by Antony Ham Pong, MBBS
Dr. Ham Pong is an allergist and researcher practising in the Ottawa, Ontario area.
Peanut Allergy in Schools and Child Care Settings
Peanut allergy is the most common life-threatening food allergy in children. It is often lifelong. Occasionally it may be outgrown. Children with peanut allergy often cannot stand the smell of peanut butter, may refuse to touch it, and do not want to stay around when peanut butter is being eaten. This type of violent rejection of peanut butter may be the first sign that a child is peanut allergic even if they have never eaten it. Sometimes these children get hives or rash where peanut butter touches the face or skin. If a peanut allergic child touches peanut butter and then rubs the eyes, the eyes may become very swollen and puffy. In the U.S., 8 lb (3-1/2 kg) of peanuts are consumed per person per year, half as peanut butter, one-third as peanuts, and the rest as peanut oil.
What can happen during an allergic reaction to peanut?
An allergic reaction to a food usually begins within 2-4 hours and usually lasts less than one day. The more severe the allergy, the smaller the amount required to cause a reaction. Typical immediate allergic reactions to foods include hives, or blotching around the mouth, which may spread to the rest of the body, immediate runny nose, sneezing and itchy watery eyes, coughing, choking or gagging, wheezing and trouble breathing, and cramps, vomiting and diarrhea. The allergic reaction can stop at any stage, or may progress to anaphylaxis and death. Anaphylaxis is a severe allergic reaction which involves several parts of the body and can lead to death.
A food does not have to be eaten to cause an allergic reaction but eating it does cause great amounts to get into the body and usually causes the most severe reactions. Hives can occur on skin contact with an allergenic food. If the food goes into the wet surfaces, e.g., through a cut in the skin or at the lips (e.g., being kissed by someone who has eaten peanut butter), or in the eye, severe reactions can occur.
How do I treat an allergic reaction on eating peanut products?
Anyone with peanut allergy should use their EpiPen® immediately when they begin to have reactions to eating peanut accidentally, even if the reaction initially is minor. This is important to prevent anaphylaxis, the most severe form of an allergic reaction. People who delay treatment with epinephrine are more likely to die. The EpiPen® should always be immediately close at hand (i.e., not in the locker, in the car, in the hotel room, or next door). A person with asthma is more likely to have a fatal food reaction. An allergic reaction, especially anaphylaxis, can recur 4-8 hours after initial treatment. It is important to go to the hospital immediately for further treatment and to be observed for several hours after.
If an allergic reaction to peanut begins, use the EpiPen® immediately as soon as any allergy symptoms develop! Take the patient to hospital immediately, preferably by ambulance.
How can I tell if my peanut allergy is “anaphylactic”?
Most if not all peanut allergy are considered potentially anaphylactic. Even a mild food allergy can cause anaphylaxis if enough is eaten. Once you have been prescribed an EpiPen®, it means that you have the potential for life-threatening reactions and are “anaphylactic”. Whether anaphylaxis will occur depends on how allergic a person is, how much of the food is eaten, how early treatment is started, whether the EpiPen® is given, and whether the person is having an asthma attack at the time or has chronic asthma.
I have had only a mild reaction to peanut in the past, and have never had breathing difficulties. Why do I need an EpiPen®?
Peanut allergy is usually potentially life-threatening and life-long. Even if mild allergic reactions have occurred in the past, severe reactions can still occur with the same amount of food (i.e., the allergy can worsen without warning). Do not also expect that you will have the same amount of time or warning before the reaction occurs as in the past. Therefore, the EpiPen® should be available at all times.
Why is peanut allergy so dangerous?
Even very small amounts can cause serious reactions. It may be found as a hidden, unlabelled part of a food sometimes because of accidental cross-contamination during manufacturing. Allergic reactions are often caused by eating unlabelled foods, by not checking food labels properly for presence of peanut, or from foods which contain hidden unlabelled peanut. Peanut may be used in many of the foods that children like and often eat. The most common types of foods causing allergic reactions due to peanut are chocolates, cookies, candies, cakes with peanut containing icing, and granola bars. Special occasions such as Easter, Halloween, Christmas and birthday parties are more dangerous for children with peanut allergy because there is more likely to be peanut containing foods eaten, and because it is more difficult to supervise children properly then. At school, allergic reactions to peanut can happen when peanut butter is used for school projects, e.g., bird seed balls, or when other children eat peanut products and shares with the allergic child, or the allergic child accidentally comes into contact with peanut on another child’s hands, mouth, toys, desk or any other area where peanut butter traces are left.
