Managing Life-Threatening Food Allergies in Child Care:
A Guide for Parents
Food allergies are a growing problem among children attending preschool and day care. The following guide is intended to help parents ensure their food-allergic child’s safety in the child care setting, whether in a large center or in a family home.
Food allergies affect up to 8% of infants and children.
Food allergic reactions can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions.
An increasing number of deaths from food allergies are being reported. A major factor in these deaths has been a delay in the administration of life-saving emergency medication, particularly epinephrine.
It is essential that child care facilities have detailed plans for both (1) avoiding accidental exposures to food allergens and (2) treating reactions for all food-allergic children.
What Is Anaphylaxis?
Anaphylaxis is an allergic reaction affecting the entire body. Upon contact with an allergen, the body releases chemicals, particularly histamines, into the tissues of the heart, lungs, digestive system, or skin. Blood vessels widen so much that blood pressure plummets.
Common symptoms include:
•Sense of impending doom.
• Flushing, tingling, or itchiness of the skin; swelling of lips or joints; hives or rash; sweating; paleness.
• A lump or tickle in the throat; throat tightness; hoarseness; difficulty swallowing; nasal congestion; runny nose; a feeling of “fullness” in the ears.
• Chest tightness; wheezing or high-pitched sounds coming from the lungs; shortness of breath.
• Nausea; abdominal cramps; bloating; vomiting; diarrhea.
• A feeling of lightheadedness; faintness; irregular or rapid heartbeat; confusion; convulsions or spasms; passing out.
Foods that most commonly cause anaphylaxis are:
• Eggs • Peanuts • Wheat • Milk • Shellfish • Tree nuts • Other legumes
Patients who do not have life-threatening symptoms initially may progress to life- threatening anaphylaxis. Adequate warning signs, such as hives, are not always present before serious reactions develop. The first warning signs may be only “a funny feeling in the mouth” or abdominal discomfort.
Exposures to food allergens can occur through:
Protecting a child from exposure to an offending food is the most important way to prevent life-threatening anaphylaxis. Most anaphylactic reactions occur as a result of accidental exposure to the allergen.
Parents and their health care providers must work with the child care facility to develop a special care plan to include:
Written instructions regarding the food(s) to which the child is allergic and steps that need to be taken to avoid that food.
A detailed treatment plan to be implemented in the event of an allergic reaction, including the names, doses, and methods of administration of any medications that the child should receive in the event of a reaction. The plan should include specific symptoms that would indicate the need to administer one or more medications.
Click here for Child Care Asthma/Allergy Action Card for documenting such information.
Parents and staff must arrange for the facility to have:
Necessary up-to-date medications.
Proper storage of such medications in an unlocked cabinet always accessible to staff.
Training to manage the child’s food allergy while the child is at the child care facility.
Based on the child’s special care plan, the child’s caregivers must receive training, demonstrate competence in, and implement measures for:
Preventing exposure to the specific food(s) to which the child is allergic.
Recognizing the symptoms of an allergic reaction.
Treating allergic reactions.
Caregivers should be aware of foods that may be called by a variety of names in an ingredient list. Milk products, for instance, may be identified as casein, caseinate, whey, and lactoglobulin.
Food sharing between children must be prevented by careful supervision and repeated instruction to children about this issue.
Caregivers should wash children’s hands and faces and all surfaces that were in contact with food in order to minimize accidental exposure.
Potentially offending foods should not be used in art, craft, science or other classroom projects, such as the use of peanut butter to make a bird feeder or wheat to make play dough.
Caregivers must promptly and properly administer prescribed medications in the event of an allergic reaction according to the instructions in the special care plan.
For all children with a history of anaphylaxis, and for those with peanut, tree nut, or fish allergy (whether or not they have had anaphylaxis), epinephrine must be readily available. This will usually be provided as a pre-measured dose in an auto-injector device (for example, the EpiPen® or EpiPen Junior®. Auvi-Q®, or other devices). Specific indications for administration of epinephrine should be provided in the detailed care plan.
“Epinephrine is the first drug that should be used in the emergency management of a child having a potentially life-threatening allergic reaction…There are no contraindications to the use of epinephrine for a life-threatening allergic reaction.”
“All individuals receiving emergency epinephrine should immediately be transported to a hospital even if symptoms appear to have resolved… Further treatments may be required, and therefore observation in a hospital setting is necessary. ..Additional epinephrine should be available during transport.”
From American Academy of Allergy, Asthma and Immunology (AAAAI) Position Statement. Treatment Strategies.
In virtually all cases, Emergency Medical Services (EMS) should be called immediately and children should be transported to the emergency room by ambulance after the administration of epinephrine. (Prior to bringing the food-allergic child into the child care setting, EMS should be contacted to determine whether they routinely carry epinephrine.)
Caregivers should be equipped with a cell phone or other communication device at all times for emergencies.
In general, the facility must:
Notify the parents of any suspected allergic reactions, the ingestion of the problem food, or contact with the problem food, even if a reaction did not occur. (Sometimes, the food allergy reaction may occur at the child care facility for the first time.)
Notify the child’s physician if the facility has had to treat the child for a food allergic reaction.
Contact the emergency medical services (EMS) system immediately whenever epinephrine has been administered.
Notify parents of all children in the child’s class to avoid their bringing any known allergens in class treats or special foods into the child care setting.
Post individual children’s food allergies prominently in the classroom and/or wherever food is served.
Routinely carry the written child care plan for the child with allergies on field trips or transport out of the child care setting.
Prohibit eating and/or trading of food on buses or vans used to transport children.
Choose field trips carefully to avoid potential allergen exposure.
Avoid meals that may be food allergy-related on field trips.
Train staff in how to read product labels and recognize food allergens.
Train staff regarding cross-contamination of food allergens, or the cooking or serving of different foods with the same utensils and surfaces, as well as the clean-up of different foods with the same sponge, which poses a serious risk to a child with food allergies.
Conduct practice drills periodically.
This information is based, in part, on Caring for Our Children: National Health and Safety Performance Standards, Standard 4.010, National Resource Center for Health & Safety in Child Care, http://nrckids.org.