Food allergy in schools and camps

INTRODUCTION — Food allergy is estimated to affect up to 8 percent of children in the United States and is an emerging public health issue globally [1-4]. The impact of this disorder is felt in daycare, preschool, school, and camp settings, environments that are integral to a child's life [5,6].

The most common food allergies in childhood are cow's milk, hen's eggs, peanuts, tree nuts, wheat, and soy [1,7]. Peanut allergy is of particular concern in the United States because it is implicated in fatal reactions more than any other food [8-10]. However, many foods can cause life-threatening allergic reactions [9,10]. It is crucial for medical professionals to understand the challenge that this disorder presents [11]. The avoidance strategies in place to keep a food-allergic child safe will often impact the entire classroom of children, particularly in younger age groups.

This topic presents an overview of the prevalence of food allergy in school-aged children; provides data about food-allergic reactions in schools, camps, and similar environments; and discusses strategies for managing food allergy in these settings. A similar discussion of food allergy in college or university students is presented separately. (See "Food allergy in college and university students: Overview and management".)

The information in this topic provides an overview of the components of effective management of food allergy in schools and camps. Various detailed publications and educational programs are available that provide further resources, such as additional forms, letters, training instructions, and examples of policies enacted by schools and daycare centers. (See 'Resources' below.)

Other aspects of food allergy are presented separately. (See "Management of food allergy: Avoidance" and "Clinical manifestations of food allergy: An overview" and "Food allergy in children: Prevalence, natural history, and monitoring for resolution".)

OVERVIEW — The safe management of food allergies in school and camp settings has become a prominent issue for many children and their caregivers and communities. The following observations about food allergy are especially relevant:

●In a survey of 400 elementary school nurses, 44 percent reported an increase in children with food allergies in their schools over a five-year period; only 2 percent reported a decrease [12]. More than one-third of the nurses reported having 10 or more students with food allergies. The school nurses ranked the challenge of managing food allergies on par with other serious health concerns, such as diabetes. In a study of 170 camps representing 122,424 campers in the US and Canada, 2.5 percent of campers had documented food allergies, although only 39.7 percent brought an epinephrine autoinjector to camp [13]. In another survey of leaders from 258 camps, 24 percent reported having anaphylaxis treated with epinephrine at their camp over the prior two years [14].

●Sending a child with food allergy to daycare or school can be terrifying to parents/caregivers. They must trust that others will be vigilant in helping their child avoid ingestion of the allergen and respond to symptoms of an allergic reaction or anaphylaxis. In addition, the widespread misunderstanding of food allergy among the general population [15] may result in both resentment from other parents/caregivers and fear and confusion on the part of staff members. Additionally, school personnel may lack sufficient knowledge about food allergy and anaphylaxis management, although educational programs may help close the gap [16-23].

●Avoidance of a food allergen is challenging. In addition to the food served in the cafeteria, there are snacks in classrooms and on the playground. Food items are used for classroom activities, such as art projects, cooking lessons, and math instruction. Examples include craft projects, such as rolling pine cones in peanut butter to make bird feeders, using empty milk containers to create cities, using candy as counting items in math class, or using peanuts in science class. In addition, school supplies may contain hidden allergens: Modeling clay can contain wheat, and egg white may be used to smooth finger paints. Holiday celebrations, birthday parties, and other special events traditionally involve food items prepared at home by the caregivers of non-food-allergic children. (See "Management of food allergy: Avoidance".)

Characteristics of reactions in schools — Insight into the nature of food-allergic reactions in schools has been provided by the following studies [1,2,24]:

●Although allergic reactions induced by food in schools are not rare, preparation for managing them is often inadequate [1,25,26]. In a telephone survey of 80 schools and the parents of 132 food-allergic children, 39 percent of schools reported at least one food-allergic reaction during the prior two years [1]. In the same period, 58 percent of food-allergic students experienced a reaction at school, and, of those, 30 percent did not have clinician's instructions or medication available at school at the time of their reaction. Preparation for management of food-allergic reactions in schools may differ by socioeconomic status [27,28].