What other foods or activities may use peanut?
Peanut butter may be used as a “glue” to hold foods together, e.g., egg rolls, rice squares. Peanut butter or peanut flour may be added to barbecue sauce or other foods, e.g., chili, mooshu sauce, plum sauce, marinades, curry sauce, pasta sauce and satay sauce, to flavour or thicken them. Some bird seed and animal food, e.g., gerbil food and dog biscuits, may contain peanut and some people have reacted to playing with animals who have been fed peanut containing food, e.g., chinchillas and gerbils, presumably because traces of peanut are on the hair of the animals. Peanut may contaminate foods manufactured on the same machines as similar foods without peanut, e.g., cookies, breakfast cereals, cheese and crackers, chocolates, chocolate candies, raisin covered chocolates, ice cream.
I have eaten foods labelled “may contain nuts” without any problems. Should I still avoid them if I am allergic to peanut?
Definitely avoid them! Companies are allowed to use “may contain nuts” if they cannot guarantee that a food they are producing is free of nuts, usually because nuts are being used in the same machines for other foods. A company that makes similar foods with and without nuts, may have difficulty cleaning the machines in between making the different foods, or packages may be mislabelled. These food manufacturing machines were designed many years ago, and were never designed to be taken apart and cleaned properly. In addition, some of these machines cannot be cleaned with water. Therefore, it is quite likely that when a food with nuts is put through the machine, traces of nuts remain on the machine. The first batches of foods made without nuts that go through the same machine will likely contain traces of nuts. Batches of foods done much later are less likely to contain traces of nuts but you cannot be sure which batch of food you are eating. Therefore they should be avoided. This cross-contamination is most likely to occur with cookies, candies, cereal, chocolate, ice cream, dried soups and nut butters.
What foods are more likely to contain undeclared nuts?
Chocolate and mint ice cream are most likely to contain undeclared nuts since leftover ice cream can be added to these without changing the flavor. See list below (What may contain peanut). European chocolates are allowed to be made with leftover chocolate which may contain nuts and may not be declared.
Should I avoid other legumes, e.g., peas, beans or soya?
No, not unless you are actually allergic to them as well. Even though the skin test is positive, if you have been able to tolerate peas, beans and other legumes before, they may be continued, unless you begin to react when you eat them. In addition to peanut, legumes include peas, beans, Soya, chick peas (garbanzo beans), lentils, split peas, lupin seeds, dahl, tamarind, licorice, carob, soy sprouts, bean sprouts, cassia, alfalfa, fenugreek, tragacanth, acacia and senna. Most peanut allergic people can eat other legumes even if they have a positive skin test to these other legumes. Because peanuts are related to peas, beans and other legumes, these other legumes may show a mild positive skin test in a peanut allergic person but that person can still eat them. However, a positive skin test to one of these legumes means that the peanut allergic person does have some chance of developing an allergy to the legume later although if an allergy does develop, it is usually mild. In these cases, the allergy may cause only itchy mouth or throat. The legumes most likely to cause allergic reactions in peanut allergic people are dried mature legumes e.g., dried peas and dried beans, whereas green peas and green beans are often tolerated. Soy is very unlikely to cause an allergy in peanut allergic people.
Is peanut oil safe?
Pure refined peanut oil, if properly processed, should contain no peanut protein and therefore should not cause allergic reactions in peanut allergic people. Refining peanut oil requires a high degree of heating which destroys the peanut protein. Most peanut allergic people avoid peanut oil because of the slight risk that the processing of peanut oil was not done properly and that there may be traces of peanut protein. Nevertheless, if a peanut allergic person accidentally eats a food with refined peanut oil, the chances of having an allergic reaction are extremely low because even if there is peanut protein in there, it will likely be in very small amounts. However peanut and nut oils are also available unrefined. They may also be called cold-pressed, unprocessed, expelled or extruded oils. These unrefined oils may have nut proteins and may cause allergic reactions. However these unrefined oils are not usually used commercially but are usually found only in specialty food shops and used for specialty ethnic cooking, but may also be more common in other countries. Peanut oil is also known as Arachis oil.
Should vegetable oil be avoided?
No. Peanut oil must be declared if it is present.
Does peanut have to be declared on a label?
