TORONTO -- Rules banning certain nuts and other foods are common in Canadian schools as a way to protect students with allergies, but a new set of proposed guidelines recommends relaxing food bans and instead training staff and making sure to have epinephrine available to treat anaphylaxis.
The advice is part of a set of recommendations from an international panel led by McMaster University and published on Wednesday in the Journal of Allergy and Clinical Immunology.
Food allergies can be a frightening subject for parents whose children are prone to anaphylactic reactions, which in some cases can be life threatening, but an epinephrine shot can help reverse the symptoms ahead of visiting a hospital.
"The management of food allergy is a sensitive topic," Susan Waserman, chair of the guidelines panel and professor of medicine at McMaster University, said in a news release. "Our goal is to help the school community understand the risk of allergic reactions — and offer evidence-informed guidance for managing it."
The study looked at existing literature and data on food allergy approaches in child care and schools, as well as the cost, feasibility, acceptability and health effects of various interventions. However, the panel said its recommendations were "conditional" given a "lack of high-quality evidence" concerning possible interventions, and that decision makers should not treat the recommendations as binding mandates.
Canadian provinces have various approaches to food allergies, but bans on certain foods are common in many schools and daycares, and some schools have allergen-restricted areas, such as ‘milk-free’ tables. Ontario operates under "Sabrina’s Law," named for a teen who suffered a fatal anaphylactic reaction in her first year of high school in 2003. The law requires school boards in the province to establish and maintain an anaphylaxis policy.
However, panel members found little evidence that food restrictions work, and instead may contribute to reduced vigilance among students or personnel. Additionally, they found that allergen-restricted zones could lead to isolation of students eating separately from their peers.
"Anxiety and fear about the risk of accidental exposure to food allergens, and the burden of managing that risk, may limit children’s participation in day-to-day activities. Children with food allergy are also at risk of allergy-related bullying," the study said.
Waserman told CTVNews.ca on Tuesday that these new recommendations are necessary to "put people on the same page" in working to ensure a "safe environment" for children.
"All recommendations were based on the currently available evidence, which up until now, has not shown any consistent benefit of banning certain foods in schools," Waserman said in a telephone interview on Tuesday.
In addition to rejecting food restrictions, the guidelines recommend that child care and school personnel receive training on how to recognize and respond to allergic reactions, and that epinephrine autoinjectors, such as EipPens, be stocked on site, rather than relying on students to bring their own.
"You've got to train your teachers, they have to know how to recognize signs and symptoms, children should be washing hands, surfaces are to be kept clean after food is eaten, and at the end of the day, children should be monitored during times of eating together by either parents or other teachers," Waserman said.
Waserman noted that these measures are "a lot better for quality of life" for those living with allergies, as many would typically have to eat separated from other classmates due to the risk of a possible allergic reaction.
However, she said that these recommendations don’t necessarily apply to all schools and child care settings.
"If the children are too young and can't self manage, if they can't be monitored, if there's no good system of oversight for these children, then perhaps in those circumstances then to ban a certain food is appropriate," Waserman said.
"Every school should make a decision based on its own context," she added.
Debbie Bruce, director of the Canadian Anaphylaxis Initiative, told CTVNews.ca on Wednesday that she is concerned about student safety should food restrictions be eased in schools.
"Imagine if the person you loved most was always only one mistake away from a life threatening anaphylactic reaction," Bruce said in a telephone interview.
Bruce, who has been dealing with this topic both professionally and personally for over 30 years, says the majority of schools need to take an "individual approach" to allergy risks and food restrictions because the issue varies between those involved.
"The school and principal really do need to go to the parents of allergic students and ask what they feel is necessary to keep their allergic students safe, because nobody wants to implement any more restrictions than absolutely necessary," Bruce said.
Given that the recommendations are only “"conditional" due to a "lack of high-quality evidence," Bruce said they in turn create mixed messaging for schools on how to actually keep students with allergies safe.
Bruce acknowledged that this is a "complex issue," but said that the “understanding of the entire school community makes it easier to find solutions.”
Bruce agreed that epinephrine should be stocked in schools and that school staff should be routinely trained on how to administer it. However, she said it should be administered for all suspected allergic reactions, not only anaphylactic ones.
While she agrees that there should be greater care in supervising students while they’re eating, as well as ensuring that tables and properly sanitized after lunch, Bruce added that there needs to be more oversight to ensure these protocols are being properly followed.
"Often only older students are supervising. Staff are not required to clean tables after lunch and custodians are not required to empty garbage after lunch. It would be a little easier if you didn't have to worry about the child's classroom being contaminated with the allergen," Bruce said.
The international panel, which included 22 health-care professionals, school administrators, parents, as well as six researchers, issued eight recommendations in total for child-care centres and schools:
- Implement training for teachers and other personnel in the prevention, recognition, and treatment of allergic reactions to food.
- Require all parents of students with diagnosed food allergy to provide an up-to-date allergy action plan.
- Implement site-wide protocols for the management of suspected allergic reactions to food in individuals with no allergy action plans on file.
- That personnel use epinephrine only when they suspect that someone is experiencing anaphylaxis, rather than use epinephrine as the first universal treatment for all suspected allergic reactions.
- That personnel do not pre-emptively administer epinephrine in cases when no signs or symptoms of an allergic reaction have developed, even if a student has eaten a food to which they have a known allergy or history of anaphylaxis.
- When laws permit, stock unassigned epinephrine autoinjectors on site, instead of requiring students with allergy to submit personal autoinjectors to be stored on site for designated at-school use.
- Do not prohibit specific foods site-wide.
- Do not establish allergen-restricted zones, except in limited special circumstances.