●Cow's milk and peanut are leading causes of school reactions in the United States. In one study, milk was reported to be the most common cause of allergic reactions in the preschool setting and peanut the leading cause in children in the kindergarten through high-school years [1].

●In two surveys, 16 to 18 percent of children with food allergy were reported to have had at least one allergic reaction while in school, and epinephrine was used in 15 to 28 percent of these reactions [1,2].

●Food-allergic reactions may take place anywhere there are students. A review of epinephrine use in Massachusetts schools over a two-year period (2001 to 2003) reported 115 administrations of epinephrine [24]. In 20 percent of these cases, the allergic reaction occurred outside the school building: on the playground, traveling to and from school, and on field trips.

●A significant percentage of children were not known to have food allergy upon entering school and had their initial food-allergic reaction at school. Two studies found that 25 percent of the food allergy reactions in the schools were initial reactions [2,24].

●Special-event and craft foods are particularly problematic. A study of peanut and tree nut reactions in the school setting showed that the majority of the reactions occurred in the classroom (79 percent), principally from food brought in for class projects or celebrations [2].

Fatal food reactions — Peanut is the food most often implicated in fatal reactions, although any immunoglobulin E (IgE) mediated food allergy has the potential to cause severe or fatal reactions [9,10]. The percent of fatal reactions reported to occur in a school or child care setting in studies of fatal food allergy-induced reactions ranges from 10 to 67 percent. (See "Food-induced anaphylaxis", section on 'Fatal reactions' and "Fatal anaphylaxis".)

Epinephrine should be administered by intramuscular injection as soon as possible in the setting of anaphylaxis [6,29]. Delayed administration of epinephrine is believed to be a contributing factor in some fatal reactions [9,10]. (See "Anaphylaxis: Emergency treatment", section on 'Epinephrine' and "Long-term management of patients with anaphylaxis", section on 'Self-injectable epinephrine' and "Food-induced anaphylaxis", section on 'Epinephrine'.)

Fatal food-allergic reactions are most common in adolescents and young adults [9,10]. Possible contributing factors that are also risk-taking behaviors associated with adolescence include reduced diligence in avoidance of allergens and delay in using or not carrying self-injectable epinephrine [30]. In an internet-based anonymous survey of 176 adolescents and young adults with food allergy, more than one-half reported purposefully ingesting a potentially unsafe food [30]. As a group, the respondents felt that education of their peers about food allergy would help them cope better with having food allergy. Thus, one strategy to reduce morbidity and mortality in this age group might be increased education on a school-wide basis.

Efficacy of avoidance — Strict avoidance of the causative food is critical for avoiding an allergic reaction. However, absolute avoidance is extremely difficult, making accidental exposures almost inevitable [1,31].

Because avoidance is so difficult, schools and similar settings must have plans in place for both effective allergen avoidance and emergency management. (See "Management of food allergy: Avoidance".)

MANAGING FOOD ALLERGY IN SCHOOLS AND CAMPS — Schools and camps should be proactive in planning how to manage food-allergic reactions [5,32-34]. Planning ahead can save valuable minutes when a reaction occurs and may be the difference between life and death for a child.

Institutional food allergy management plan — The food allergy management plan of a school or camp should include policies regarding the use of food throughout the day and in various activities, where medications will be kept, and protocols for contacting emergency services and parents/caregivers during a reaction. Guidelines for managing students with food allergies, developed in consultation with a number of professional societies, have been published (table 1) [34-36]. Preliminary evidence supports the usefulness of such policies [37]. (See 'Resources' below.)

Education about food allergy and its treatment should be provided to all staff who supervise children [34,35,38]. Staff to receive training should include teachers, coaches, administrators, transportation drivers, dining hall/cafeteria workers, camp nurses, counselors, specialty area workers, volunteers, chaperones, and anyone else who may offer food or be involved with parties, events, or activities. School nurses may not be available for children at risk, so training of non-nursing staff is key [23,34,39].