Generally, yes. Unfortunately there are exemptions. “Flavour, natural flavour, spice, seasoning, curry “are terms used on labels which may occasionally contain peanut but do not have to be declared. This is more likely to be found in imported foods especially from countries which use peanut as a flavouring agent. Peanut oil, however, must be declared without exemptions.
Can I react to the smell of peanut?
The smell of a food can cause allergic reactions but not usually severe reactions unless there is an extremely high concentration, or if the person is already having an asthma attack at the time, or has poorly controlled asthma. These lesser degrees of exposure by smell usually cause only minor allergic symptoms and discomfort e.g., itchy eyes or runny nose near an open jar of peanut butter, or people eating peanuts on an airplane.
What about hydrolysed vegetable protein?
Hydrolysed vegetable protein or hydrolyzed plant protein is usually made from Soya, wheat or corn, and are added to foods to improve flavour and texture. It is rare to have hydrolysed vegetable protein made from peanut. However if it is made from peanut, it does not have to be labelled as peanut but may merely say “hydrolysed vegetable or plant protein.” Therefore while quite unlikely, the possibility of peanut being present is there. Hydrolysed peanut protein is cheaper in other parts of the world and therefore imported foods containing hydrolysed vegetable protein has a higher chance of having peanut protein. If in doubt, check with the manufacturers.
Three quarters of children with food allergies and eczema develop asthma and environmental allergies. This is called the ‘allergic march’. First eczema beginning at age 6 weeks – 3 months, then food allergies, then asthma usually before age 5 years, then environmental allergies. The most common food allergies in young children are milk, eggs and peanut.
WHAT CONTAINS PEANUT
(those marked with * have caused deaths)
|peanut* / peanut butter* / peanut meal||Arachide / cacahuete/ cacahuate|
|peanut soup/ peanut punch/ peanut drink||ground nuts / beer nuts|
|peanut popcorn / peanut shells/ peanut flour||goober nuts / goober peas|
|peanut sauce / satay sauce*||Mandelona nuts / Nu-Nuts|
|peanut scented fishing lure (Mann’s Vworm)||peanut butter flavour lip gloss
( Bonne Bell)
|Roy Rodgers Butterfinger milkshake||Rocky Road ice cream|
WHAT MAY CONTAIN PEANUT
(those marked with an asterisk (*) have caused deaths)
|chocolate / candies / cookies||European chocolates *|
|Desserts * / sweets * / Almond paste *||Chili * / egg rolls* / salsa / barbecue sauce|
|Designer jelly beans / donuts / muesli||pesto sauce / curry sauce / marinade|
|Ice cream / sundaes / cereal / milkshakes||plum sauce / mooshu sauce|
|Granola bars / rice squares||Vegetable burgers / dried salad dressing|
|Pet food e.g., gerbil, birdseed||some European cow’s milk formula|
|Animal food, pellets at petting farms||some “Lean Cuisine” meals / Arachis oil|
|homemade play dough||Bean bags with peanut shells|
|Peanut butter suet cakes||Milk in the US may sometimes have peanut oil or fish oil (to carry added vitamins). Risk is probably low.|
European chocolate often has nut pieces which are not declared on the label. Some zinc and Castol oil creams, vitamin syrups and Nutella, Pears soap may have peanut oil. Peanut allergic people are not allergic to the peanut plant.
Features of anaphylaxis are:
- Swelling of the upper airway causing trouble breathing, croup like symptoms and suffocation
- Swelling of the lips and tongue with trouble swallowing and breathing
- Runny nose, nasal congestion, sneezing, itchy watery eyes
- Skin eruptions such as hives or redness. Itching anywhere
- Constriction of the lower airways with wheezing, asthma and cough
- Dizziness, and feeling like dying. Low blood pressure, shock
- Nausea, cramps, diarrhea and vomiting
Examples of how accidents with foods can happen (* have resulted in deaths)
- Eating unlabelled foods *. If in doubt, don’t.
- Accidental contamination of other foods (e.g., jam, butter or of eating utensils, food trays, table and toys). A common problem is jam contaminated with peanut butter by using the same knife*. Remember that even if a peanut allergic child is not offered peanut butter, eating jam at home where there is peanut butter may not be safe. Packing peanut butter sandwiches with other food*.
- Unpackaged foods (e.g., cookie jar) may contain traces of nuts from previous nut containing cookies. Another cookie taken from that jar may contain traces of nuts on it. Bulk foods, and buffet meals may also be dangerous because of cross contamination. Free cookies at stores.
