By Arianne Corbett, RD 2014-06-12 18:32:59
The Buzz on (Food) Bans There are a variety of approaches to developing the right food allergy management and prevention plan for your school or district. In the 1960s, Cleta Long was diagnosed with multiple food allergies to dairy, wheat, beef, soy, onions and even chocolate. Very few substitutions were available for these common menu items, which included all her favorites. “The only nondairy item even out there was a frozen product called Coffee Rich,” Long recalls. “I can remember thinking, ‘I am going to starve!’” Not unlike children diagnosed with food allergies and intolerances today, Long remembers feeling unsure of the future ahead. What would she eat? How would she participate in her favorite activities with friends? Today, Dr. Cleta Long, SNS, is school nutrition director for Bibb County Schools in Macon, Ga., and regularly faces challenges in accommodating student customers with food allergies. Although the number of substitutions has increased—alternative proteins are available, wheat-free options are plentiful and one can even find ice cream and milkshakes made from coconut milk— she knows all too well the complexity of such special needs diets and the feelings of isolation experienced by today’s young food allergy sufferers. The U.S. Centers for Disease Control and Prevention (CDC) reports that food allergies currently affect an estimated 4% to 6% of U.S. children—that’s nearly 6 million. In fact, the prevalence of food allergies among children increased a whopping 18% from 1997 to 2007, and the majority of affected children attend school or early care and education programs on a daily basis. In 2006, an estimated 88% of schools had one or more students with a food allergy. Schools and school nutrition programs must, often by government mandate, accommodate the needs of this steadily increasing population. Different Strokes Just like nearly every other aspect of school nutrition, each state agency, local municipal government, school district administration and even individual cafeteria site may have a different approach to managing food allergies. The reason? Every child who presents with food allergies may require a unique individualized care plan. Studies show that 16% to 18% of children with food allergies have had a reaction from accidentally eating food allergens while at school. In addition, 25% of the severe and potentially life-threatening reactions reported at schools occurred among children with no previous diagnosis of food allergy. School staff should be ready to address the individual needs of children with known food allergies, but they must also be prepared to respond effectively to the emergency needs of a child who exhibits allergic signs and symptoms without prior history. Finding that balance of proactive and reactive management can help you provide a safe environment for all of the students you serve. A common approach for many schools upon initially dealing with food allergies has been to ban the potential allergen. Most frequently, these bans tend to involve peanuts. Although only one of eight foods that cause 90% of severe allergic reactions, peanuts have been the target of the most aggressive management approaches—the food ban—perhaps because they are less essential menu ingredients than wheat, eggs and dairy, perhaps because they are more common than, say, shellfish, soy and tree nuts or maybe some combination. Regardless, for those at risk of a severe, life-threatening, allergic reaction called anaphylaxis, strict avoidance of the food item is essential. As a result, a few years ago, “peanut-free” schools began popping up all around the country. Today, many school districts ban specific foods (peanuts and others) district-wide, while many other child nutrition operations remove products and recipes from their menus on a school-by-school basis and still others have decided to focus on increasing awareness, without making menu changes. In this article, School Nutrition will attempt to review the spectrum of food allergy management approaches. Whether peanuts or other food allergens remain on your menus, effective food allergy management should go far beyond menu offerings and apply a coordinated, school-wide approach. The Flexible Ban Bibb County Schools’ Cleta Long uses a combined approach to food allergy management. She has comprehensive policies and procedures in place for student identification, staff training, documentation of accommodation and emergency response in the event of a reaction. She also works very closely with her school administrators and parents to help each of the district’s schools meet the needs of their students. “I’ve had a lot of requests to remove peanuts from the cafeteria and to take them off the menu,” Long explains. “I tell them I am more than happy to make those substitutions, but I also educate. A ‘peanut-free’ school is more than just a ‘peanut-free’ cafeteria.” To emphasize the concept of a “peanut-free school,” Long takes the opportunity to help everyone involved understand their roles. To be truly peanut-free, the entire school community—parents, students, teachers and visitors—must comply. This means that no one can bring a Snickers® bar or Reese’s® cups or other peanut-based candy onto school grounds. Peanut butter art projects are disallowed. Meticulous monitoring, enforcement, handwashing and sanitizing are needed across the school campus. The scope of such requirements may prompt schools to focus on meal substitutions for the individual student instead of a ban, supported by improved awareness of risks and reactions among staff and students outside the cafeteria, too. Long reports that some of Bibb County’s sites are going the distance, while others provide more of a hybrid approach. When Foodservice Director Tazeen Chowdhury of Mt. Lebanon