It is essential that the staff responsible for the safety of a food-allergic child is able to do the following:

●Recognize a food-allergic reaction

●Obtain access to epinephrine rapidly and reliably

●Know when and how to use epinephrine

●Administer epinephrine without first having to contact the child's parent/caregiver or retrieve the school nurse

Training and allowing a variety of staff members to administer epinephrine is recommended because most schools and camps do not employ full-time nurses. In addition, nurses are often in charge of hundreds or thousands of children in a large physical area.

Many schools and camps are including epinephrine autoinjectors as part of the school's general first aid supplies, in the event of a first-time reaction, or if an additional dose of epinephrine is needed. This is now legally mandated in many states and encouraged in others through federal legislation [6,40].

Food allergy management requires a school-wide approach that may have many facets to ensure allergen avoidance and prompt recognition and treatment of reactions [6,34]. In addition, individual students may be provided with an Individualized Health Plan (IHP) addressing daily management. Food allergy may also qualify as a disability under the US federal disability law, and a Section 504 plan or Individualized Education Plan (IEP) can be written to provide accommodations, if needed. The nature of the care to be provided may vary among individual children depending upon their allergies, age, and developmental abilities. As an example, a six-year-old child with severe peanut allergy who may take another child’s food may need more supervision than a 12-year-old child with the same allergy.

Personalized food allergy action plan — Each child who has a food allergy requires a personalized management plan. Most schools and camps will have standardized health forms for documenting food allergies. Action plan forms are available from Food Allergy Research and Education (Food Allergy and Anaphylaxis Emergency Care Plan), the American Academy of Allergy, Asthma & Immunology (Anaphylaxis Emergency Action Plan - English) (Anaphylaxis Emergency Action Plan - Spanish), and the American Academy of Pediatrics [41]. A personalized action plan should include:

●List of foods to which the child is allergic

●Signs and symptoms the child might experience during an allergic reaction

●Appropriate treatment instructions from the child's clinician

●Emergency contact information for the child's parents/caregivers and clinician (including cell phone numbers or pagers)

This document helps assure that the critical information has been reviewed and management individualized for the child in question. This document can also form the basis of a detailed discussion between parent/caregiver and clinician and, subsequently, between parent/caregiver and staff member about the child's condition and past reactions.

Finally, the plan should be reviewed and updated regularly to reflect changes in the child's allergies as well as the age appropriateness of medication doses.

Clinician's responsibility — Clinicians should educate patients about the importance of avoidance of the allergens. Parents/caregivers should be given written instructions, reviewed and signed by the clinician, for how to handle an allergic reaction. These should include what medications and doses to use and timing instructions.

In some cases, the clinician may be involved in educating school and camp staff and others who may be providing care for the allergic child.

Staff's responsibility — All individuals on the school or camp staff should understand food allergy, should be able to recognize symptoms and respond to a reaction, and should be vigilant and proactive in eliminating food allergens from the allergic student's meals, educational tools, arts and crafts projects, or incentives. In particular, food service staff must understand how to provide safe, allergen-free meals, including appropriate substitutions, when children with food allergies are obtaining meals from the cafeteria.

Generally, school or camp nurses conduct training sessions prior to the start of the school year or camp term. During these sessions, relevant staff members can review information about the food-allergic child, treatment protocols, reading food labels, and other risk-reduction strategies designed to keep the child safe.

Nurses and other staff members should be trained in the proper use of epinephrine injectors. They should have access to training devices and should practice using them so that they are confident and capable of administering epinephrine quickly and properly. All staff members should know where epinephrine autoinjectors are stored and should either be trained or be aware of another staff member who has been trained and will be reliably available. (See 'Epinephrine location' below.)

Staff should contact the local municipal emergency response team and find out if ambulances in the area are equipped with epinephrine and if the attendants are allowed to administer it. Emergency teams differ in this respect, and schools should summon a team that is able to provide this treatment when possible. They should also notify the response team periodically that there are students at the school with life-threatening food allergies. If none of the local emergency teams are able to administer epinephrine, we suggest informing the child's parent/caregiver of this in writing so that the situation is properly addressed.