- Contamination during preparation (e.g., a cutting board used to cut 2 foods such as chicken and fish, the chicken served to a fish allergic person or the same board or knife to slice or grind nuts). Using the same oil to fry different foods, or the same batter for different foods, or the same frying utensils for different foods without washing in between can all cause cross contamination. Grinding specialty nut flavoured coffees in a coffee grinder. Baking muffins with and without nuts if leftover batter is used for other muffins or if baking pans are not properly cleaned.
- Contamination during serving (e.g., sauces mixed by spillage, the same scoop used to take scoops of different ice creams, some of which contain nuts; a knife used to cut a nut containing dessert and used to cut another dessert).
- Relying on someone who does not know but who tells you the food is safe (e.g., another child, or someone who did not prepare the food such as a waiter, salesclerk or flight attendant).
- Trying a food to see if you are “still allergic” especially with an anaphylactic allergy.
- Tasting a food carefully to see if it is safe or not is dangerous. *
- A change in the way a usual food is made (e.g., a change in the ingredient list without any obvious change on looking at the container. A new chef at a restaurant may change the recipe and add a “secret ingredient”).*
- Candy machines may have different foods at different times and candies may be contaminated with traces of nuts if there were nuts in the dispensing machine before.
- Be aware of unusual sources of allergenic foods. See list “What may contain peanut”.
- Non-food sources of peanut (e.g., homemade playdough, homemade scented crayons, cosmetics or fishing lures with peanut, peanut shell stuffing in bean bags, draft stoppers, stuffed toys, peanut in animal food (e.g., hamster, gerbil and bird food granules such as lovebirds)).
For further reading and resources:
Allergy/Asthma Information Association, 1-800-611-7011
The Food Allergy Network
Anaphylaxis: A Handbook for School Boards, published by the Canadian School Boards Association and Health Canada. Canadian School Boards Association, 130 Slater Street, Suite 350, Ottawa, ON K1P 6E2.
Anaphylaxis in Schools and Other Childcare Settings. Canadian Society of Allergy and Clinical Immunology and Allergy Asthma Information Association.
B. Avoidance of peanut
C. Emergency response procedures in case of accidental exposure.
A. Information and Awareness
The peanut allergic child must be identified to all adults dealing with the child. There should be school wide understanding of the severity of peanut allergy, and of procedures to prevent exposure, and to treat an emergency should an allergic reaction occur. Use of the EpiPen® should be taught to all staff, including part-timers, substitute teachers, and a written emergency protocol should be developed. The anaphylactic child should be identified by a poster with the child’s name, followed by a description of emergency procedures. Sharing information with other children and other parents is also useful to obtain their cooperation. However, for secondary school children, the anaphylactic children should not be identified without permission from the student.
Other important information to be aware of include:
- Trace amounts of peanut not visible to the naked eye can cause severe allergic reactions even on table tops or toys.
- The potential for cross-contamination of foods or articles with peanut is high because it is in many foods, and is difficult to remove thoroughly by wiping.
- Many foods which children like, e.g., sweets, candies, chocolates, cookies, cakes and granola bars have a higher risk of containing peanuts. Even if peanut products are not sent to school, to be aware of the possibility for cross-contamination with foods such as jam (contaminated by using the same knife used for peanut butter), cookies (bulk cookies or cookies from a cookie jar which also contained peanut butter cookies), donuts (which may have touched peanut butter coated donuts).
B. Avoidance of peanut
Provide a safe environment for the child. It is not possible to reduce the risk to zero. Therefore, the approach should be “allergy safe” rather than “allergy free”. Procedures should be flexible enough to adapt to the needs of different children. The following guidelines should be considered:
- Providing allergen free areas.
Up to early public school grades, if there are peanut allergic children in the class, no peanut products should be allowed since it is very difficult to avoid accidental contact and possible ingestion. If possible, avoid using the classroom of a peanut allergic child as a lunchroom. If there are common eating areas, consider not allowing peanut products in that area or establishing a “peanut-free” area within the eating room. Alternatively, establish a room where children who bring peanut products can eat them, but only in that room. Those peanut eating children must thoroughly wash hands and face after eating.
- Establish safe lunchroom and eating area procedures.
Require anaphylactic children to eat only foods prepared at home. Discourage sharing of foods, utensils and containers. Hand washing is encouraged before and after eating. Surfaces such as tables, toys, should be washed clean of contaminating foods. Consider placing food on wax paper or paper napkins rather than directly on desks or tables.
- Allergens hidden in school activity.
