious health issue (Grundy, Matthews, Bateman, Dean, & Arshad, 2002; Sicherer et al., 2003; Wegrzyn-Nowak, Conover-Walker, & Wood, 2001) and the increasing number of people affected. This trend has prompted immunologists and researchers to raise questions about environmental, immunological, and genetic factors as possible links to peanut and tree nut allergies (Sicherer & Sampson, 2007).

According to the Centers for Disease Control and Prevention (CDC), food allergies are abnormal immune responses to specific foods that the body reacts to as harmful (n.d.). Once the body reacts to the allergen (e.g., peanut) as a dangerous food, the body produces immunoglobin E (antibodies) in order to counterbalance the threat. When the next contact with peanuts occurs, antibodies send a signal to the brain to release histamines into the bloodstream. The histamines and the other chemicals that are released can lead to an allergic reaction, which may include hives, shortness of breath, vomiting, nausea, abdominal pain, diarrhea, drop in blood pressure, or tingling sensation on the tongue or a constricted feeling in the throat. Anaphylactic shock is the most severe reaction and can result in death in a matter of minutes.

Munoz-Furlong (2006) posits that 600,000 children in the United States are allergic to peanuts and that the rate of young children diagnosed with peanut allergies has doubled since 1997. The initial onset of an allergic reaction to peanuts can occur as early as age 2. Possible reasons for the present-day increase of peanut allergies include:

* Roasted peanuts, such as those used in peanut butter, produce more allergy-triggering compounds

* Two-year-olds, whose immune systems are not fully developed, are being introduced to peanuts too early

* Some skin ointments, creams, and lotions contain peanut oils

* The use of soy infant formula

* A genetic predisposition to such allergies. (Sicherer et al., 2003, p. 1206)

Although several studies have been published on children and food allergies, research findings have been inconclusive in determining the causes of peanut or other food allergies. Several immunologists and allergists propose a genetic link to allergies. Another cause may be the use of nut-based products with infants or the overuse of antibacterial products, which can cause children's immune systems to become more prone to allergies. Over the last several years, antibacterial products have become more available to the public and are included in many cleansers, hand lotions, linens, and mattresses. The cause for concern here is that the overabundant use of these products can contribute to the development of resistance to specific bacteria. Levi (2001) posits that the number of children with asthma, allergies, and eczema has increased in communities that have been overly protected against bacteria. This phenomenon is referred to as the "hygiene hypothesis" (p. 514). A study by Fahrlander et al. (1999) showed that children living in farming communities had fewer allergies than children raised in other environments. The results of these studies provide evidence that the more that bacteria is eliminated from living environments, the larger the increase of children with immune systems that cannot produce antibodies.

A study in the United Kingdom (Grundy et al., 2002) tested 2,800 children in the same geographical area (Isle of Wight) via a skin-pricking test for a 6-year period. Their findings show that the amount of children testing positively for peanut allergies increased significantly within that period. Lack, Fox, Northstone, and Golding (2003) conducted a longitudinal study of more than 13,000 preschool-age children, of whom 36 were confirmed to have peanut allergies. Results of their study were puzzling and difficult to explain. They found that mothers engaging in peanut consumption during pregnancy was not a prevalent factor in children developing peanut allergies. They agreed with Sicherer et al. (2003) that, aside from genetic links to peanut allergies, eczema, and other allergies, the most common factor was the use of creams or oils containing peanut oil during the first 6 months of life (p. 982). These three studies, conducted simultaneously in the United Kingdom and United States, show similar results in the possible development of allergies.

Taking into consideration all of the symptoms and reactions to deadly allergens, child care centers, schools, and other environments need to be aware of the dangers involved in serving food, such as peanuts, that can be harmful to children. Children are naturally social creatures who like to touch one another or sample each other's food. They are unaware of the danger of exposing others to allergic foods, such as peanuts. According to the American Academy of Allergy, Asthma and Immunology (n.d.), children with peanut allergies can be exposed to peanuts in three distinct ways:

* Direct contact with peanuts--not being aware of peanut traces in certain foods or ointments, kissing someone who has eaten peanuts, or shaking hands with someone who has eaten peanuts

* Touching materials that have been contaminated by cross contact (unintended exposure to peanuts)

* Inhalation of peanuts through such products as cooking oils, or peanut dust left at the bottom of an empty can tossed into a garbage bin.