Bus safety — Bus drivers are often not employed by the school or camp, but rather are employees working for privately run transportation companies. In many cases, bus drivers are not trained to recognize and respond to allergic reactions. If bus drivers are not trained, staff and parents/caregivers have been able to help ensure the safe transport of food-allergic children using any or all of the following strategies [34]:

●Equipping the driver with communication devices (cell phone, walkie-talkie) in case of an emergency

●Enforcing a "no eating" policy on the bus

●Assigning the food-allergic child to the front seat

●Having a nurse's aide, teacher, or other sort of adult chaperone ride the bus with the food-allergic child

●Self-carrying of epinephrine once the child is old enough to self-administer his/her auto-injector

Parent's/caregiver's responsibilities — Parents/caregivers should regularly provide the staff with updated information concerning their child's food allergy. Ideally, this should include:

●A current and detailed food allergy action plan for their child

●Suggested alternatives (ie, soy nut butter instead of peanut butter) or a box of "safe" foods

●Medication to be left at the school or camp (ie, autoinjectable epinephrine, diphenhydramine, etc)

Parents/caregivers should also inform the responsible clinician about any reactions so that the child's food allergy action plan can be modified, if necessary.

Parents/caregivers can be strong advocates of change. A motivated parent/caregivers can help to convince a school to be more proactive about food allergy policies and can help to evaluate and modify classroom activities. Parents/caregivers should approach school and camp staff with a positive and informed outlook about food allergy and offer their time and knowledge on an ongoing basis.

Child's responsibilities — Depending upon age and maturity level, food-allergic children should be taught to do the following:

●Not to trade food with other children

●Avoid eating anything likely to contain the allergen or any food with unknown ingredients

●Wash hands thoroughly before and after eating

●Be involved in the care and management of their food allergies

●Notify an adult immediately if they suspect they may be having a reaction

●Know how to use autoinjectable epinephrine

●Notify an adult if they are being bullied or harassed because of their food allergy

Bullying — Bullying, particularly at school, is a common problem faced by children with food allergies that can have a negative impact on quality of life. School staff should adopt a zero-tolerance policy for bullying, have a plan for quickly handling any reports of this behavior, and institute programs to combat bullying [42]. Clinicians may be reluctant to inquire about food allergy-related bullying or not know the best advice to provide (for example, having parents/caregivers inform the school is advised, but having the victim confront the bully is not advised) [43,44]. Resources about combatting bullying are available at StopBullying.gov. (See "Food allergy: Impact on health-related quality of life", section on 'Children' and "Food allergy: Impact on health-related quality of life", section on 'Adolescents'.)

A survey of parents of children with food allergy and of teens and young adults with food allergy (n = 353) showed that 24 percent (or 35 percent of participants over age five years) had been victims of bullying, teasing, or harassment [45]. The majority of victims were male (61 percent). The most common trigger for this behavior was simply the individual having a food allergy (79 percent). Other cited causes included their carrying medications, sitting at separate tables, or having other forms of special treatment. The teasing, harassment, and bullying occurred multiple times for most of these individuals (86 percent), primarily in the school settings (82 percent) by classmates (80 percent). Unfortunately, one-fifth of those bullied, teased, or harassed were subjected to this behavior by school staff members. The children and young adults were verbally teased and physically threatened with the food to which they are allergic. Two-thirds of respondents reporting consequences indicated that they or their child felt sad, depressed, and embarrassed or humiliated because of the teasing, bullying, and harassment.

Similar results were found in another survey of parents and children aged 8 to 17 years with food allergy, with 25 percent of parents and 32 percent of children reporting bullying due to food allergy [46]. Quality-of-life and distress levels were negatively impacted by bullying in both children and parents, although the effect was lessened in children whose parents were aware of the bullying. Food allergy-related bullying often persists but is less likely to if action is taken, primarily by informing school personnel [47]. However, in one study, 33 percent of parents who were aware of bullying did not inform the school [48]. Thus, schools may wish to solicit this information, and health care providers aware of bullying should advise parents/caregivers to inform the school.