Use of foods in crafts and cooking classes may need to be restricted, e.g., peanut butter used to make playdough or bird seed balls, stuffed toys and bean bag made with peanut shells, etc.
- Holidays, special occasions and field trips.
On occasions like these, normal routine may be forgotten in the excitement, the EpiPen® may be mislaid and the number of different foods from different people may make it difficult to determine whether there are peanuts in the foods. Some suggestions include having the parents send special treats for the peanut allergic child and eat only those foods, and to have a stockpile of those foods in school in the event that a special occasion arrives unexpectedly. If foods come into the classroom from home, remind parents of the child’s peanut allergy, and insist on ingredient lists. For field trips, ensure that the adults accompanying the child are trained in the use of the EpiPen® and emergency procedures. Take several EpiPen®s® if the trip is going to be more than 1/2 hour away from the nearest hospital. Consider carrying a cellular phone in that case.
C. Emergency Response Protocol
Ask the teacher to send non-threatening letters to parents of other children informing them of the child’s peanut allergy, the dangers of life-threatening reaction with trace amounts of peanut, and the potential for cross-contamination and request their cooperation in not sending peanut products to school.
School and childcare settings can be dangerous places for children with peanut allergy because peanut products are common, and they are present in many foods that children like. Peanut butter is also very viscous (thick) and is difficult to clean properly from tabletops and toys. Young children eating peanut butter can cause peanut allergic children to accidentally ingest small quantities of it, e.g., by getting peanut butter on toys, tabletops, eating utensils and containers. These children may have peanut butter on their hands and mouths and when playing with peanut allergic children may transfer some to those children.
Accidental allergic reaction to peanut can occur despite avoidance measures. Treatment must immediately be available for these emergencies. The school must have a written response protocol, and all staff must know the protocol. A separate emergency plan should be developed for each child in conjunction with the child’s parents, with the child’s photograph on it, and kept in a readily accessible place. Anaphylactic children usually know when an allergic reaction is happening. School personnel should be encouraged to listen to the child. The EpiPen® should be used immediately when an allergic reaction begins to accidental ingestion of peanut to prevent anaphylaxis. There is no danger in reacting too quickly. There are no contraindications to the use of epinephrine for a life-threatening reaction. Waiting for more severe reactions to occur before treatment is dangerous. Transport the child to hospital at once, preferably by ambulance. The EpiPen® may be repeated every 10-20 minutes during transport but only if the allergic reaction is not being controlled or worsens, especially if there are persistent breathing difficulties or there is decreasing level of consciousness. Assign a staff person to accompany or follow the child to the hospital to administer an additional Epipen® if necessary, as the issue of whether ambulance attendants will give the EpiPen® has not satisfactorily been resolved.
(A poster is available under Calgary Board of Education policy – “Student Poster”).
What contains soy:
Soy meal, soy flour, soy sauce, soybean sprouts, soy margarine, miso, tofu, tofutti, soy yogurt, black bean sauce, brown bean sauce, hoisin sauce, hydrolyzed soy protein, soy protein isolate.
What may contain soy:
Soups, vegetarian meals, vegetarian burgers, light peanut butter, batter, hot dogs, processed meats, canned fish, sweet and sour sauce, hydrolyzed plan proteins, hydrolyzed vegetable protein, natural flavour, baked bread (most UK bread have unlabelled soy), flour, sauces, soy lecithin, fish food, animal feeds, pet foods, hair and skin care products, coloured printing (e.g., newspaper flyers).
Soy is often added to the above foods to increase protein, and may be used in baked bread to replace milk. Any food labelled as containing “flour” may actually contain pea and soy flour in small quantities without having to be labelled as such. Soy may also be used as a filler or binder in breads, meat, fish, poultry and batter and must be labelled as such. However, if these foods are then added to another food in a small amount (e.g., bread or meat containing Soya is added to another dish to make a new food), then the label of the new food will only say “bread” or that particular meat but will not indicate the presence of Soya or other binders such as milk or egg. Soy protein sprays are being developed in Europe for vegetables, fruits and meat to prevent drying. Refined soy oil and vegetable oils should be safe for Soya allergic people except perhaps for those with anaphylactic soy allergy (see discussion on “peanut oil”). Soya lecithin has minimal amounts of soy protein if any, and does not have to be avoided except if you have anaphylactic soy allergy. Soy sauce can often be taken by most Soya allergic people and does not need to be avoided unless you have an anaphylactic Soya allergy or it does cause an allergic reaction.