School District in Pittsburgh, Pa., started in the district 13 years ago, only 3 schools out of 10 were participating in the National School Lunch Program (NSLP). While working to improve this ratio, Chowdhury also addressed the growing number of life-threatening peanut allergies in her district. “School nurses were bringing all these allergies to our attention, so when we brought the NSLP to our seven elementary schools, we developed menus free of peanuts and peanut products,” she recounts, adding, “We didn’t have to go backward or take anything away. It was an easy solution for our district.” Chowdhury emphasizes, however, that peanut-free menus is just one piece of the larger food allergy management policy in place at the school. Lisa Griffin, director of child nutrition for Union Public Schools in Tulsa, Okla., also has decided to implement a ban on peanuts. “We will not buy foods that have peanuts or that are processed in a plant with peanuts [for menus served] at the elementary school level, but we also try to work with students and parents on an individual basis,” Griffin explains. “We know the severity of a life-threatening reaction. The parents appreciate it, and it helps us knowing the kids are safer,” she adds. Other safeguards the team has implemented include a point-of-sale allergy alert system and significant training on food allergies and the prevention of cross contamination in meal production. “Our managers and employees take it seriously,” Griffin asserts. Apply Awareness Staffers at Hudson (Wis.) School District consider themselves “peanut aware.” By choosing not to eliminate peanuts or any other allergens from menus, “Our policy is to teach children life skills and how to live in the real world,” describes Nutrition Services Director Peggy Eller. Also in the Midwest, Saint Paul (Minn.) Public Schools (SPPS) has implemented a similar policy in which the school nutrition team identifies food ingredients and common food allergens in menus and identifies students with allergies coming through the serving line, but does not eliminate any foods from production or service. In both districts, school staff, nutrition services staff, students and parents understand the different allergens that are present in each menu item and choose meals accordingly. Angie Gaszak, nutrition specialist for SPPS, feels strongly that a ban would not work in her district. “It just wouldn’t be fair to ban one food for a student with a food allergy when there are other students allergic to [other] foods that are not banned,” she explains. As noted earlier, there are eight foods/categories that cause the most prevalent and serious food allergy reactions, but a whopping 170 different food items have been known to cause allergies! Gaszak also believes an item ban might lead to people letting their guard down, and this sentiment is reiterated in the district’s policy. Saint Paul’s Managing Food Allergies Policy in School reads, “’Peanut-free’ creates a false sense of security for students, parents/guardians and staff. Food allergies are increasing; 3% to 8% of children have reactions to some foods—commonly milk, soy, eggs, wheat, peanuts, tree nuts, fish and shellfish. School districts could not effectively ‘ban’ all of these common foods.” The policy also includes a comprehensive list of responsibilities for parents and guardians, school staff and school nurses, so that each party at the school knows their role in food allergy management and prevention. Other directors are more blunt about that “false sense of security,” asserting concerns about the legal liability of attempting to establish a peanut-free (or other allergen) environment. Can schools truly be the gatekeepers that fully eliminate such risks? And in our litigious society, can a district count on parents to have reasonable, “real world” expectations, if there’s an incident of failure in a ban-based policy? Where Do You Begin? Is your school or district ready to begin the process of creating a policy for food allergy management and prevention tailored to your specific needs? You’ll want to be sure to review the Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs, released by the CDC in 2013. According to Gina Clowes, director of education for Food Allergy Research & Education (formerly the Food Allergy and Anaphylaxis Network), “The CDC guidelines include information about federal laws and contain broad food allergy information, as well as concise tips and recommendations for all groups involved. We support what the CDC recommends.” These voluntary guidelines will arm you with everything you need to understand about federal requirements, background on types of food allergies and symptoms of an allergic reaction, and they offer recommended actions for school board members, administrators and staff at the district and school level. The guidelines also offer a hefty list of resources to help your district develop a comprehensive food allergy management and prevention policy matched to your district’s needs and characteristics. You can view this resource at www.foodallergy.org/cdc. Following are summaries of some of the tips for school nutrition directors, managers and employees included in these recent CDC guidelines. • Participate in the school’s coordinated approach to managing food allergies. Work with others in the district to develop a comprehensive food allergy management and prevention plan that applies both inside and outside the cafeteria. Sherry Coleman Collins, RD, a nutritionist and consultant for the National Peanut Board, clarifies, “The most important piece of managing food allergies is a well-developed, comprehensive plan. It gives a school more credibility with parents and more power in a positive way.” And don’t forget—food allergy reactions don’t just happen during school lunch. Ensure that