The Great Debate: Should Peanut Butter Be Banned From Schools?

Research and physical evidence concerning peanut allergies is alerting us to a slow-moving epidemic. For the last 10 years, the idea of peanut-free zones in schools has caused quite a controversy. Parents of non-allergic children take offense in not being able to send their children to school with one of America's favorite lunch staples, the peanut butter and jelly sandwich. On the other hand, parents who live with the daily fear of anaphylactic shock advocate for peanut-free schools to protect their allergic children. Teachers, administrators, and school personnel are troubled by the possible repercussions of legislation concerning children with food allergies in schools. For example, the National Center for Policy Analysis (2001) reports that a growing number of school principals and program administrators fear being sued under the Americans With Disabilities Act or of being accused of discrimination against children disabled by a peanut allergy. School and program administrators are perplexed and apprehensive over the demands of both groups of parents (those with children who have allergies and those without).

Meeting the needs of children with allergies and those who do not have allergies is a burden for all involved, both inside and outside the school environment (Munoz-Furlong, 2003). According to another study, "It is common for food allergic children to experience allergic reactions in schools and preschools, with 18% of children having had at least one school reaction" (Wegrzyn-Nowak et al., 2001, p. 790). In the aforementioned study, Wegrzyn-Nowak et al. conducted a telephone survey to identify and differentiate food allergic reactions in 132 children, ages 2-19 years, in schools and preschools. Their aim was to determine what policies and procedures were in place at their centers and schools to respond to possible allergens. Children who suffered allergic episodes were treated most often by a school nurse, administrator, emergency medical personnel, or teacher (p. 793). Their findings show that at least 1 in 5 of the children surveyed experienced an allergic reaction at school. Although schools were aware of the children with food allergies, reactions to allergens did occur. Reactions can occur at any time, as stated by Sicherer et al. (2001), who found that some children reacted to foods with peanut and tree nut allergens used in class projects and activities. This study demonstrates a direct example of first-time reactions occurring in peanut allergic children outside of the school cafeteria.

According to the U.S. Department of Agriculture, Food and Nutrition Services (2001), children with food allergies or intolerances do not have a disability, as defined under either Section 504 of the Rehabilitation Act or Part B of IDEA, and the school food service may, but is not required to, make food substitutions for them. However, when, in the licensed physician's assessment, food allergies may result in severe, life-threatening (anaphylactic) reactions, the child's condition would meet the definition of "disability," and the substitutions prescribed by a licensed physician must be made.

Under this federal ruling, schools are required to accept all children regardless of their food allergies and have allergen-free substitutions for children participating in free or reduced-price meal programs. Moreover, schools are required to administer medications (Epi-pens and other medications) during a reaction as well as have an "action plan" from the physician. So the question remains, "Should schools ban peanut butter?" The pros and cons for peanut-free zones in school are many and each stance is supported by parents, immunologists, allergists, and school personnel alike.

Supporting Peanut-free Schools

Life-threatening peanut allergies warrant the need for peanut-free schools. Allergic children exposed to peanuts can suffer anaphylactic shock and other reactions most schools would not be prepared to handle. The breath-restricting, chest-compressing symptoms of peanut allergies are far more hazardous than most of the prescribed drugs allowed in schools. Allergist Dr. Richard Loria (1999) posits that "allowing peanut butter around the peanut allergic child is like allowing smoking at the gas pump. It's a formula for disaster." Children with peanut allergies can have a reaction from contaminated materials in the classroom. For example, a child who has had a peanut butter sandwich for lunch may unwittingly leave peanut residue on the keyboard of a computer or other surface. Having a peanut-free environment means not only eliminating peanut butter or peanut products from the lunch room, but also eliminating peanut products altogether. Some schools and programs have addressed this health issue by banning the use of peanuts for school projects, having a "peanut-free" table in the cafeteria, and designating a person to be responsible for supervising the peanut-free table. Several schools--for example, in Vail, Colorado; Fairfield, Connecticut; and Toronto--have separate areas designated in the cafeterias where peanut butter sandwiches can be eaten. These policing procedures are used to help lessen the confusion for school personnel during lunch periods.