Strategies for minimizing risks at school — A number of strategies for managing food allergies in schools have been devised, although none have been validated. Approaches vary depending on the size of the school, whether or not there is a full-time nurse, the proximity to emergency rescue services (rural versus urban), and the number and age of the students with food allergies. Below are some of the policies that are commonly adopted:

●No food trading.

●No food in the classrooms.

●No homemade food allowed for class celebrations or parties (commercially prepared foods with preprinted ingredients lists intact are allowed).

●Designating the parent/caregiver of the allergic student to be responsible for selecting food for class celebrations (difficult if there are multiple food-allergic children).

●Celebration of birthdays or other special events with books or music instead of food.

●Designated allergen-safe tables in the cafeteria.

●School-wide food allergy education and management plans.

●Education of all students and implementation of student-focused allergy awareness programs. Children should be taught from a young age that teasing other children because of any medical condition is not acceptable. (See 'Resources' below.)

Camp-specific policies — In several respects, the management of food allergy in the camp setting is similar to that in school. Camp staff must be educated in the recognition and treatment of food allergies and anaphylaxis [20]. A personalized food allergy action plan should be provided for each child.

Selecting a camp that can monitor food and work with the parents/caregivers to identify risks to the child is critical for success. Parents/caregivers should discuss their child's food allergies with camp staff as they are choosing a camp. Ideally, the camp should have a full-time nurse and easy access to a medical facility. The parents/caregivers of the allergic camper are an excellent source of information and guidance for developing a plan for a safe camp experience. Other issues are specific for the camp setting and may vary according to the type and size of the camp and the severity of the camper's allergies. Guidelines for managing food allergies at camp have been published (table 2).

Camp-specific issues include the following:

●Ensure that there is phone access in case of a reaction requiring a call to 911.

●Keep medications within easy access and stored in appropriate temperature.

●Label each camper's medication and put it in an individual bag that can easily be carried from place to place or allow each camper to carry their own medications.

●Review foods to be used in craft projects to ensure that they do not contain an allergen that may cause a reaction.

Special considerations are needed for overnight trips and travel to remote areas, such as bringing extra supplies of safe food for the allergic camper and ample supplies of medications needed to treat a reaction. The supervising staff member should carry a well-charged cell phone and assure that the group will remain in cell phone-accessible territory.

Eating safely at camp — Some parents/caregivers provide food for their child to minimize the chances of a reaction. For campers staying overnight, parents/caregivers can ship or personally deliver food at the beginning of each week. The food should be clearly labeled with the child's name and cabin information.

For children eating camp-provided food, strategies for minimizing risks include separating and labeling "safe" products in the kitchen with stickers so that food can be prepared and served without cross-contamination. Alternatively, if the allergic camper must avoid certain dishes, then allowing that child to be the first in the buffet line and discouraging return trips through the food line for "seconds" should help reduce the risk of a reaction from cross-contact through serving utensils.

The sharing of care packages of homemade foods should be avoided by those with food allergies, unless prepared by their own parents/caregivers. Children with food allergies should only consider eating food from care packages if it is commercially prepared and an ingredients list is provided on the packaging.

OTHER CONSIDERATIONS

Peanut bans — School staff and parents/caregivers may decide to institute peanut-free policies, excluding peanut from schools, specific classrooms, or tables. School-wide bans are particularly controversial because of issues such as a potential false sense of security, difficulty in enforcement, impact on unaffected children, and attention to some food allergens and not others [49]. Unfortunately, reactions have been reported in schools with active peanut (or tree nut) bans, indicating that bans are not sufficient to protect allergic children from exposure [2,50]. In a study of Massachusetts public schools, allergic reactions were still reported in all schools with "peanut-free" policies [51]. Although a number of peanut-free policies were used, schools with peanut-free tables compared with those without this restriction had lower rates of epinephrine administration (2 versus 6 per 100,000 students). Guidelines emphasize that additional safety measures must be in place, even if schools choose to ban specific foods from a classroom or school [34]. A 2021 practice guideline suggested as a conditional recommendation (level of evidence graded as very low certainty) that schools not prohibit specific foods site-wide and not establish allergen-restricted zones except in special circumstances, such as having students who by age or developmental capacity have limitations in self-management [6].

