Managing Food Allergies in
School Nutrition Programs
Beth Foland, MS, RD
July 21, 2014
Topics for Today
 An Overview of Food Allergies,
 Reading and Managing Food Labels,
 Accommodating Students with Food Allergies,
 Avoiding Cross Contact, and
 Food Allergy Awareness/Resources.
Pre-assessment:
Test your food allergy
knowledge
All About Allergies
Objectives
 Describe a food allergy, and its symptoms and
treatments.
 Distinguish between food allergy and food
intolerance.
 Identify the “Big 8” food allergen
 Review reading food
allergens on a food label.
What is a Food Allergy?
Food Allergy
An immune-mediated adverse reaction to a food
protein
Body’s Immune System
Body identifies a food protein as dangerous
creates antibodies (Immunoglobulin E (IgE)) against
the protein
EVEN A BITE can result in an allergic reaction.
How a Child Might Describe Symptoms
This food is too spicy.
There’s something stuck in my throat.
My lips feel tight.
It feels like something is poking my tongue.
My throat feels thick. My tongue (or mouth) is tingling.
My mouth feels funny.
There is a frog in my throat.
My tongue (or mouth) itches.
My tongue is hot (or burning).
It feels like there is a bump on the back of my tongue.
Allergic Symptoms
Trouble
swallowing
Shortness of
breath
Repetitive
coughing
Voice change
Nausea &
vomiting
Diarrhea
Abdominal
cramping
One or more symptoms
can occur within minutes up
to 2 hours and can be MILD to
SEVERE
Swelling
Hives
Eczema
Itchy red rash
Drop in blood pressure
Loss of consciousness
Death may occur
Anaphylaxis-rapid onset; can cause
death
An epinephrine autoinjector is used to treat
anaphylaxis.
Most commonly heard trade
name is EpiPen (but there
are others, e.g. Auvi-Q,
Twinject..)
Team Discussion With
School Nurse Should
Include:
 Where are the devices kept in the school; are they
accessible?
 Do you need to be trained to administer an
autoinjector?
 What if it inject the person, and they are not really
having an allergic reaction?
 How do substitutes know how to respond?
 Do the phones near you get an outside line to call 911?
 Will local EMTs have epinephrine when they arrive?
What is a Food Intolerance?
Food Intolerance
An abnormal physiological response to eating
Involves the Gastrointestinal System
 Food intolerance presents with symptoms affecting the skin,
respiratory tract, and gastrointestinal tract; individually or in
combination. Detrimental reaction (nausea, diarrhea, vomiting).
 Come on gradually, not life threatening, affect the body’s
organs
 Symptoms are often confused with food allergies.
Medical name: Non-allergic Food Hypersensitivity
Causes of Food Intolerance
 Absence of an enzyme to digest food
 Irritable bowel syndrome
 Food poisoning
 Sensitivity to food additives
 Recurring Stress
 Celiac Disease
Treatment is determined between the Licensed
Physician and the patient.
Food Allergy Background
 More than 3 million children have some type of food allergy.
 Food allergies affect an estimated 4%–6% of children in the United
States.1 (1, 2)
 Children with food allergies are 2-4 times more likely to have other
related conditions such as asthma and other allergies, compared
with children who do not have food allergies.
 Reactions primarily caused by food used in class projects and
celebrations ; – 79% Classroom – 12% Lunchroom
25% of reactions in those with no known allergy!
The “Big 8” Food Allergens
Eggs
Milk
Peanuts
Tree Nuts
Fish
Shellfish
Soy
Wheat
Prevention:
Strict Avoidance
of Known Food Allergens
Food Allergen Labeling and
Consumer Protection Act (FALCPA)
Food labels must declare major food allergen in
plain language: Milk, eggs, fish, shellfish, peanuts,
tree nuts, soy, and wheat
Either in the ingredient list by either of these two
methods:
“Contains” followed by the name
Example: “Contains: milk and wheat”
Parenthetical statement in the list of ingredients
Example: “albumin (egg)”
Label Samples
Contains…..
Parenthesis…
Recall Notifications
Subscribe to food
allergy recall notices
and a have system to
take action if you
serve the product
being recalled
www.foodsafety.gov
Precautionary Labeling
Not regulated
Not safe for people
with known food
allergies
“May Contain”
statement
“..made on
equipment that also
makes….”
