Peanut Allergy in the School Environment: Myths and Facts: Part 1 of a 2-Part Series
For generations peanuts have been a favorite, healthy, American snack food. In recent years, however, peanuts have become a life-threatening nuisance. The profitable, little protein-packed legume is responsible for about 160 deaths annually in the United States. This is equivalent to 80% of all food allergy fatalities. It is estimated that 1.5 million Americans have peanut allergies and that hospital emergency departments treat about 30,000 cases of food-related allergic anaphylaxis per year. The incidence of food allergies have been reported to be 1-2% in the general population and as high as 5% in children under 5 years, with 1.3% of all children exhibiting an allergic reaction to peanuts. The most common food trigger of anaphylaxis as well as the most common overall trigger is peanut allergy. There is evidence that the prevalence of peanut allergy increased from 0.4% in 1997 to 1.0% in 2002. Alarmingly, peanut sensitivity on a standard skin prick test has increased by 55%, while allergic reactions increased by 95% in the past ten years. This increase may not only be attributed to increasing sensitivity but also an increased awareness of allergies and improved reporting and management.
The increase in peanut allergy prevalence has lead to heightened public and health care professional awareness and demands from both for a rational plan for prevention. Initiation of “peanut-free” policies has become a common administrative solution to preventing full-blown anaphylactic reactions to peanut allergy, especially in schools and daycare settings. The interpretation and enforcement of “peanut-free” is not easy.
Exposure to peanut allergen is difficult to control. Peanut butter sandwiches have been a staple of the typical school lunchroom. And, the school environment has maintained, as a primary function, the encouragement of group and social eating habits. Children bring from home their brown bag lunches, often holding a “PB & J” sandwich, and often pool resources into a collective meal. It is obvious that eliminating the threat of the peanut for an allergic child is rational prevention for food-related anaphylaxis since without exposure to the peanut, the reaction cannot occur. But, what about the cupcake made with sesame oil or the potato chip fried in peanut oil? How much protein triggers a response, and can such a response be triggered from ingestion, a kiss, a handshake or an airborne inhalation? Elimination of peanut oils and food containing peanuts seems rational, yet with so many pre-packaged and processed foods being used for meal preparations, the likelihood of exposure is great.
Recently concern has been raised that peanut protein in the air will trigger a full-blown anaphylaxis since respiratory exposure can occur in the school setting as food proteins aerosolize into vapors during cooking at high temperatures, even in well-ventilated cafeterias. When airborne peanut protein exposure and reactions of children with known peanut allergies were explored, no allergic symptoms or anaphylaxis were observed when peanut allergic children were not aware of the airborne exposure. Interestingly, when aware of the exposure, symptoms of itchy eyes, sneezing, and runny nose resulted. In a research article by Perry, et al. (2004), no peanut allergen was detected in the air after subjects consumed peanut butter, shelled peanuts, and unshelled peanuts. As Dr. Michael Young notes in his 2006 book, The Peanut Allergy Answer Book, predicting who will have a life-threatening anaphylactic response to airborne allergy is very unpredictable and the likelihood of it is very, very small. Most exposures to airborne peanut protein result in itchy eyes, sneezing, and a runny nose. There remains no evidence that exposure to airborne peanut protein worsens allergy or results in anaphylaxis for the majority of peanut allergic individuals. There always remains the possibility that someone who is exceptionally sensitive will experience a severe reaction, however, protecting them from all possible exposures to peanut protein is extremely difficult.
Cutaneous reactions in the form of rash from exposure were consistent with the amount of skin exposure to the peanut protein. These exposures occurred from handshakes, kissing, and the wiping of eyes, nose or oral mucosa contaminated with peanut allergen. Perry’s (2004) study also showed that handwashing with soap and water effectively removed peanut protein from the hands. Common cleaning agents effectively removed peanut allergen from tabletops, although dishwashing liquid left some residue on 4 out of 12 tables. In conclusion, the chance of a life threatening anaphylactic reaction from airborne and/or touch exposure was small and insignificant. Life threatening exposures result most often through direct ingestion.
Parents want to protect their children and this desire extends into the school environment where they themselves are not present. Concerned parents communicate with the school frequently. They also educate their children about the importance of knowing what foods are near them. Children with peanut allergies have to be constantly aware of any potential hazards in their environment and should carry an Epi-pen injection to treat food-induced anaphylaxis.
School staff and administration must do their part as well. Carefully scrubbing down lunch tables, prohibiting the sharing of food and drinking straws, washing shared utensils, prohibiting home-made birthday snacks where ingredients are unknown, and regulating dietary practices in the school all decrease risk of allergen exposure. These are prudent strategies to minimize the school’s exposure to legal liability.
Perry, T., Conover-Walker, M., Pomes, A., Chapman, M., & Wood, R. (2004). Distribution of peanut allergen in the environment. Journal of Allergy and Clinical Immunology, 113, 973-976.
Jill F. Kilanowski, MSN, RN, CPNP, Doctoral Student: Health Disparities, College of Nursing, The Ohio State University
Ann Stalter, MS, RN, Doctoral Student: Community Health, College of Nursing, The Ohio State University
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