We favor an approach based upon education and cooperation from the entire school community, rather than blanket bans of certain foods. However, bans (in particular allergen-safe tables with increased supervision) are an option for younger children and in specific circumstances. The specific recommendations presented previously should be effective in preventing the majority of reactions and successfully managing the rest. We are not in favor of isolation of the child with food allergy from social settings. (See 'Managing food allergy in schools and camps' above.)

Epinephrine location — Children may be permitted to carry self-injectable epinephrine, depending upon local policies. We encourage school staff to recognize that permission to carry is not equivalent to delegation of responsibility solely to the child to self-treat. A survey of caregivers of children with food allergy indicated that they thought children can have responsibility to self-treat with epinephrine starting at approximately age 6 to 11 years [52], while a survey of allergists thought this transition should be at approximately ages 12 to 14 years [53]. A survey of 123 caregivers showed that 45 percent thought age 9 to 11 years was an appropriate age range for education about self-injection of epinephrine, but almost half of the caregivers lacked confidence in doing this training [54]. Ultimately, an adult should be assigned responsibility for ensuring prompt treatment with epinephrine when it is needed.

In the event that the food-allergic child is not mature/responsible enough to carry their own epinephrine, every effort should be made to ensure that epinephrine is kept in a secure but unlocked location known to all staff members and accessible within minutes. This sometimes involves epinephrine being "handed off" from teacher to teacher or between camp staff as the child changes locations throughout the day.

Providing a safe environment — A focus on avoidance of ingestion of the allergen is key because ingestion is more likely than skin or inhalation exposure to cause anaphylaxis [33,49]. There is one reported case of a fatality in a 13-year-old child with cow's milk and wheat allergy, poorly controlled asthma, and atopic dermatitis who had cheese with bits of wheat bread on it thrown at him during an episode of bullying [55]. The cheese fell down the back of his shirt, resulting in scratching at the skin and cheese and bleeding, which was presumed to have increased systemic exposure and resulted in anaphylaxis. Although most anaphylaxis is related to allergen ingestion, several factors played a role in this exceptional, tragic case including an unusual amount of skin exposure, delayed use of epinephrine, and having poorly controlled asthma. The lessons demonstrated include the need for attention to eliminate bullying and to respond rapidly and appropriately to allergic reactions and anaphylaxis [56].

A study looking at food allergens in table wipes and floor dust samples from schools and from student homes detected milk, hen's egg, peanut, and nuts, but the amounts in schools were generally lower than or not exceeding the levels detected from homes [57]. In addition, levels were deemed unlikely to result in severe reactions. However, special care is needed regarding use of foods in science, cooking, or craft projects or for younger children who may transfer allergens from hand to mouth

Parents/caregivers and school staff are often concerned about the best methods for removing food from desks, tables, hands, and other surfaces. In one study, investigators sampled the efficacy of a variety of cleaning methods in removing 5 mL of peanut butter from tabletops [8]. The following products effectively reduced peanut allergen to undetectable levels:

●Plain water

●Formula 409 cleaner

●Lysol sanitizing wipes

●Target brand cleaner with bleach

Various liquid dishwashing detergents were only partially effective. The investigators concluded that routine cleaning of tables and desks with common cleansers, with the exception of dishwashing liquids, was sufficient to minimize the risk to allergic individuals.

To remove peanut residue from adults' hands, the following were tested and found effective [8]:

●Tidy Tykes Wipes

●Wet Ones antibacterial wipes

●Liquid soap

●Bar soap

However, plain water and alcohol-based hand sanitizer did not remove peanut completely from adults' hands. Small children may need help cleaning their hands effectively.