your policy addresses foods available outside of school meals, such as those available in vending machines, school stores, fundraisers, class parties, athletic events and afterschool programs. • Ensure the daily management of food allergies for students. An important first step is to develop and implement a system for identifying students with food allergies and documenting all required accommodations and substitutions. Work with other district staff to develop standardized forms and documentation for special diets and physician communication. Look to your state agency or local health department for assistance and resources. Work with school nurses and teachers to relay new diagnoses and with your district’s registration department to notify the school nutrition department when a student with food allergies is registered to attend school. Consider developing a flow chart or decision tree for the district to outline responsibilities for notification of students with food allergies. Collins explains, “A consistent, standardized approach provides a safer environment.” Following initial identification or registration, daily identification of students with food allergies is critical. A common approach, with recent advances in point-of-sale (POS) technology, is to add an allergy alert to a student’s meal account. Union Public Schools’ Lisa Griffin details, “In our district, employees know the individual students with food allergies, but our POS system also reminds them with a note that comes up on the cash register.” A standardized abbreviation system also can help assist nutrition services staff in understanding the type of food allergy affecting each student. Angie Gaszak created such a system for SPPS. “’ANA’ stands for an allergy with an anaphylactic reaction, while ‘FA’ is used for all other non-life-threatening food allergies,” she says. Policies and procedures for food safety in meal production and preparation also should be top of mind. All school nutrition staff should practice and understand the importance of proper handwashing and glove changing procedures. Each kitchen should have a designated allergen-safe food preparation area, and staff should know how to properly handle and store foods, as well as separate equipment and utensils to prevent cross contact. Read and reread all food labels for potential allergens. Recheck each purchase for formula changes and manufacturer substitutions. Keep all food labels from all foods served to children with allergies for at least 24 hours after offering the food in case the child has a reaction. And keep current contact information for vendors and suppliers so you can obtain food ingredient information if needed. • Prepare for food allergy emergencies. Work with your district to develop protocols for how to respond to a child with a food allergy reaction. All nutrition service employees should know their role in an emergency situation. This includes recognizing symptoms (see the box below) and knowing whom to notify in an emergency situation and where a child should be taken immediately to receive treatment with epinephrine. Betsy Craig, CEO of Menu-Trinfo, a provider of foodservice allergen training, explains, “The head-in-the-sand approach doesn’t work. You know what to do for fire drills; you don’t pretend you aren’t going to have a fire. It’s just another type of fire drill.” Hudson School District’s Peggy Eller agrees. “What parents want is a plan. We tell parents, we are planning that your child will have a reaction while at school. We will do everything we can to prevent it, but we are trained for the day it happens,” she says. Is a Food Allergy a Disability? Schools participating in U.S. Department of Agriculture (USDA) meal programs are required to make meal or food substitutions or modifications for students whose allergies are considered disabilities under USDA regulations. Under current USDA guidance, when a licensed physician includes in a signed medical statement that a student’s food allergy may result in a severe, life-threatening (anaphylactic) reaction, the allergy would meet the definition of a disability. BONUS WEB CONTENT Be sure to take a look at additional online content extras for this article, which include more tips for school nutrition staff for developing a food allergy management and prevention plan, as well as sample documents you can adapt for your own needs. Visit www.schoolnutrition.org/snmagazinebonuscontent. Food Allergy Symptoms in Children When developing your food allergy management plan, it’s essential to be familiar with the common food allergies that might be present in your enrollment. Some reactions can be life-threatening, so you also want your onsite cafeteria team members to know how children might communicate early symptoms, in order to react quickly and effectively. More than 170 foods are known to cause food allergies. In the United States, the following eight foods or food groups account for 90% of serious allergic reactions: Children with food allergies might communicate their symptoms in the following ways: “This food is too spicy.” “My tongue is hot [or burning].” “It feels like something’s poking my tongue.” “My tongue [or mouth] is tingling [or burning].” “My tongue [or mouth] itches.” “It [my tongue] feels like there is hair on it.” “My mouth feels funny.” “There’s a frog in my throat.” “There’s something stuck in my throat.” “My tongue feels full [or heavy].” “My lips feel tight.” “It feels like there are bugs in there.” (to describe itchy ears) “It [my throat] feels thick.” “It feels like a bump is on the back of my tongue [throat].” Arianne Corbett is managing director of Leading Health, LLC, in Arlington, Va., and a former manager of nutrition advocacy at SNA. Photography by Karen Sarraga/Jiunlimited.
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