The French Ministry of Education created a policy that specifically included safety regulations for children with food allergies. "Their policy includes the creation of a Personal Care Plan (PCP) indicating the particular food allergy, risks involved, and information concerning the first symptoms and the steps to be taken in case of an emergency" (Moneret-Vautrin et al., 2001, pp. 1071-1072). Wegrzyn-Nowak et al. (2001) posit that prevention is the best way to provide safety for food-allergic children. They propose that although elimination diets (e.g., peanut-free) are difficult to initiate and control, they are one proven method for preventing food-allergic reactions in schools. Providing information and training to schools is a critical step in helping to make schools a safe place for children with peanut allergies.

Moneret-Vautrin et al. (2001) evaluated the PCP school management program used in France. The researchers were particularly interested in how well-prepared school systems are when dealing with allergic children, as well as with the efficiency of the emergency kits used. Results show that schools that had PCPs in place were more successful dealing with allergic reactions to foods. The PCPs used elimination diets, whereby parents brought in prepared meals to school or children ate at home. The program did not eliminate all reactions in such schools, but no fatalities occurred (Moneret-Vautrin et al., 2001).

Challenging the Need for Peanut-Free Schools

The main reason for not having peanut-free schools is that many believe they create a false sense of security. In other words, children would lower their guard against possible peanut contamination in these environments. The aforementioned studies--Wegrzyn-Nowak et al., 2001, Moneret-Vautrin et al., 2001, and Grundy et al., 2002--all show that even schools that have eliminated allergens have seen children experience reactions to food allergens (although the children's reactions were minor and not deadly). Parents of allergy-free children are not the only ones who are challenging the need for peanut-free schools. Some parents of children with peanut allergies support limiting the risks by taking precautions rather than banning all peanut or tree nut allergens. They recommend educating the school by keeping communication channels open between physicians, parents, and school personnel. In addition, many parents do not want their children singled out. Scott Sicherer, who has conducted research on allergies (2004), recommends setting up peanut-free zones in child care centers, where cross-contamination is a high risk as young children drool on toys and other materials in the classroom.

Another reason for challenging peanut-free schools is the restrictions placed on non-allergic children from having a nutritious food staple, or for those particular children whose only nourishmentis peanut butter. In one New York City public school, a parent is collecting signatures to protest the designation of a peanut-free neighborhood school. She believes that her child is being discriminated against because he only eats peanut butter.

Furthermore, children need to be aware of the ingredients they can or cannot eat and be aware of the materials, ingredients, and substances that are harmful to them. Eliminating peanut butter and other food allergens does not allow children to make decisions for themselves. Parents can take responsibility for sending their children to school knowledgeable about the repercussions of eating food items or of exposing themselves to harmful items.

Advocating Empathy: Responsive Schools, Parents, and Health Professionals

Parents, educators, administrators, and health professionals know the dangers of exposure to peanut and food allergens and need to be prepared to care for allergic children in schools, and keep the channels of communication open by sharing what they know.

Parents need to educate teachers and schools on their children's particular allergy. It is imperative to share with schools all medical information from doctors, allergists, or immunologists. Work with the child's allergists and write an "Action Plan" describing all of the information the school nurse, teacher, and administrators need about the child's allergies. Supply the school with the child's prescription medications and directions for administrating it. All schools should have a school nurse, teacher, or administrator who is trained to administer Epi-pens or other medicines. Most important, keep the school updated on changes in medicines or new diagnoses.