Legal issues — Certain issues relevant to food allergy in schools and camps have been addressed with specific legislation. These include defining the rights of food-allergic children and protecting those who attempt to help an individual during a food-allergic reaction from subsequent legal action.

In 2013, the School Access to Emergency Epinephrine Act was signed into law in the United States. This act encourages states to adopt laws requiring schools to have "stock" epinephrine autoinjectors on hand. Several studies have underscored the benefit of having stock epinephrine autoinjectors available. In a Chicago survey of school district-issued epinephrine autoinjectors, 55 percent were administered for first-time anaphylaxis [58], and, in a survey of 12,275 US schools receiving stock epinephrine autoinjectors, 24.5 percent of administrations involved those with no known allergy [59]. The benefits of stock epinephrine also include expanding availability to those unable to afford the devices. A 2021 practice guideline noted that implementation of stock epinephrine could supplant the need for individually assigned epinephrine autoinjectors (which could then be optional) [6].

Legal rights of food-allergic children — Children with life-threatening food allergies are protected under federal civil rights laws, such as Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) [60,61]. This is because a severe food allergy meets the legal definition of a "disability" (ie, a physical impairment that substantially limits one or more major life activities [such as eating or breathing]).

The spirit of these two federal laws is essentially the same: to prevent discrimination on the basis of a disability. The major difference between the laws lies in their application: Section 504 applies to public schools and other institutions that receive federal funding. The ADA, however, typically applies to institutions that are privately run, such as private child care centers, preschools, private schools, and privately run recreational camps.

Under these laws, schools cannot turn away a child based on the child's food allergies or the school's perceived inability to manage the food allergies. According to the law, facilities must address the health and safety needs of the child with a disability and must provide accommodations to ensure that the child participates safely and equally in all normal facets of the program, including classroom activities, field trips, and eating in the cafeteria [62].

Similar legislation has been put into effect in other countries. In Ontario, Canada, an Act to Protect Anaphylactic Pupils (Sabrina's Law), which established minimum standards for managing anaphylaxis in schools, was enacted in 2006 [63].

Liability for harming a child as a result of improper treatment of allergic reactions is sometimes cited as a concern by schools or camps. However, there is no legal precedent involving a school or camp staff member being sued for administering epinephrine. In contrast, litigation has been brought against school staff for not responding quickly or appropriately during an anaphylactic reaction [64]. In addition, most states have "Good Samaritan" laws, which are designed to protect individuals from liability who render emergency assistance in good faith, with no expectation of payment, and who transfer care of the patient to appropriate medical personnel (eg, emergency medical technicians, the school nurse) as soon as possible. Furthermore, some states have enacted Good Samaritan laws that specifically cover epinephrine administration.

Resources — Various professional and governmental organizations have created guidance documents on food allergy management [6,32-34,36]. Some of these provide in-depth tools for establishing institutional plans for managing food allergy, as well as educational materials, forms, response protocols, and informational posters and signs.

Professional organizations — These include the following:

●The National Association of School Nurses

●The American Academy of Pediatrics

●The American Medical Association

●The American Academy of Allergy, Asthma & Immunology

●The American College of Allergy, Asthma, & Immunology

Governmental organizations — State Departments of Education may provide guidance on food allergy management.

The CDC developed the Voluntary Guidelines for Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs in conjunction with the US Department of Education and several other federal agencies [34]. The five areas that they recommend schools/programs address are:

●Ensure the daily management of food allergies in individual children. This includes identifying children with food allergies, developing a plan to manage and decrease the risk of a reaction in each child, and helping children manage their own food allergies.

●Prepare for food allergy emergencies. This includes setting up an easy-to-use communication system and ensuring that staff have quick and easy access to autoinjectable epinephrine, understand the protocol for its use, and know their role in an emergency. In addition, the response to a food allergy emergency should be documented, and plans should be in place to address reactions in children without a prior history of food allergies.