Take Caution When Making Statements!
 “Peanut-free” may create a false sense of security
 FOCUS: STRATEGIES TO REDUCE ACCIDENTAL
EXPOSURE
Allergen-safe tables/classrooms are options to schoolwide bans.
Banerjee, D. K., Kagan, R.S., Turnburr, E., et al. Peanut-free guidelines reduce
school lunch peanut contents. Arch Dis Child. 2007
Allergy ALERT
We appreciate your
cooperation
DO NOT
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Bring peanut/tree nut
products
Into this classroom
Barilla Whole Grain Spaghetti,
Thin
Made with 51%
whole wheat,
Ingredients Whole
Grain Durum Wheat
Flour, Semolina
(Wheat), Durum
Wheat Flour, Oat
Fiber.
Warnings Contains
wheat ingredients.
This product is
manufactured on
equipment that
processes products
containing eggs.
19
Hamburger Buns
Enriched wheat flour, B vitamins, water, yeast, high
fructose corn syrup or sugar, soybean oil contains 2% or
less of wheat gluten, salt,calcium sulfate, vinegar, vitamin
D, cornstarch,wheat starch, dough conditioners, soy flour,
calcium propionate, whey, soy lecithin.
What allergens are in the hamburger bun?
20
A very common ingredient used in making
salad dressing, coleslaw and potato salad.
Do I contain allergens?
My ingredients include: Water, soybean oil, vinegar, high
fructose corn syrup, modified food starch, sugar, salt,
enzyme modified egg yolks, mustard, flour, artificial
color, potassium sorbate, paprika, spice, natural flavor,
dried garlic, beta carotene.
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Strategies to Manage Labels and
Ingredient Lists
Communicating
Food Allergy
Label
Information
School Nutrition Staff
School Nurse
Students, Parents or
Guardian
Website , handouts,
other
Accommodating Students with
Food-Related Disabilities:
The Law
Respect and Protect
Children with Food Allergies
 Civil rights and privacy must
not be violated
 Prevent a child with food
allergies from being singled
out
 Be alert to prevent and
address bullying from other
children and/or adults
Federal Laws
Rehabilitation Act
of 1973
Prohibits discrimination against qualified persons
with disabilities in programs or activities of any
agency of the federal government’s executive branch
or any organization receiving federal financial
assistance.
Programs receiving federal assistance: National School Lunch
Program, School Breakfast Program, Fresh Fruit & Vegetable
Program, After School Snack Program
Federal Laws (continued)
Individuals with
Disabilities Education Act
(IDEA) 1975, Part B 2006
Requires a free and
appropriate public
education be provided
for children with
disabilities aged 3-21.
Americans with
Disabilities Act (ADA) 1990
and 2008 Amendments
Broadens and extends civil
rights protections for
approximately 50 million
Americans with
disabilities.
Respect Privacy Laws
HIPAA
The Health Insurance Portability & Accountability Act (1996)
- Requires all medical records disclosed be kept properly
confidential.
- Gives the patient rights control how health information is
used.
FERPA
Family Educational Rights and Privacy Act (1974)
- Protects the privacy of health information entered into a
student’s record
Accommodating
Children with Special
Dietary Needs in the
School Nutrition
Programs
Guidance from USDA
http://origin.www.fns.usda.gov/cnd/Guidance/special_dietary_needs.pdf
School Meal Requirements
 Schools must make substitutions in the
reimbursable meal for disabled students whose
disability prevents them from consuming the
school meal as prepared.
 No extra charge
 A disability determination can only be made by a
licensed physician.
Disability
VS
 Diet Order components
o
o
o
o
o
Specify disability
How restricts diet
Major life activity affected
Foods to omit
Foods to substitute
 Signed by licensed MD
 Menu substitutions
required
Non-Disability
 Diet Order components
o How restricts diet
o Foods to omit
o Foods to substitute
 Signed by recognized
medical authority
 Option to provide menu
substitutions
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Food Allergy Action Plan
1 (5)
Recommended for each child with a known food allergy
 Completed by student’s MD
or MD designee
 Use by nursing AND
school personnel
 Outlines care in emergency
situation
 For the student’s safety
 Do you have a formal
plan written for your school?