Become involved in your child's classroom activities. For example, supply allergy-free snacks when children celebrate holiday or birthday parties at schools. Be aware of arts and crafts materials (food-related) that can expose the child to allergens. Advise teachers to read labels on materials used in the classroom. Some items may have nut allergen deposits.

Parents also should educate their allergic children on what they can or cannot eat. Parents need to instill in their children the responsibility for following food rules. By age 4, children can follow food rules: for example, only eat what you bring from home, do not eat someone else's food, tell the teacher or lunch supervisor if you think you ate or touched something that makes you feel funny. Teach them about the symptoms to be aware of, such as itchiness, shortness of breath, and rash. By adhering to these recommendations and working with schools, parents can ensure safe environments for their allergic children.

Schools are required by law to be responsive to allergic children by providing a safe environment. Awareness of such laws as the Americans With Disabilities Act (ADA), Individuals With Disabilities Education Act (IDEA), Family Educational Rights and Privacy Act (FERPA), and Section 504 of the Rehabilitation Act are just part of a school's vast responsibility. Aside from knowing the policies, restrictions, and criteria of the laws, schools need to conduct regular reviews of children's health records. Policies and practices should be created to review and update medical information of allergic children, submitted by parents and physicians. Schools should have action plans signed by physicians or health professionals for each allergic child. Review the action plans with all staff and faculty and become familiar with specific procedures in the plans. These need to be reviewed when they are submitted to the school, not while the child is having a reaction. Also, make sure that the medications have not expired.

School administrators should assemble a team of trained personnel, including teachers, counselors, nurses, food service managers, nutritionists, and others to work with children and their families in creating prevention policies. This support group can make decisions about responding to peanut and food allergies. Members of this team also should be savvy about medications and administering prescriptions (e.g., Epi-pens, etc.). Under the principal's and school nurse's guidance, medications and emergency kits should be safely stored but remain accessible for emergency use. When age appropriate, children in elementary schools, with a doctor's permission, should carry their own epinephrine, if allowed by state law (New York City Department of Education, and New York City Department of Health and Mental Hygience, Regulation of the Chancellor, 2007, p. 1).

Frequent communication with parents is crucial. Letters should be sent out to all parents alerting them of allergic children in their own child's classroom as well as providing information about dangerous foods and the precautions they need to consider when sending foods or snacks to the classroom.

Teachers have one more added responsibility: fostering empathy. One of the principal constructs of teaching is creating community in the classroom. Teachers are trained to work with children on accepting one another despite differences in beliefs, appearance, or background. Addressing health concerns in the classroom, such as peanut and food allergies, is one way of demystifying them. Fostering empathy for allergic children allows children to understand how others feel. Many allergic children feel isolated and singled out by others in school. Being "banished" to specific peanut-free tables and watched over and questioned about their allergies can create some discomfort. Teachers can use such books as Allie the Elephant by Nicole Smith, The Peanut Pickle by Jessica Ureel, The Peanut Butter Jam by Elizabeth Sussman, and The Peanut Free Cafe by Gloria Koster to discuss with all children the problem of peanut allergies. Such discussions can help others realize the constraints and dilemmas associated with food allergies. Teachers need to provide the venue to augment empathy and kindness for all children.

Health professionals play a critical role in the dissemination of information for parents and allergic children. Allergists, immunologists, pediatricians, and other health professionals should also consider ways to share information about specific allergies with schools. Health professionals should provide schools with up-to-date action plans for allergic children that outline the proper emergency procedures to be followed in the event of an allergic reaction. School personnel teams and health professionals should build partnerships and communicate frequently. Meetings can be held at schools, where health professionals can be invited to discuss peanut and other food allergies with the whole school community, parents, teachers, food service personnel, etc.

Peanut allergies and all food allergies affect the entire world of the child. Whether the child is at home, at school, visiting friends, participating in sports or other extracurricular activities, or on field trips, we need to provide the safest environments possible. It is our responsibility as parents and educators.