●Providing professional development on food allergies for staff members. This includes providing general training on food allergies for all staff and more in-depth training for staff who have frequent contact with children with food allergies. In addition, specialized training should be provided for clinicians and other health care workers who are responsible for managing the health of children with food allergies on a daily basis.

●Educate all children and their caregivers about food allergies.

●Create and maintain a healthy and safe educational environment by decreasing the risk of exposure to food allergens in all common areas and developing food-handling policies and procedures to prevent cross-contact, while creating and maintaining a positive psychosocial climate.

Other organizations — The organization Food Allergy Research and Education (FARE) is a national, nonprofit, member-supported organization dedicated to education, awareness, advocacy, and research in food allergy. FARE's materials are all reviewed by a panel of scientific advisors comprised of the world's leading experts in food allergy to ensure medical accuracy. FARE offers a range of instructional programs, including the following:

●Food Allergies: Keeping Students Safe and Included

●Online Food Allergy Toolkit for School Nurses

●Food Allergies in the Classroom

Additional programs are available from other sources [65-67].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Food allergy".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)" and "Patient education: Food allergen avoidance (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Overview – Food allergy affects up to 8 percent of school-age children and is increasing in prevalence. Policies to keep food-allergic children safe often affect all members of the student body and staff within a given setting. (See 'Introduction' above.)

●Reactions in schools – Food is ubiquitous in most schools, and reactions can occur in unexpected places. Allergic reactions to food are not rare, with approximately 40 percent of schools reporting at least one event in the previous two years. Approximately one-quarter of these reactions occur in children not previously recognized to have food allergy. Milk and peanut are leading causes of school reactions in the United States. (See 'Characteristics of reactions in schools' above.)

●Treatment of anaphylaxis – Severe reactions should be treated with injected epinephrine administered as rapidly as possible, ideally within a few minutes. Delayed administration of this medication is believed to be a contributing factor in many fatal reactions. Treatment of anaphylaxis and fatal anaphylaxis are reviewed in greater detail separately. (See 'Fatal food reactions' above and "Anaphylaxis: Emergency treatment", section on 'Epinephrine' and "Food-induced anaphylaxis", section on 'Epinephrine' and "Food-induced anaphylaxis", section on 'Fatal reactions' and "Fatal anaphylaxis".)

●Avoidance – Strict avoidance of the allergy-causing food is extremely difficult. Patients often develop reactions from foods they thought were safe. For these reasons, reactions are virtually inevitable, and schools and similar settings must have plans in place for effective emergency management. (See 'Efficacy of avoidance' above.)

●Institutional food allergy management plan – The food allergy management plan of a school or camp should include policies regarding where food is allowed, where medications are stored, and protocols for contacting emergency services and parents/caregivers during a reaction (table 1 and table 2). It is essential that the staff have access to autoinjectable epinephrine, understand when and how to use it, and have permission to administer it without first having to contact the child's parent/caregiver or retrieve the school nurse. (See 'Institutional food allergy management plan' above.)

●Individual food allergy and anaphylaxis emergency action plan – Each child who has a food allergy requires a personalized management plan that identifies his/her food allergies, outlines treatment for specific symptoms, and serves as a means of transmitting critical information among the clinician, parent/caregiver, and staff (Food Allergy and Anaphylaxis Emergency Care Plan) (Anaphylaxis Emergency Action Plan - English) (Anaphylaxis Emergency Action Plan - Spanish). (See 'Personalized food allergy action plan' above.)

●Roles of staff and clinicians and strategies to minimize risk – The roles of the clinician, staff, parent/caregiver, and child are distinct and must be integrated. Specific strategies for minimizing risks in school and camp settings are provided. (See 'Strategies for minimizing risks at school' above and 'Camp-specific policies' above.)

●Additional considerations – Common issues that arise in schools and camps include the implementation of bans on specific foods, the fear of liability, the legal rights of food-allergic children, where epinephrine should be stored, and how to effectively remove food from various surfaces. (See 'Other considerations' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Anne Munoz-Furlong, BA, who contributed to earlier versions of this topic review.