Team Approach
 Leaders
Administrators
School RN
Foodservice Director
Teachers
 Others need to be informed: Classroom Aides,
Janitors, Bus Drivers, Coaches, Foodservice
personnel, After-School Staff, Substitute
Teachers, anyone working in the building
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Strategies to Accommodate
Students with Food Allergies
STEP 1
 Menu planning, label reading, follow HACCP principles
STEP 2
 Know the requirements for serving food to
students with special dietary needs.
 USDA FNS Guidance for serving children
with disabilities and special dietary needs
in child nutrition programs
www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf
Step 3
Licensed
Healthcare
Professional
The Partnership
Communication / Education
Child’s
Safety
Family
Parents
Child
School
Administrator
Nurse
School Nutrition
Faculty
Others
Step 4: Accommodating Students
with Food-Related Disabilities
Step 4
 Implement the directives in the Special Dietary Form
signed by a licensed physician.
 If the form indicates the student has a DISABILITY,
School Nutrition Services is required to make the
accommodation.
 If there is no disability, the accommodation is
optional.
Licensed Physician Provides
 5 Key Elements
 What the disability is
 How it restricts the diet
 Major life activity affected
 Food(s) to be omitted
 Food(s) to be substituted
Accommodating Students with
Other Food-Related Disabilities
Food Related
Disabilities
 Diabetes
Other
Accommodations
 Texture
 Phenylketonuria (PKU)  IV
 Food Anaphylaxis
 Celiac Disease
 Tube Feeding
Communication with Key Partners
 Work with distributors, brokers, and
manufacturers to purchase foods to meet the
needs of students with allergies.
 Get specifications, ask for clarification, develop a
relationship with your key partners (includes
RN).
 TIP: When getting information for USDA Foods,
call the manufacturer, not USDA or the State
Agency.
Secure, Accessible Location
41
Cross Contact vs. Cross
Contamination
Cross Contact
 Allergen accidentally
transferred from a food
containing an allergen to
a food or surface that
does not contain the
allergen.
 Cooking does not reduce
or eliminate allergen.
Cross Contamination
 Microorganisms from
different sources
contaminate foods during
preparation and storage.
 Cooking does reduce or
eliminate
microorganisms.
Cross Contact Can Be Deadly
 Sabrina Shannon : teen had fatal anaphylactic
reaction during her first year of high school, 2003.
 Reaction triggered by dairy protein - likely due to
cross- contamination from tongs used for poutine
(potatoes topped with curd cheese and a tomatobased sauce) after ordering French fries from school
cafeteria
 "A Nutty Tale“ first-person radio documentary
http://www.anaphylaxis.ca/flash/
Avoid Cross Contact – Potential
Sources
 Food handling and preparation
 Insufficient handwashing
 Insufficient cleaning
 Shared equipment and utensils
 Cutting boards, counters
 Griddles
 Splatter or steam from cooking
 Salad bars, buffets, serving stations
Avoid Cross Contact – Prevention
Ideas
 Color Coding
 Isolate ingredients containing allergens
 Individual preparation of menu items with
allergens
 Sticker or color code wrapped food
 Standard Operating Procedures for handwashing
and cleaning
 Include allergen risk assessment in the Food
Safety Plan based on HACCP
Standard Operating Procedures
Clean and Sanitize
Clean with soap, hot/warm water, and friction;
WILL REMOVE ALLERGEN RESIDUE
Sanitize to reduce microorganisms that cause disease;
WILL NOT REMOVE ALLERGEN RESIDUE
Sanitation SOPs are important
for managing food allergens.
 Examples:
 NFSMI’s HACCP-based Cleaning and
Sanitizing Food Contact Surface SOPs
 NFSMI’s Serving Safe Food to Student
with Food Allergies SOP
 NOTE: remember food sources outside
café (BIC, FFVP, classroom projects/ASP)
General Tips – In the Cafe
 Offer designated allergen-friendly tables for
young students (? optional for students with
parental and physician authorization to sit at
“regular” table)
 Clean tables carefully
 Prevent food trading
 Encourage students to wash hands
 Provide supervision to ensure orderly
behavior
 Be prepared for an emergency (know role in
FAAP)
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RESOURCES
USDA
CDC
RESOURCES (continued)
National Education Association
(NEA) Health Information Network
National School Boards Association
Post-assessment-on your own
Questions???
Beth Foland
[email protected]