References and Resources

American Academy of Allergy, Asthma and Immunology. (n.d.). Anaphylaxis in schools and other child-care settings.

Retrieved March 5, 2008, from http://aaaai.org Beck, R. (November, 2000). School educates kids, families about food allergy. Retrieved March 8, 2008, from http:// boothbayregister.maine.com/2000.

Centers for Disease Control and Prevention. (n.d.) Food allergies. Retrieved February 13, 2008, from www.cdc. gov/healthyyouth/foodallergies

Fahrlander, B., Gassner, M., Grize, L., Neu, U., Sennhauser, F. H., Varonier, H. S., Vuille, J. C., & Wuthrich, B. (1999). Prevalence of hay fever and allergic sensitization in farmers' children and their peers living in the same rural community. Journal of Clinical and Experimental Allergy, 29(1), 28-34. Retrieved March 4, 2008, from www.foodallergens.de/j-index/j-index99-01.htm.

Grundy, J., Matthews, S., Bateman, B., Dean, T., & Arshad, S.H. (2002). Rising prevalence of allergy to peanut in children: Data from 2 sequential cohorts. Journal of Allergy and Immunology, 110(5), 784-789.

Lack, G., Fox, D., Northstone, K., & Golding, J. (2003). Factors associated with the development of peanut allergy in childhood. New England Journal of Medicine, 348(11), 977-985.

Levi , S.B. (2001). Antibacterial households products: Cause for concern. Journal of Emerging Infectious Diseases, 7(1) (supplement), 512- 515.

Managing food allergies in school. Retrieved February 11, 2008, from http://foodallergy.org?school/lunch.html.

Moneret-Vautrin, D. A., Kanny, G., Morisset, M., Flabbee, J., Guenard, L., Beaudoiun, E., & Parisot, L. (2001). Food anaphylaxis in schools: Evaluation of the management plan and the efficiency of the emergency kit. Allergy, 56, 1071-1076.

Munoz-Furlong, A. (2006). Going nuts over allergies. The Education Digest, 71(6), 33-34.

National Center for Policy Analysis. (2001). Retrieved February 11, 2008, from www.ncpa.org/pd/regulat

New York City Department of Education and New York City Department of HealthandMentalHygiene. (May 30, 2007). Regulation of the chancellor: Administration of epinephrine to students with severe allergies. New York: Authors.

Peanut butter allergy. Retrieved March 3, 2008, from http:// peanut-butter.org.

Sicherer, S., Furlong, T. J., DeSimone, J., & Sampson, H. A. (2001). The US peanut and nut tree allergy registry: Characteristics of reactions in schools and day care. Journal of Pediatrics, 138(4), 560-565.

Sicherer, S., Munoz-Furlong, A., & Sampson, H. (2003). Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: A 5-year follow-up study. Journal of Allergy and Clinical Immunology, 112(6), 1203-1207.

Sicherer, S., & Sampson, H. A. (2007). Peanut allergy: Emerging concepts and approaches for an apparent epidemic. Journal of Allergy and Clinical Immunology, 120(3), 491-503.

U.S. Department of Agriculture, Food and Nutrition Services. (2001). Accommodating children with special dietary needs in school nutrition programs. Washington, DC: Author.

Wegrzyn-Nowak A., Conover-Walker, M. K., & Wood, R. (2001). Food-allergic reactions in schools and preschools. Archives of Pediatric Adolescent Medicine, 155(7), 790-795.

Children's Books on Peanut Allergies

Koster, G. (2006). The peanut free cafe. Morton Grove, IL: Albert Whitman.

Smith, N. (2002). Allie the elephant. Colorado Springs, CO: Jungle Communications.

Sussman, E. (2001). The peanut butter jam. Santa Fe, NM: Health Press.

Ureel, J. (2004). The peanut pickle. Livonia, MI: First Page Publications.

Nancy S, Maldonado is Associate Professor, Lehman College of the City University of New York.
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Author:Maldonado, Nancy S.
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Date:Sep 22, 2009
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